Samuel S Silva

Cox maze operation without cryoablation for the treatment of chronic atrial fibrillation

BACKGROUND From August 1993 to May 1994, 20 patients (mean age, 43 years) with atrial fibrillation underwent the maze operation without cryoablation. Ten patients had mitral stenosis, 5 had mitral insufficiency, and 5 had a mixed mitral lesion. The mean left atrial diameter as measured on echocardiograms was 6.1 cm. The cause was rheumatic in 17 patients (85%) and degenerative in 3 (15%). Seven patients had had previous episodes of thromboembolism. METHODS Mitral valvuloplasty was performed on 7 patients, mitral commissurotomy on 4, and mitral valve replacement on 9. Thrombi were found in the left atrium of 7 patients and also in the right atrium in 2. The mean cross-clamp time was 73 minutes (range, 52 to 108 minutes). RESULTS Patients were discharged from the hospital in good condition. Hemodynamic studies and Doppler echocardiograms showed significant reduction in the left atrial diameter (mean diameter, 4.9 cm; p < 0.01) in 18 patients. The two-channel Holter monitor showed sinus rhythm in 15 patients, atrial ectopic rhythm in 4, and atrial fibrillation in 1. Eleven patients (55%) experienced atrial fibrillation (9 in the first 3 months postoperatively), which was reversed with quinidine. Ninety percent of patients had development of an effective, synchronous, atrial systole. Six to 15 months postoperatively (average follow-up, 10 months), all patients were in functional class I, and 18 were not on a regimen of antiarrhythmic medication. CONCLUSIONS This simplification of the maze operation has been demonstrated to be an effective alternative for the treatment of chronic atrial fibrillation.

Partial tricuspid valve transfer for repair of mitral insufficiency due to ruptured chordae tendineae

BACKGROUND A new technique is suggested for the reconstructive surgical treatment of mitral regurgitation. It involves partial transfer of the tricuspid valve of the patient to the mitral valve, in order to provide chordae to correct anterior leaflet prolapse of the mitral valve, secondary to rupture of the chordae tendineae. METHODS From January 1991 to May 1997, 20 patients with mitral insufficiency due to rupture of the chordae were operated on. The prevailing cause was myxomatous degeneration (70%). Patients were in New York Heart Association functional class III and IV. RESULTS There were no hospital deaths. Two patients were reoperated on. Eighteen patients (90%) are alive with their own valves (class I and II). Doppler echocardiogram mean values were: ejection fraction, 0.65; left atrial diameter, 4.2 cm; mitral area, 2.4 cm2; mitral transvalvular gradient, 3.3 mm Hg. No regurgitation or mild regurgitation was observed in 16 (94.1%) of the 17 cases evaluated. Mean tricuspid valvular area was 3.3 cm2. In all cases, no tricuspid regurgitation was present or it was mild. CONCLUSIONS Partial transfer of the tricuspid valve to the mitral valve is an effective procedure for the surgical treatment of mitral valve insufficiency secondary to ruptured chordae tendineae of the anterior leaflet.

Técnica de Cox sem crioablação para tratamento cirúrgico da fibrilação atrial

Six patients with atrial fibrillation were submitted to maze operation (Cox) without crioablation. Four patients had also mitral stenosis, one had mitral insufficiency and one mitral insufficiency plus mitral stenosis. The mean left atrium diameter was 6.0 cm (5-7.3) in the preoperative ecodopplercardiogram. The ethiology was rheumatic in all but one patient. Conservative mitral valve surgery was performed in five patients and mitral valve replacement in one. Thrombosis of the left atrium was present in four patients. The mean cross-clamping time was 91 minutes (80-108). In the operating room, sinus rhythm was observed in two patients and junctional rhythm in four. In the first postoperative day all patients were in junctional rhthminfour. In the firstpostoperative day all patients were in junctional rhythm. The Holter (24 hours) in the eighteeth postoperative day showed sinus rhythm in five and atrial ectopic rhythm in one. The hemodynamic data and the ecodoppler showed synchronic left atrial contraction in all but one patient and a mean left atrium diameter of 4.8 cm (3.7-5.2). The patients discharged from hospital (8-27 days) are in excellent conditions.

Correção cirúrgica simultânea da fibrilação atrial e da insuficiência mitral em criança

A combined mitral reconstructive surgery and Cox-maze operation without cryoablagao was performed in a 12-year-old female patient for the correction of a rheumatic mitral insufficiency and chronic atrial fibrillation. One year postoperative the patient was assymptomatic, in sinusal rhythm and no murmurs were observed. The Doppler echocardiogram showed an important reduction of the left atrial diameter and the cardiac catheterism confirmed an effective atrial systole.

