Sérgio de Almeida Oliveira

Redução do período de internação e de despesas no atendimento de portadores de cardiopatias congênitas submetidos à intervenção cirúrgica cardíaca no protocolo da via rápida

OBJECTIVE To assess the care provided to patients with congenital heart diseases and ischemic heart diseases undergoing cardiac surgery according to the fast-track recovery protocol compared with those undergoing the conventional procedure. METHODS The transfer of patients from one hospital unit to another was assessed for 175 patients, 107 (61%) men and 68 (39%) women, with ages ranging from 0.3 to 81 years. RESULTS The discharge rate from the different hospital units per unit of time of the patients with congenital heart diseases treated according to the fast-track recovery protocol compared with that of patients conventionally treated was as follows: a) 11.3 times faster than the discharge rate of patients treated according to the conventional protocol, in regard to the time spent in the operating room; b) 6.3 times faster in regard to the duration of the surgical intervention; c) 6.8 times faster in regard to the duration of anesthesia; d) 1.5 times faster in regard to the duration of perfusion; e) 2.8 times faster in regard to the stay in the postoperative recovery I unit; f) 6.7 times faster in regard to hospital stay (time period between hospital admission and hospital discharge); g) 2.8 times faster in regard to the stay in the preoperative unit; h) 2.1 times faster in regard to the stay in the admission unit after discharge from postoperative recovery; i) associated with reduced costs. The difference was not significant for patients with ischemic heart disease. CONCLUSION A reduction in the length of hospital stay and costs for the care of patients undergoing cardiac surgery according to the fast-track protocol was observed.

Hemólise em circulação extracorpórea: estudo comparativo entre bomba de rolete e bomba centrífuga

O uso de bomba centrifuga como suporte circulatorio para pacientes em choque cardiogenico, apos a realizacao de cirurgia cardiaca e como suporte para pacientes com falencia cardiaca que estao aguardando doacao para transplante cardiaco, tem sido progressivamente ampliado. Alguns centros utilizam a bomba centrifuga em circulacao extracorporea de rotina, como substituto do rolete arterial,. No INCOR, operamos dois grupos de pacientes triarteriais submetidos a revascularizacao do miocardio, operados pelo mesmo cirurgiao, com o mesmo metodo de protecao miocardica (cardioplegia cristaloide, hipotermia sistemica a 28oC e topica com soro fisiologico). Todos os parâmetros dos dois grupos foram sem diferenca estatistica no pre-operatorio: idade, sexo, superficie corporea e parâmetros hematologicos. Foram operados 27 pacientes consecutivos e divididos, alternadamente, em 13 pacientes com bomba centrifuga e 14 com rolete arterial. O oxigenador utilizado em todos foi o de bolhas da Macchi. O perfusionista foi sempre o mesmo. O tempo de perfusao medio foi de 105 minutos no Grupo 1 (rolete) e 103 minutos no Grupo 2 (bomba centrifuga). Analisamos os seguintes parâmetros: haptoglobina (HP), tempo de tromboplastina parcial ativada (TTPA), tempo de trombina (TT) e numero e plaquetas pre e pos circulacao extracorporea e, comparando-se os dois grupos, nao houve diferenca estatistica significante entre eles, nos diversos parâmetros. Concluimos que, para circulacao extracorporea com duracao habitual, nao ha diferenca hematologica no uso da bomba centrifuga em relacao ao rolete arterial.

Tratamento cirúrgico da dissecção da aorta

Between January 1979 and December 1989, eighty five operations were performed to treat aortic dissection, including fifty in the acute phase, and thirty five in a chronic phase. The Hospital mortality was 21.1% (eighteen patients) and low cardiac output was the major cause of death. The mortality was higher in the group of patients operated upon in the acute phase. Four patients were operated upon for redissection or dissection in other localization of the aorta, and all of them died. One patient developed paraplegy in the postoperative period. The late follow-up showed good evolution in the survivors group.

Fibroma cardíaco mimetizando cardiomiopatia hipertrófica

A 33 year-old woman was seen, for the first time, ten years ago, for evaluation of a recurrent chest pain, dyspnea and arrhythmia. She was submitted to echocardiographic studies and a cardiac catheterization. The diagnoses was endomyocardial fibrosis at first, and hypertrophic cardiomyopathy after. Despite treatment with propranolol and quinidine, the episodes of dyspnea and tachyarrhythmias became more frequent and severe, and the patient was guided to our Service. Cardiac re-catheterization, echocardiographic and computed tomography studies identified in traumural cardiac fibroma and the patient was referred for surgical treatment. The cardiac fibroma was successfully resected on extracorporeal bypass and with cardioplegic arrest of the heart. Repair of the heart was accomplished with a patch placed to close the left ventricular cavity. The postoperative course was uncomplicated, and she remains assymptomatic two years later. We have emphazied tha this tumor often produces clinically obscure disease, simulating particularly the left ventricle hypertrophic cardiomiopathy.

