Abstract Objective: Elaboration and internal validation of the Quality of Life in Cardiovascular Surgery (QLCS) questionnaire adapted to the reality of Brazilian cardiovascular surgery. Methods: Cross-sectional pilot study of a prospective cohort included in the Documentation and Surgical Registry Center (CEDREC) for internal validation of the QLCS questionnaire. Four hundred forty-five patients submitted to cardiovascular surgery and who answered a QLCS questionnaire 30 days after hospital discharge were included. It was applied via telephone. To verify the questions' internal consistency, Cronbach's alpha was used. The total QLCS score was calculated as the sum of 5 questions, ranging from 5 to 25 points. Mann-U-Whitney test was used to relate the symptoms with the quality of life (QoL). Level of significance was 5%. Results: After 30 days of surgery, about 95% of the patients had already returned to normal routine and 19% of them were already performing physical activity. In the evaluation of the QLCS's internal consistency, a Cronbach's alpha of 0.74 was found, suggesting that this was probably an adequate questionnaire to evaluate QoL in this population. In the comparison between the presence and absence of symptoms and the median of QoL, the presence of pain at the incision (P=0.002), chest pain (P<0.001), shortness of breath (P<0.001), and return to physical activity (P<0.001) were statistically significant. Conclusion: The process of elaboration and validation of questionnaires includes a series of steps. The QLCS questionnaire is probably an adequate tool for the evaluation of QoL in the postoperative patient of cardiovascular surgery, in this first stage of internal validation.

Abstract Introduction: Active infective endocarditis is associated with high morbidity and mortality. Surgery is indicated in high-risk conditions, and the main determinants of mortality in surgical treatment should be evaluated. Objective: To identify mortality predictors in the surgical treatment of active infective endocarditis in a long-term follow-up. Methods: This prospective observational study involved 88 consecutive patients diagnosed with active infective endocarditis, who underwent surgery between January 2005 and December 2015. Fifty-eight (65.9%) patients were male, the mean age was 50.87±16.15 years. A total of 31 (35.2%) patients had a history of rheumatic fever; 48 (54.5%) had had heart surgery with prosthetic valve implantation; 45 (93.8%) had biological prosthetic valve endocarditis and 3 (6.3%) mechanical prosthetic valve; 40 (45.5%) patients had the disease in their native valve. The mean EuroSCORE II was 8.9±6.5%, and the main surgical indication was refractory heart failure in 38 (43.2%) patients. A total of 68 bioprosthesis (36 aortic, 32 mitral) and 29 mechanical prostheses (12 aortic, 17 mitral) were implanted and three mitral valve plasties performed. A total of 25 (28.4%) patients underwent double or triple valve procedures. Aortic annulus reconstruction by abscess was performed in 18 (20.5%) and six (6.81%) patients had combined procedure. The mean surgery time was 359±97.6 minutes. Results: The overall survival in up to a 10-year follow-up period was 79.5%. In the univariate analysis, the main mortality predictors were positive blood cultures (P=0.003), presence of typical microorganisms (P=0.008), most frequently Streptococcus viridans (12 cases; 25%); C-reactive protein (hazard ratio [HR] 1.034, 95% confidence interval [CI] 1.000 to 1.070, P=0.04); creatinine clearance (HR 0.977, 95% CI 0.962 to 0.993, P=0.005); length of surgery: every five minutes multiplies the chance of death 1.005-fold (HR 1.005, 95% CI 1.001 to 1.009, P=0.0307); age (HR 1.060, 95% CI 1.026 to 1.096, P=0.001); and EuroSCORE II (HR 1.089, 95% CI 1.030 to 1.151, P=0.003). Conclusion: A positive blood culture with typical microorganism, C-reactive protein, age, EuroSCORE II, total surgical time and the presence of postoperative complications were the major predictors of mortality and significantly impacted survival in up to a 10-year follow-up period.

