ABSTRACT The perspective of the integrated health system has a network of care with multiple integration dimensions among subsystems as nuclear representation, relating the clinical aspects and governance to the representations and collective values. The normative integration aims to ensure coherence between the system of representations and values of society simultaneously with the interfaces of clinical and functional integration. It builds a bridge with governance, which allows, through their skills, management of all system components, encouraging cooperation, communication and information, in order to ensure the population under their responsibility to access excellence services, exceeding their expectations. The integration of care consists of a durable coordination of clinical practices for those who suffer from health problems in order to ensure continuity and full range of the required professional services and organizations, coordinated in time and space, in accordance with the available knowledge. It is possible to establish the type of health equipment for each level of care for patients with congenital heart diseases. This strategy intends to offer timely care in appropriate moments and places, efficiently, operating cooperatively an interdependently, with ongoing exchange of its resources. Thus, situational integration establishes the system connection with the assessment environment that proposes to carry out value judgment, guided by an objective worldview, about an intervention or any of its components, in order to objectify the decision making.

OBJETIVO: A bandagem da artéria pulmonar (BAP) é um procedimento tecnicamente simples, mas envolto em várias peculiaridades que o fazem apresentar elevadas taxas de morbidade e mortalidade. O objetivo deste estudo é analisar a experiência de um hospital de referência na bandagem da artéria pulmonar, avaliando e correlacionando diversas variáveis relacionadas ao procedimento. MÉTODOS: Entre janeiro de 2000 e dezembro de 2008, 61 pacientes submetidos a BAP por cardiopatia congênita de hiperfluxo no Hospital do Coração de Messejana-Fortaleza/CE foram avaliados quanto a mortalidade, complicações, permanência em ventilação mecânica (VM) e terapia intensiva (UTI), uso de drogas vasoativas, dificuldade de ajustes transoperatórios e reoperações para reajuste. Análise estatística foi realizada para comparações entre subgrupos. RESULTADOS: Em 46,8% dos pacientes, não se conseguiu o ajuste pressórico pretendido e 6,5% precisaram ser reoperados para reajustes. O tempo médio UTI e VM foi 14,16 ± 10,92 dias e 14,1 ± 49,6 dias, respectivamente. Em 82,6% dos pacientes foram administradas drogas vasoativas por 10,30 ± 12,79 dias. Complicações graves incidiram em 49,15% dos pacientes, com predominância da insuficiência cardíaca (44%). A taxa de mortalidade foi de 8,2%, não influenciada por peso, procedimentos associados ou cardiopatia univentricular ou biventricular. CONCLUSÃO: Neste estudo, a BAP foi realizada com taxas de mortalidade aceitáveis, compatíveis com a literatura mundial. No entanto, os ajustes transoperatórios são de difícil análise, tornando o procedimento complexo e justificando elevados índices de complicações, resultando em longa permanência em UTI. Nenhuma variável isolada representou significante fator de risco, dentre as quais, fisiologia uni ou biventricular

OBJECTIVE: Although pulmonary artery banding (PAB) seems to be a technically simple procedure it presents several peculiarities and is related to a significant morbidity and mortality. The aim of this study is to analyze the experience of a tertiary hospital on the PAB by assessing and correlating many aspects related to the procedure. METHODS: Between January 2000 and December 2008, 61 patients undergone PAB due to congenital heart disease with increased pulmonary blood flow at Messejana Heart Hospital were assessed as for mortality, complications, stay in mechanical ventilation and need for intensive care unit (ICU), use of vasoactive drugs, difficulties in the adjustment on the banding and reoperations. Some statistical analyzes were performed to compare the subgroups. RESULTS: In 46.8% of the patients the intended pressoric adjustment was not achieved and in 6.5% it was necessary another surgery to readjust the banding. The mean time of mechanical ventilation was 14.1±49.6 days and ICU 14.16±10.92 days. In 82.6% of the patients vasoactives drugs were administrated for 10.3±12.79 days. Severe complications were noted in 49.15% of patients and cardiac insufficiency was the most common one with an incidence of 44%. The mortality rate was 8.2% and it was not influenced by weight or associated procedures with the PAB neither if univentricular or biventricular heart disease. CONCLUSION: The PAB can be performed with acceptable mortality rates compatible with the ones of the world literature. Nevertheless, the adjustment of the banding is difficult to be assessed during the surgery by making the procedure complex and justifying the high incidence of complications and long stay in ICU. It wasn't found any specific risk factor significant to mortality neither uni- or biventricular heart disease