Revascularização direta do miocárdio com as duas artérias mamárias internas: análise de 442 casos

From June 1984 to November 1989, 4958 patients (pts) were submitted to myocardial revascularization in the Heart Institute, and in 54% at least one internal mammary artery was used. In 442 (8,9%) pts both intenal mammary arteries, right (RIMA) and left (LIMA) were used, isolated or associated to ther grafts. The age ranged from 30 to 78 years old (52,7y) and 399 were male. The pts were separated in 4 groups, being: G I 232 (52,4%) pts - LIMA to left anterior descending artery (LAD) and RIMA to LAD branches or circumflex (Cx) branches in retroaortic position; G II 135 (30,5%) pts - LIMA to LAD and RIMA to right coronary artery (RCA); G III 48 (10,8%) pts - LIMA to Cx branches and RIMA to LAD as a free graft; G IV 27 (6,1%) pts - different associations with both arteries. The LIMA was used in situ in 440 pts and as free graft in 2; the RIMA was used in situ in 379 pts and as free graft in 63; The average number of grafts/pts was 3,17, considering the association with saphenous vein and other grafts. Respiratory insufficiency and low cardiac output syndrome were the main complications in 37 (8,3%) and 23 (5,2%) pts, respectively; 16 (3,6%) pts had post operatory myocardial infarction and 15 (3,3%) had wound closure complications. The mortality rate was 4,91% (22 pts) and the main causes of deaths were multiple system organ failure in 7 (31,8%) and myocardial insufficiency in 6 (27,3%). The mortality rate was higher in pts with severe myocardial dysfunction and older than 60 years old and the best graft patency was observed when the LIMA was anastomosed to the LAD (93,8%). The use of both intenal mammary arteries showed good results and acceptable morbidity and mortality.

Revascularização miocárdica de urgência após complicação de angioplastia transluminal coronária: abordagem cirúrgica atual

Between July 1981 and February 1990, 2431 patients underwent attempted percutaneous transluminal coronary angioplasty (PTCA). Seventy-nine (3.2%) patients subsequently underwent emergency miocardial revascularization, and 32 (40.5%) developed myocardial infarction with 12 (15.2%) deaths. The operative mortality rate was significantly increased among elderly patients, those with left main occlusive dissection, late coronary thrombosis, and specially among patients with hemodynamic instability after PTCA. Additional minutes or hours of low myocardial and systemic perfusion after failed PTCA also increase the risk of immediate surgical revascularization. Despite the growing role of PTCA in the treatment of more complex coronary atherosclerotic heart diseases, the number of failed procedures that necessitate coronary artery bypass surgery decreased last two years (10/1351). This have been possible by placing a reperfusion catheter (Stack) across the narrowed coronary artery lumen. Surgical results were consistently improved by modifications in myocardial protection techniques, besides the use of reperfusion catheter after failed PTCA.

Tratamento cirúrgico da comunicação interventricular pós infarto agudo do miocárdio: conduta atual

The authors describe the experience with surgical treatment of 42 patients with ventricular septal rupture (VSR) in post acute myocardial infarction (AMI). They showed increased mortality in patients with cardiogenic shock (66.6%) with respect to others (9.5%). Sudden descompensations in patients hemodinamically stable were indications to early surgeries, if possible when the diagnosis of ventricular septum rupture (VSR) was made. The compromise of multiple coronary arteries and advanced age were considered as aggravating factors in the prognosis of surgery. The same prognosis did not occur regarding pulmonary/systemic flow and shunt E-D. The technique of exposure in both ventricular cavity and reinforcement in the both sides of the ruptured septum with biological tissue offered good results in the correction of posterior VSR.

Aspectos práticos na indicação de revisão de hemostasia no pós-operatório imediato de cirurgia cardíaca

Foram estudados restrospectivamente os coagulogramas de 65 pacientes submetidos a revisao de hemostasia no pos-operatorio imediato de cirurgia cardiaca. Os coagulogramas foram considerados compativeis ou nao com disturbio da coagulacao sanguinea, por hematologista que desconhecia o achado cirurgico. Dentre 51 pacientes cujos valores do coagulograma foram considerados normais, 46 (90,2%) apresentavam sangramento ativo localizado, passivel de correcao cirurgica. Os 5 (9,8%) demais pacientes apresentavam sangramento difuso. Dentre os 14 pacientes restantes, cujo coagulograma encontrava-se alterado, 8 (57,2%) apresentavam sangramento difuso e 6 (42,8%), localizado. Os autores concluem que, na persistencia de sangramento excessivo pos-operatorio e coagulograma normal, a revisao de hemostasia devera ser prontamente indicada. Entretanto, se houver alteracao do coagulograma, dever-se-a empregar, inicialmente, o tratamento clinico, desde que o ritmo do sangramento o permita. Caso o sangramento persista, mesmo com melhora do coagulograma, devera ser pesquisada a presenca de coagulos retidos no mediastino. Se positiva, deve-se programar nova toracotomia, visando a remocao de coagulos do mediastino.

Origem anômala da artéria circunflexa da artéria pulmonar direita

A case never described in adults before is here reported. A 35-year-old patient who had referred precordial pain in effort for seventeen years was investigated after having been submitted to correction of coarctation of the aorta, and had the following diagnosis: anomalous origin of the circunflex artery. In the intraoperatory, the latter was found to proceeed from the right pulmonary artery. The anomalous ostio was sutured and a free graft was made, from the right internal thoracic artery to the circunflex coronary. In addition to the unusualness of such pathology, some physiopatologic considerations related to the coarctation of the aorta may be made, in this particular case.