Abstract Introduction: Replacement of the aortic valve in patients with a small aortic annulus is associated with increased morbidity and mortality. A prosthesis-patient mismatch is one of the main problems associated with failed valves in this patient population. Objective: To evaluate the long-term mortality predictors in patients with a small aortic annulus undergoing aortic valve replacement with a bioprosthesis. Methods: In this retrospective observational study, a total of 101 patients undergoing aortic valve replacement from January 2000 to December 2010 were studied. There were 81 (80.19%) women with a mean age of 52.81±18.4 years. Severe aortic stenosis was the main indication for surgery in 54 (53.4%) patients. Posterior annulus enlargement was performed in 16 (15.8%) patients. Overall, 54 (53.41%) patients underwent concomitant surgery: 28 (27.5%) underwent mitral valve replacement, and 13 (12.7%) underwent coronary artery bypass graft surgery. Results: Mean valve index was 0.82±0.08 cm2/m2. Overall, 17 (16.83%) patients had a valve index lower than 0.75 cm2/m2, without statistical significance for mortality (P=0.12). The overall 10-year survival rate was 83.17%. The rate for patients who underwent isolated aortic valve replacement was 91.3% and 73.1% (P=0.02) for patients who underwent concomitant surgery. In the univariate analysis, the main predictors of mortality were preoperative ejection fraction (P=0.02; HR 0.01) and EuroSCORE II results (P=0.00000042; HR 1.13). In the multivariate analysis, the main predictors of mortality were age (P=0.01, HR 1.04) and concomitant surgery (P=0.01, HR 5.04). Those relationships were statistically significant. Conclusion: A valve index of < 0.75 cm2/m2 did not affect 10-year survival. However, concomitant surgery and age significantly affected mortality.

Fundamento: O enxerto de artéria radial (AR) foi o segundo enxerto arterial a ser introduzido na prática clínica para revascularização miocárdica. A técnica de esqueletização da artéria torácica interna esquerda (ATIE) pode, de fato, alterar a capacidade de fluxo do enxerto com potenciais vantagens, o que leva à suposição de que o comportamento da AR, como enxerto coronariano, seja semelhante ao da ATIE esqueletizada. Objetivo: Este estudo avaliou enxertos aortocoronários "livres" de AR, quer esqueletizados, quer com tecidos adjacentes. Métodos: Foi realizado um estudo prospectivo randomizado comparando 40 pacientes distribuídos em dois grupos. No grupo I, foram utilizadas artérias radiais esqueletizadas (20 pacientes), e no grupo II, artérias radiais com tecidos adjacentes (20 pacientes). Após o procedimento cirúrgico, os pacientes foram submetidos a medidas da velocidade de fluxo. Resultados: As principais variáveis cirúrgicas foram: diâmetro interno, comprimento e fluxo sanguíneo livre da AR. Os diâmetros médios dos enxertos de AR calculados através de angiografia quantitativa no pós-operatório imediato foram semelhantes, assim como as variáveis de medidas de velocidade de fluxo. Por outro lado, a cinecoronariografia mostrou a presença de oclusão em um enxerto de AR e estenose em cinco enxertos de AR no GII, enquanto que apenas um caso de estenose em um enxerto de AR no GI (p = 0,045). Conclusão: Os resultados mostram que tanto as características morfológicas e anatomopatológicas quanto o desempenho hemodinâmico dos enxertos livres de artéria radial, quer preparados de forma esqueletizada ou com tecidos adjacentes, são semelhantes. Entretanto, pode-se observar um maior número de lesões não obstrutivas quando a AR é preparada com tecidos adjacentes.

Background: Radial artery (RA) was the second arterial graft introduced in clinical practice for myocardial revascularization. The skeletonization technique of the left internal thoracic artery (LITA) may actually change the graft's flow capacity with potential advantages. This leads to the assumption that the behavior of the RA, as a coronary graft, is similar to that of the LITA, when skeletonized. Objective: This study evaluated 'free' aortic-coronary radial artery (RA) grafts, whether skeletonized or with adjacent tissues. Methods: A prospective randomized study comparing 40 patients distributed into two groups was conducted. In group I, we used skeletonized radial arteries (20 patients), and in group II, we used radial arteries with adjacent tissues (20 patients). After the surgical procedure, patients underwent flow velocity measurements. Results: The main surgical variables were: RA internal diameter, RA length, and free blood flow in the radial artery. The mean RA graft diameters as calculated using quantitative angiography in the immediate postoperative period were similar, as well as the flow velocity measurement variables. On the other hand, coronary cineangiography showed the presence of occlusion in one RA graft and stenosis in five RA grafts in GII, while GI presented stenosis in only one RA graft (p = 0.045). Conclusion: These results show that the morphological and pathological features, as well as the hemodynamic performance of the free radial artery grafts, whether prepared in a skeletonized manner or with adjacent tissues, are similar. However, a larger number of non-obstructive lesions may be observed when RA is prepared with adjacent tissues.