OBJETIVO: Este trabalho relata a experiência no manuseio da crise hipertensiva pulmonar (CHP) refratária, com o uso do óxido nítrico inalatório (NOi) no pós-operatório imediato do transplante cardíaco (TC) ortotópico. MÉTODOS: De outubro/1997 a fevereiro/2002 foram realizados 31 TC em adultos, sendo incluídos pacientes com RVP < 6uW, ou < 2,5uW na prova farmacológica. Após o período de circulação extracorpórea (CEC) (M=101±21 minutos), todos fizeram uso de dobutamina, dopamina e milrinona; entretanto, frente à ausência de resposta adequada e CHP, administrou-se NOi em doses crescentes de 20 a 40ppm. Foram utilizados registros das pressões através de cateter no átrio esquerdo e no tronco da artéria pulmonar, gasometria arterial seriada e ecocardiograma transtorácico (ETT). O tempo médio de morte encefálica (ME) do doador foi de 16<FONT FACE=Symbol>±5,1</FONT>horas<FONT FACE=Symbol>.</FONT>RESULTADOS: Cinco pacientes (1 mulher), com idade média de 42 anos, fizeram uso de NOi por apresentarem critérios de CHP, todos com sinais de baixo débito cardíaco. O tempo médio de CEC foi de 150,8±34,3 minutos, a média sistólica arterial pulmonar foi de 87mmHg (75-115) e a PO2 média de 60mmHg (FiO2 100%), sendo evidenciada dilatação moderada a severa do ventrículo direito no ETT. Foi administrado NOi durante uma média 35h (6-96), iniciando-se desmame após estabilização hemodinâmica. O tempo médio de ME do doador foi de 27,6±5,5horas, a internação hospitalar média foi de 63 dias (17-145), uma morte ocorreu por sepse no 17º PO e os demais pacientes estão em CF I (NYHA). CONCLUSÕES: O tempo de CEC superior a 120 minutos e tempo de ME do doador superior a 20 horas sugerem fatores de risco para CHP no período pós-operatório imediato do TC. O NOi é uma ferramenta útil no manuseio desta complicação, refratária ao tratamento convencional no POI de pacientes submetidos ao TC.

OBJECTIVE: This study reviews our experience with the use of nitric oxide inhalation (NOi) in the treatment of the refractory pulmonary hypertensive crisis (PHC) during the immediate post-operative period (IPOP) of heart transplantation (HT). METHOD: Between Oct/97 and Feb/02, 31 HT in adults were performed. Among them were patients with Pulmonary Vascular Resistance (PVR) greater than 6 uW, or patients with PVR greater than 2,5 uW during the pharmacological test. All patients were weaned from the CPB (M=101±21 minutes) in use of dobutamine, dopamine and milrinone. In the absence of an adequate response to these drugs and with the evidence of PHC, NOi was given, beginning with 20ppm and increasing, when necessary, up to 40ppm. The recording of the left atrium and pulmonary artery pressures, serial arterial blood gases samples and trans-thoracic echocardiograms (TTE) were performed. The donor's brain death (BD) time mean was 16±5,1 hours. RESULTS: In five patients (1 female) (mean age = 42 years) NOi was employed, due to low cardiac output signs and evidence of PHC and right ventricular dysfunction. The mean CPB time was 150,8±34,3 min. The pre-NOi mean PAP was 87 mmHg (range 75-115), and the mean arterial PO2 = 60mmHg (FiO2=100%). The TTE showed moderate-severe dilation of the right ventricle. NOi was given during a mean of 35h (range 6 to 96), being weaned only after hemodynamic stability was achieved. There was only one early death, at the 17th post op. day due to sepsis. All the remaining patients are in NYHA class I. CONCLUSIONS: The prolonged CPB time (> 120 min) and the time of brain death of the donor are factors that increase the risk of PHC. The NOi is a useful tool in dealing with this complication when there is an inadequate response to the conventional treatment.