Modified technique for total cavopulmonary connection

The laterolateral anastomosis between the superior vena cava and the pulmonary artery trunk is presented as a modified technique for total cavopulmonary connection. This procedure was successfully performed on a 9-year-old girl, associated with the exclusion of the right atrium, for the treatment of tricuspid atresia and transposition of the great arteries.

Autotransplante de cordas tendíneas: nova técnica para o tratamento cirúrgico da insuficiência mitral por rotura de cordas tendíneas da cúspide anterior

One of the most frequent causes of mitral valve prolapse is rupture of the chordae tendineae. Several techniques have been used to correct severe mitral regurgitation. However, mitral valve replacement is the principal surgical approach to it. We describe a technique used in four patients with marked mitral regurgitation due to ruptured chordae tendineae of the anterior leaflet. We have grafted chordae tendineae from the tricuspid valve onto the mitral valve. In the first and fourth case we removed part of the anterior leaflet of the tricuspid valve, together with chordae tendineae and part of the papillary muscle. In the other two cases we removed the posterior leaflet, together with its chordae tendinease and papillarly muscle. In the first and fourth cases the tricuspid valve was repaired. In the other two cases it was turned into bicuspid valve by means of an annular plication. The first extremity of the graft to be sutured was the papillary muscle, followed by the leaflet. Studies carried out 15, 11, 2 and 1 month, postoperatively, showed that both valves, i. e., mitral and tricuspid, were competent and the patients were asymptomatic. In spite of our limited experience, we believe, this technique is a sensible alternative to mitral valve replacement.

Tratamento cirúrgico da insuficiência mitral em crianças: dez anos de técnicas reparadoras

From April 1979 through January 1989, 71 patients with mitral insufficiency were surgically treated, 53 of them (74,6%) submitted to valvuloplasty. From this group 21 patients had associated mitral estenosis. Rheumatic fever was the major cause of the mitral lesions (79,2%). All patients, but 3, were situated in funcional class III and IV (NYHA). Anuloplasty (Carpentier ring and Gregori-IMC) were made associated to plastic procedures at the leaflet and the subvalvar set. In the postoperative period, we observed: no hospital mortality; early postoperative evolution was better in patients subjected to surgery in the period from 84 through 89, in comparison to the anterior period (79-83); reoperation index very acceptable at the late postoperative (5,7%); satisfactory clinical and hemodynamic late evolution; better evolution in the group of patients in the functional class postoperative II and III; better evolution in the group of patients with mitral insufficiency without associated stenosis.

Secção da aorta descendente por traumatismo fechado do tórax: tratamento cirúrgico com sucesso

E descrito caso de seccao da aorta toracica descendente, apos a emergencia da arteria subclavia esquerda decorrente de trauma fechado do torax. O diagnostico precoce e o rapido tratamento cirurgico foram fundamentais para a excelente evolucao pos-operatoria. O emprego de circulacao extracorporea atrio esquerdo-femoral para a interposicao de tubo de Dacron restabelecendo o fluxo arterial, foi fundamental para a prevencao de paraplegia por lesao da medula espinhal ja levemente isquemica.

Dúvidas na indicação cirúrgica da cerclagem do tronco pulmonar

From February 1979 to March 1986, 50 patients were submitted to pulmonary artery banding in order to control congestive heart failure and to prevent pulmonary vascular disease. Twenty-three patients were male and 17 were female. The mean age was 6 months (20 days to 17 months). The preoperative diagnosis were: ventricular septal defect (22), atrioventricular canal (6), double outlet right ventricle (2), tricuspid atresia (2), transposition of the great arteries (3), truncus arteriosus (2), single ventricle (1) and complexes pathologies (2). The pulmonary banding was carried out under control of the pulmonary artery pressure. Two patients (5 per cent) died on the immediate postoperative period: one patient in atrioventricular block and another in sepsis. One patient died of pneumonia on the late postoperative period. The remaining patients had a satisfactory evolution, increasing 400g of weight monthly. Thirteen patients were submitted to hemodynamic studies on the postoperative period (mean 21 months). Important reduction in pulmonary pressures and flows were then observed, including in five cases with A-V canal. Thirteen patients were reoperated on to correct their underlying defects one year after the banding. Then, one patient died in the immediate postoperative phase and another on the late phase. One of the six patients with A-V canal died on the immediate postoperative period and the others were reoperated for correction of the defects, with good results.