OBJETIVOS: O objetivo primário deste estudo é identificar preditores de óbito hospitalar em pacientes submetidos à cirurgia de aorta. O objetivo secundário é identificar fatores associados ao desfecho clínico composto hospitalar (óbito, sangramento, disfunção ventricular ou complicações neurológicas). MÉTODOS: Delineamento transversal com componente longitudinal; por meio de revisão de prontuários, foram incluídos 257 pacientes. Os critérios de inclusão foram: dissecção crônica de aorta tipo A de Stanford e aneurisma de aorta ascendente. Foram excluídos casos de dissecção aguda de aorta, qualquer tipo, e aneurisma de aorta não envolvendo segmento ascendente. As variáveis avaliadas foram demografia, fatores pré, intra e pós-operatórios. RESULTADOS: Variáveis com risco aumentado de óbito hospitalar (RC; IC95%; P valor): etnia negra (6,8; 1,54 30,2; 0,04), doença cerebrovascular (10,5; 1,12-98,7; 0,04), hemopericárdio (35,1; 3,73-330,2; 0,002), operação de Cabrol (9,9; 1,47-66,36; 0,019), cirurgia de revascularização miocárdica simultânea (4,4; 1,31-15,06; 0,017), revisão de hemostasia (5,72; 1,29-25,29; 0,021) e circulação extracorpórea (CEC) [min] (1,016; 1,007-1,026; 0,001). Dor torácica associou-se com risco reduzido de óbito hospitalar (0,27; 0,08-0,94; 0,04). Variáveis com risco aumentado do desfecho clínico composto hospitalar foram: uso de antifibrinolítico (3,2; 1,65-6,27; 0,0006), complicação renal (7,4; 1,52-36,0; 0,013), complicação pulmonar (3,7; 1,5-8,8; 0,004), EuroScore (1,23; 1,08-1,41; 0,003) e tempo de CEC [min] (1,01; 1,00-1,02; 0,027). CONCLUSÃO: Etnia negra, doença cerebrovascular, hemopericárcio, operação de Cabrol, revascularização miocárdica simultânea, revisão de hemostasia e tempo de CEC associaram-se com risco aumentado de óbito hospitalar. Dor torácica associou-se com risco reduzido de óbito hospitalar. Uso de antifibrinolítico, complicação renal, complicação pulmonar, EuroScore e tempo de CEC associaram-se ao desfecho clínico composto hospitalar.

OBJECTIVES: The primary objective was to identify predictors of hospital mortality in patients undergoing aortic surgery. The secondary objective was to identify factors associated with clinical outcome composed hospital (death, bleeding, neurologic complications or ventricular dysfunction). METHODS: A cross-sectional design with longitudinal component. Through chart review, 257 patients were included. Inclusion criteria were: aortic dissection Stanford type A and ascending aortic aneurysm. Exclusion criteria were acute aortic dissection, of any kind, and no aortic aneurysm involving the ascending segment. Variables assessed: demographics, preoperative factors, intraoperative and postoperative. RESULTS: Variables with increased risk of hospital mortality (OR, 95% CI, P value): black ethnicity (6.8, 1.54-30.2; 0.04), cerebrovascular disease (10.5, 1.12-98.7; 0.04), hemopericardium (35.1, 3.73-330.2; 0.002), Cabrol operation (9.9, 1.47-66.36; 0.019), CABG simultaneous (4.4; 1.31 to 15.06; 0.017), bleeding (5.72, 1.29-25.29; 0.021) and cardiopulmonary bypass (CPB) time [min] (1.016; 1.0071.026; 0.001). Thoracic pain was associated with reduced risk of hospital death (0.27, 0.08-0.94, 0.04). Variables with increased risk of hospital clinical outcome compound were: use of antifibrinolytic (3.2, 1.65-6.27; 0.0006), renal complications (7.4, 1.52-36.0; 0.013), pulmonary complications (3.7, 1.58.8, 0.004), EuroScore (1.23; 1.08-1.41; 0.003) and CPB time [min] (1.01; 1.00 to 1.02; 0.027). CONCLUSION: Ethnicity black, cerebrovascular disease, hemopericardium, Cabrol operation, CABG simultaneous, hemostasis review and CPB time was associated with increased risk of hospital death. Chest pain was associated with reduced risk of hospital death. Use of antifibrinolytic, renal complications, pulmonary complications, EuroScore and CPB time were associated with clinical outcome hospital compound.