A disfunção do ventrículo direito no pós-operatório do transplante cardíaco é uma complicação freqüente com morbimortalidade elevada. A avaliação hemodinâmica pulmonar dos candidatos precisa, às vezes, do emprego de prova farmacológica com o uso de drogas endovenosas vasodilatadoras tipo nitroprussiato de sódio (NTPNa), visando reduzir os níveis de pressão e resistência vascular pulmonar (RVP) elevados a níveis compatíveis com os protocolos de inclusão dos Programas de Transplante Cardíaco. Valores de RVP acima de 6 unidades Wood sem droga vasodilatadora, ou acima de 2,5 com a utilização destas, excluem os pacientes do Programa. Entre janeiro de 1997 e janeiro de 2000 foram submetidos a cateterismo direito, 40 pacientes candidatos a transplante. A maioria homens, com idade mé (±12 anos). As etiologias mais encontradas foram miocardiopatia dilatada idiopática (59%) e miocardiopatia isquêmica (25%). Todos em CF IV da NYHA, com fração de ejeção média do ventrículo esquerdo de 0,21 (± 0,03). A monitorização do débito cardíaco (DC), pressão da artéria pulmonar (PAP) e RVP foi feita pelo método contínuo, utilizando para isto cateter de artéria pulmonar especial. Em 5 pacientes a prova farmacológica foi interrompida devido aos efeitos sistêmicos do NTPNa com queda da PAM, RVP e DC. Todos foram submetidos a inalação de óxido nítrico (NO) por máscara, a uma dose de 20 ppm durante 10 minutos. Em 3, a RVP reduziu de 7,8 (±0,88) para 2,4 (±0,36) unidades Wood, e eles foram incluídos no Programa de Transplante. Nos outros 2, apesar de doses de NO de 20,30 e 40 ppm, a redução foi de 8,4 (±2,12) para 4,9 (±0,42) unidades Wood, ou seja, insuficiente para serem incluídos nos Programas de Transplante. Não tivemos óbitos, nem complicações durante os procedimentos. O NO inalatório na avaliação hemodinâmica dos candidatos a TC -- pelo seu efeito vasodilatador seletivo -- permite identificar aqueles com hiper-resistência vascular pulmonar, que não respondem ao uso de drogas vasodilatadoras endovenosas convencionais, evitando que sejam excluídos dos benefícios do procedimento do TC.

The right ventricle dysfunction in the post-operative period of the heart transplantation (HTx) surgery is a frequent complication with high morbidity and mortality . In order to reduce the high pulmonary vascular resistance (PVR) and pulmonary artery pressure (PAP), often found in the patients candidates to HTx, it is, sometimes, necessary to use endovenous infusion of sodium nitroprusside (NaNTP) (the pharmacologic test), during the pre-operative hemodynamic assessment of the pulmonary circulation, in attempt to reduce the PVR and PAP to compatible levels, allowing the inclusion of these patients in the HTx program protocol. Values of PVR over 6 Wood units without drugs (such as NaNTP) or 2.5 Wood units with drugs will exclude the patient from the HTx program. Between January 1997 and January 2000, 40 patients (70% males) (mean age = 42 +/- 12), candidates to HTx were submitted to cardiac catheterization (right side). 24 patients (59%) had dilated idiopathic cardiomyopathy, 10 (25%) ischemic myocardiopathy. All were in Class IV (NYHA), with mean left ventricular ejection fraction (LVEF) of 0.21 (+/- 0.03). Continuous measurement of the cardiac output, PAP and RVP were done with the help of a special Swan-Ganz catheter. In 5 patients the pharmacologic test was interrupted owing to systemic effects of NaNTP (important drop of arterial blood pressure and cardiac output). Then, they were submitted to inhalation of 20 ppm of nitric oxide (NO), though facial mask, during 10 minutes, in three patients the RVP dropped from a mean of 7.8 (+/- 0.88) to 2.4 (+/- 0.36) Wood units and so they could be included in the transplantation program. The two other patients did not achieve RVP drops enough to be candidates to HTx, once, even though the amount of NO inhaled had reached 20, 30 and 40 ppm, the reduction of the RVP was from 8,4 (+/- 2.12) to 4,9 (+/- 0.42) Wood units. There were no deaths or complications during these producers. The NO inhalation during hemodynamic evaluation of candidates to HTx, owing to its selective vasodilator effect, allows us to identify those patients with pulmonary vascular hyperresistance, who do not respond to the use of endovenous vasodilator drugs, thus avoiding them to be excluded from the benefits of the HTx.