FUNDAMENTO: A grande diversidade de apresentações anatômicas encontradas em pacientes com endocardite infecciosa, especialmente nos que desenvolvem abscessos do anel aórtico ou fistulas intracardíacas, tem sido um complicador para o tratamento cirúrgico dessa doença. Por esse motivo, os cirurgiões têm desenvolvido opções táticas para sua correção. A consciência geral de que a retirada do tecido infectado promove uma limpeza radical, o aparecimento de colas biológicas que facilitam o fechamento dos abscessos e o surgimento de novos substitutos valvares melhoraram o resultado do tratamento. OBJETIVO: Demonstrar mais uma opção no tratamento do abscesso aórtico, para casos selecionados, tubo valvulado em posição infra-coronariana. MÉTODOS: Empreendemos a técnica em três pacientes: em dois, empregamos tubo valvulado com prótese mecânica, e em um, com prótese biológica. Dois pacientes necessitaram procedimentos associados com troca da valva mitral em um deles e plástica da valva tricúspide no outro. Todos eram reoperações de próteses em posição aórtica. RESULTADOS: A evolução cirúrgica e pós-operatória imediata foi satisfatória com os três recebendo alta da Unidade de Terapia Intensiva para o quarto. Um dos pacientes evoluiu para óbito durante a internação em razão de co-morbidades graves que já apresentava no pré-operatório, relacionadas a varizes de esôfago e comprometimento hepático. Os outros dois apresentam boa evolução no pós-operatório tardio. CONCLUSÃO: Acreditamos que essa opção seja mais uma alternativa para o tratamento de abscessos com grande comprometimento de estruturas do anel aórtico e da continuidade mitro-aórtica.

BACKGROUND: Patients with infective endocarditis show a large diversity of anatomical presentations, which has been a complicating factor for the surgical treatment of this condition, especially in those who develop abscesses in the aortic ring or intracardiac fistulae. For this reason, surgeons have been developing tactical options to repair it. There is consensus around the fact that the removal of infected tissue promotes radical cleaning, and that the outcome of the treatment has been improved by the manufacture of biological glues which facilitate the closure of abscesses and by the creation of new valve replacements. OBJECTIVE:To demonstrate yet one more treatment option for aortic abscess for selected cases: a valved conduit placed in infra-coronary position. METHODS: We employed the technique in three patients: in two of them we employed a valved conduit with a mechanical prosthesis and in one of them a valved conduit with a biological prosthesis. Two patients needed associated procedures such as replacement of mitral valve in one of them and tricuspid valvoplasty in the other. All cases involved reoperation of prostheses in aortic position. RESULTS: The progression during surgery and in the early postoperative period was satisfactory and the three patients were discharged from the Intensive Care Unit and were sent to hospital rooms. One of the patients progressed to death during hospital stay due to severe comorbidities which were present in the preoperative period, and which related to esophageal varices and hepatic involvement. The other two progressed well in the late postoperative period. CONCLUSION: We believe that this option is yet one more alternative for the treatment of abscesses with great involvement of aortic ring structures and mitro-aortic continuity.

OBJETIVO: Descrever a utilização de ambas artérias mamárias internas (MIs) em pacientes submetidos à operação de revascularização do miocárdio (RM), que sejam portadores de diabetes mellitus (DM). MÉTODO: No período compreendido entre janeiro de 1995 e agosto de 2005, 4.569 pacientes foram submetidos a RM em nossa instituição, sendo que 1.298 eram portadores de DM. A média de idade era de 62 anos, e a mortalidade global foi de 2,18% (100 pacientes). Ambas MIs foram empregadas em 700 pacientes, que foram divididos em dois grupos, portadores de DM (grupo I, com 148 pacientes) e não portadores de DM (grupo II, 552 pacientes). A seleção de pacientes para utilizar estes enxertos foi baseada nas características angiográficas das artérias coronárias e qualidade do esterno quando de sua transsecção. Quando ambos fatores eram considerados favoráveis, foram dissecadas ambas MIs, independente de o paciente ser portador ou não de DM. Durante a dissecção dos enxertos arteriais, tomava-se o cuidado de procurar manter as cavidades pleurais fechadas. RESULTADOS: Houve pouca variação entre os grupos de pacientes no tocante a morbidade e mortalidade. CONCLUSÃO: Nossos dados sugerem que pacientes portadores de DM podem se beneficiar do uso de ambas artérias MIs, com pouco acréscimo de risco quando sua aplicação for adequadamente indicada.

OBJECTIVE: We sought to describe the use of both internal mammary arteries (IMA) in patients with diabetes mellitus (DM) submitted to coronary artery bypass grafting (CABG). METHOD: Between January of 1995 to August of 2005, 4.569 patients received isolated CABG in our institution, of these, 1.298 had DM. Mean sample age was 62 years, and total mortality was 2.18% (100 patients). We have used both IMA's in 700 patients, that here are split in two groups, with DM (group I, 148 patients), and without DM (group II, 552 patients). Patient selection for double IMA grafting was based on coronary artery anatomy and sternal bone quality, the later was evaluated during sternal transsection. When these two factors were considered favorable, we harvested both IMA's, not mattering if the patient had or had not DM. During IMA's harvest, care was taken not to open the pleural spaces. RESULTS: There was small difference between the two groups in terms of morbidity and mortality. CONCLUSION: Our data suggest that patients with DM can benefit of double IMA's grafting, with little increase in risk for complications if its application is carefully indicated.

OBJETIVO: A aortoplastia trapezoidal é uma variante técnica da anastomose término-terminal que, amparada em elementos da geometria, objetiva aumentar o diâmetro da aorta ao nível da sutura reduzida e, consequentemente, a manutenção de gradientes pressóricos residuais ou recorrentes indesejáveis a curto e a longo prazo. MÉTODOS: Após a ressecção da área coarctada e tecido ductal, são confeccionados em cada coto aórtico 3 trapezóides que, ao serem confrontados, criam linha de sutura com aspecto sinusoidal (zigue-zague). Foram operados por esta técnica 33 pacientes, a maioria homens, com idades variando de 3 meses a 36 anos (m 9,5 ± 9,7). RESULTADOS: Não ocorreu mortalidade imediata ou tardia e o tempo de evolução a longo prazo foi de 1,1 a 7,6 anos (m 3,6 ± 3,4). A maioria dos pacientes ficou assintomática com níveis normais de pressão arterial, possibilitando a descontinuação da terapêutica antihipertensiva (p<0,0001). Constatou-se importante redução dos gradientes pressóricos observados ao ecodopplercardiograma e ao cateterismo cardíaco (p<0,001). A análise das imagens das aortografias mostrou boa continuidade anatômica na região da anastomose e o estudo morfométrico da aorta revelou efeitos benéficos do método traduzidos pelo aumento do calibre da aorta no segmento distal do arco, istmo e porção descendente. CONCLUSÃO: A aortoplastia trapezoidal mostrou resultados clínicos satisfatórios que autorizam sua aplicação em todos os casos de anastomose término-terminal indicados.

OBJECTIVE: Trapezoidal aortoplasty is a technical variant of end-to-end anastomosis, which, based on elements of geometry, aims at increasing the diameter of the aorta at the level of the suture, therefore reducing the occurrence of residual or recurrent pressure gradients in the short and long run. METHODS: After resecting the coarcted area and ductal tissue, 3 trapezoids are confected in each aortic stump, which, when confronted, create a suture line with a sinusoidal aspect (zigzag). Thirty-three patients underwent surgery with this technique, 22 (66.7%) males, with ages ranging from 3 months to 36 years (mean of 9.84 ± 9.69). RESULTS: No immediate or late deaths occurred. Follow-up ranged from 1.1 to 7.6 years (mean of 3.6 ± 3.4). Most patients became asymptomatic with normal blood pressure levels, enabling the discontinuation of antihypertensive therapy (P<0.0001). A significant reduction in the pressure gradients was observed on Doppler echocardiography and during cardiac catheterization (P<0.001). The analysis of the images of aortography showed good anatomical continuity in the region of the anastomosis, and the morphometric study of the aorta revealed the beneficial effects of the technique indicated by the increase in the caliber of the aorta in the distal segment of the arch, isthmus, and descending portion. CONCLUSION: Trapezoidal aortoplasty showed satisfactory clinical results that allow its application in all cases indicated for end-to-end anastomosis.

OBJETIVO: Avaliar a utilização de conduto extracardíaco na confecção de derivação cavopulmonar total nos diferentes tipos de cardiopatias complexas nas quais está indicado este tipo de correção. MÉTODO: Entre maio de 2000 e janeiro de 2003, foram operados 18 pacientes, 10 do sexo masculino, com idades entre 1 e 12 anos e peso variando de 11 a 29 quilos. O diagnóstico principal foi atresia tricúspide em oito pacientes, conexão atrioventricular univentricular em oito e defeito total do septo atrioventricular desbalanceado em dois. Apenas um paciente foi operado sem cirurgia paliativa prévia. A operação foi realizada com emprego de circulação extracorpórea com temperatura acima de 32ºC orofaríngea e sem isquemia aórtica. Foram empregados, entre a veia cava inferior e a circulação pulmonar, 10 tubos de PTFE, quatro de Hemashield e quatro de pericárdio bovino, com números variando de 16 a 22mm de diâmetro. RESULTADOS: Ocorreram quatro casos de trombose no tubo, todos reoperados, com um óbito. Em um paciente, após 69 dias da operação, foi realizado "takedown" para Glenn bidirecional. Entre os 18 pacientes ocorreram três óbitos, um por trombose do tubo e dois por síndrome de baixo débito no pós-operatório imediato. CONCLUSÃO: O emprego de tubo extracardíaco já faz parte da técnica de derivação cavopulmonar total, mas sua indicação merece cuidados especiais.

OBJECTIVE: This study evaluates a new technique of an extracardiac conduit in total cavopulmonary connection in complex congenital heart disease. METHODS: Between May 2000 and October 2002, 18 extracardiac conduit surgeries were performed. The patients' weights ranged from 11 to 29 kilograms, the ages ranged from 1 to 12 years old and 10 patients were male. There were eight patients with tricuspid atresia, eight with univentricular heart, and two with unbalanced total atrioventricular septal defect. There were 17 patients who had been submitted to a previous palliative surgery. The surgery was performed at over 32º centigrade without aortic ischemia. Ten PTFE, 4 Hemashield and 4 bovine pericardium tubes were used with diameters ranging from 16 to 22 mm. RESULTS: There were four cases of tube thrombosis and these patients were a reoperation was performed with one death. In one patient a takedown was performed on the 69th postoperative day. There were three deaths, one due to tube thrombosis and two due to low cardiac output. CONCLUSION: Extracardiac conduit is already used for total cavopulmonary connection, but despite encouraging early results, a longer follow-up is necessary to prove its real advantages.

CASUÍSTICA E MÉTODOS: Foram analisados, retrospectivamente, 80 transplantes cardíacos realizados no Instituto Dante Pazzanese de Cardiologia (IDPC) no período de novembro de 1991 a agosto de 2000. Houve predomínio do sexo masculino em 70% dos casos e a idade variou de 7 a 69 anos, com média de 44,8 anos. Doze (15%) pacientes se encontravam em prioridade, em uso de drogas inotrópicas endovenosas no momento do transplante. As etiologias determinantes da insuficiência cardíaca congestiva grave foram: miocardiopatia dilatada idiopática em 37,5%, miocardiopatia isquêmica em 33,75%, miocardiopatia chagásica em 17,5% e outras causas em 11,25%. Foram realizados 78 transplantes ortotópicos e 2 heterotópicos. A técnica empregada foi bicaval/bipulmonar em 63,75%, atrial em 27,5%, bicaval/unipulmonar em 6,25% e heterotópico em 2,5%. A mortalidade hospitalar (30 dias) foi de 18,75%. RESULTADOS: A sobrevida para o transplante ortotópico em um ano foi de 72,7%, em cinco anos 61,5% e em sete anos 56,4%. A sobrevida após o transplante foi correlacionada com as variáveis idade, causa de óbito e sexo do doador, e pelo transplante ter sido ou não a primeira cirurgia cardíaca do paciente.

From November 30, 1991 to August 31, 2000, 80 cardiac transplants have been analyzed retrospectively at Instituto Dante Pazzanese de Cardiologia. Seventy percent of the recipient were male, and the recipient average was 44.8 years(range: 7 to 69 years). Twelve patients(15%) were considered priority, receiving inotropic drug support at the moment of transplantation. The diagnosis of the recipients included primary dilated cardiomiopathy (37.5%), ischemic cardiomiopathy (33.75%), cardiomiopathy by Chagas disease (17.5% ) and others (11.25%). Seventy eight transplants were orthotopic, and two heterotopic. Surgical technique used was bicaval/bipulmonar (63.75%), atrial (27.5%), bicaval/unipulmonar (6.25%) and heterotopic (2.5%). The 30 day mortality for all patients was 18.75%. The survival after orthotopic transplant in one year was of 72.7%; in five years was 61.5%, and in seven years was of 56.4%. The survival after transplant was related to the following variables: age, cause of death and sex of the donor, and wheter the transplant was or not the patient's first cardiac surgery .

CASUÍSTICA E MÉTODOS: No período de novembro de 1996 a dezembro de 1997, 15 crianças portadoras de canal arterial (CA), sendo 12 do sexo feminino, com idade média de 2,7 anos, peso médio de 13,9 kg foram submetidas a fechamento do CA por minitoracotomia. O ecodopplercardiograma confirmou o diagnóstico em todos o casos e mostrou o diâmetro do CA entre 2 mm e 10 mm, com média de 4,06 mm. A indicação cirúrgica foi eletiva em todos os casos. A operação consistiu de minitoracotomia esquerda no 4º espaço intercostal de 2,5 cm a 3,0 cm, seguida de dissecção do CA e clipagem do mesmo com 2 clips metálicos. Não foi utilizada drenagem pleural em nenhum dos casos. RESULTADOS: Todos os pacientes receberam alta em média no 4º dia de pós-operatório, sem nenhum escape pelo CA ao ecodopplercardiograma. CONCLUSÃO: O fechamento de CA por minitoracotomia é uma alternativa de tratamento que reduz o período de internação, bom efeito cosmético e baixo índice de complicações.

OBJECTIVE:The purpose of this study was to describe a new technique for closure of patent ductus arteriosus (PDA) by minithoracotomy (2.5 a 3.0 cm) and clipping the PDA with titanium clips. MATERIAL AND METHODS: From November 1996 to December 1997, 15 children with PDA underwent surgical closure. The mean age at the time of operation was 2.7 years, mean weight was 13.9 kg. The procedure was through a left minithoracotomy at the 4º intercostal space. The ductus was identified, dissected and isolated. Interruption of ductal flow was performed by direct clipping with two clips. The chest was closed without a chest drain. Unless the patient was ventilator dependent before the closure, the child usually was extubated in the operating room. RESULTS: Color doppler echocardiography demonstrated total occlusion of the ductus in all patients. All 15 patients were discharged from the hospital on the 4º postoperative day (mean). CONCLUSION: We conclude that surgical closure of patent ductus arteriosus with minitoracotomy, without chest tube drainage can be accomplished safely and with low incidence of complications.

Há trinta anos tem sido empregada a técnica descrita por Lower e Shumway para o transplante cardíaco ortotópico, com bons resultados. Complicações, como estase venosa, formação de trombos, arritmias atriais e insuficiência das valvas tricúspide e mitral, estão presentes no pós-operatório tardio. A partir de 1995, passamos a utilizar a técnica bicaval em todos os casos (6 pacientes). Cinco eram do sexo masculino e a média de idades dos receptores era de 50,6 anos. A cardiomiopatia era dilatada e isquêmica em 2 casos cada, e chagásica e reumática nos demais. Três pacientes apresentavam operações prévias, sendo que um deles havia sido submetido a três operações de prótese valvar aórtica, o segundo a implante de marcapasso epimiocárdico definitivo, e o último a duas operações de revascularização do miocárdio associada a aneurismectomia de ventrículo esquerdo. A técnica cirúrgica consistiu, na maioria dos casos, na anastomose das veias pulmonares, em conjunto com o átrio esquerdo do coração a ser implantado e, a seguir, a da cava superior, inferior, do tronco pulmonar e aorta. Todos os doadores estavam em hospitais da cidade e com retirada múltipla de órgãos. Não tivemos óbito hospitalar e todos os pacientes estão vivos para um período de um a quinze meses de pós-operatório. Não houve diferença significativa quando se comparou as duas técnicas para o tempo de anóxia, tempo de C E C, tempo de implante, presença de taquiarritmias atriais, sangramento e permanência hospitalar. Houve diferença significativa (p<0,05) para a utilização de marcapasso temporário e presença de insuficiência tricúspide. Acreditamos que a técnica bicaval, além de reduzir o tamanho das cavidades atriais, é uma técnica simples, com índice menor de complicações e que poderá ser empregada com mais freqüência.

During almost 30 years the Lower and Shumway's technique for orthotopic heart transpantation has been performed with very good results. Complications like venous stasis, thrombus formation, atrial arrhythmias and also tricuspid and mitral regurgitation have been found in the late postoperative period. In 1995 we started to use the bicaval technique in all cases (6 patients). Five patients were male and the mean age was 50,6. Dilated and ischemic myocardiopathy was present in two cases in each group; Chagas' disease and rheumatic disease in others. Three patients had undergone prior surgeries; in one case three consecutive aortic valve replacement; in other one a definitive pacemaker implantation; and the last one had 2 myocardial revascularizations. The surgical technique in most cases consisted of the anastomoses of all the pulmonary veins with the left atrium of the donor followed by anastomoses of the superior and inferior vena cava, pulmonary artery and aorta. All donors were procured in city hospitals, and underwent multiple organ harvesting. There were no immediate postoperative deaths ; and at follow-up varying from 1 to 15 months all patients are alive. No significant differences in the both groups were observed for the anoxic time, extracorporeal circulation time, implantation time, atrial tachyarrhythmias, bleeding and the hospital discharge time. A significant difference was observed (p<0,05) for the temporary pacemaker utilized and for the tricuspid valve regurgitation. We believe that the bicaval technique besides reducing the atrial cavity, is a simple technique, with low complications and might be used more frequently.

Com o objetivo de evitar complicações de reestenose da aorta na evolução tardia dos pacientes submetidos ao tratamento cirúrgico da estenose supravalvar aórtica localizada, provocada por calcificação e enrijecimento de material protético utilizado para ampliação de um ou mais seios de Valsalva, com ou sem secção transversal da aorta, desenvolvemos, de outubro de 1991 a dezembro de 1995, uma modificação técnica, que, sem utilização de enxertos artificiais, apenas com tecido sadio da aorta ascendente, permite ampliação adequada da porção inicial da aorta. Neste período, foram operados 10 pacientes, com diagnóstico clínico e hemodinâmico de estenose supravalvar aórtica localizada. As idades variaram de 11 meses a 38 anos (m = 13,2 anos), o peso variou de 7,500 kg a 56 kg (m = 29,1 kg) e a altura variou de 72 cm a 1,68 m (m = 1,5 m). Seis pacientes eram do sexo masculino. Três eram assintomáticos, 4 tinham dispnéia, 2 cansaço aos esforços, 2 palpitações, 1 parestesia de membros inferiores e 1 cianose ao choro. Seis pacientes eram portadores de síndrome de Williams. O gradiente sistólico entre a cavidade livre do ventrículo esquerdo e aorta variou de 50 mmHg a 100 mmHg (m = 73,5). Os pacientes foram operados com auxílio de circulação extracorpórea, hipotermia moderada, cardioplegia cristalóide, nos 7 primeiros casos, e cardioplegia sangüínea nos 3 últimos. A aorta ascendente foi amplamente dissecada até os vasos da base. Após a transecção total da aorta e ressecção do tecido fibrótico estenosante, realizamos incisões longitudinais do bordo da porção proximal da aorta até o fundo dos seios de Valsalva; a seguir, foram feitas incisões longitudinais na porção distai, nas regiões correspondentes aos postes comissurais, de maneira que cada prolongamento da aorta distai ampliasse um fundo de seio de Valsalva, obtendo uma aorta inicial de aspecto anatômico e dimensões normais.Atualmente, com um período pós-operatório de 3 meses a 4 anos e 5 meses, não houve óbito; todos os pacientes estão assintomáticos, evoluindo satisfatoriamente, sem gradiente entre a cavidade livre do ventrículo esquerdo e aorta ascendente, conforme ecocardiograma, Doppler, ressonância nuclear magnética e estudo hemodinâmico. Estes resultados nos permitem concluir ser esta técnica adequada para a correção cirúrgica da estenose supravalvar aórtica localizada, por não utilizar enxertos artificiais e realizar a sutura da aorta em uma linha sinusoidal, evitando, assim, reestenose.

A technical modification in the surgery of supravalvar aortic stenosis has been developed since October 1991 to December 1995, without using artificial grafts, but only healthy tissue of the ascending aorta thus permitting a suitable enlargement of the aortic root. The aim of this technique is to avoid complications of re-estenosis of aortic root in the late evolution of patientes submitted to surgical treatment of localized supravalvar aortic stenosis which was provoked by calcification and hardening of prosthetic material used for the enlargement of one or more Valsalva sinuses, with or whitout transversal section of the aorta. Ten patients underwent a surgery in this meantime, with clinical and hemodynamic diagnosis of localized supravalvar aortic stenosis. Their ages varied from 11 months to 38 years (mean = 13.2 years), the weight varied from 7.500 kg to 56 kg (mean = 29.1 kg), and the height varied from 72 cm to 1.68 m (mean = 1.5 m). Six of these patients were male. Three of them were asymptomatic; 4 had dyspnea, 2 were tired at efforts, 2 had palpitations, 1 had paresthesia in the lower limbs, and 1 cyanosis at crying; 6 of them bore Williams syndrome. The systolic gradient between free cavity of left ventricle and aorta varied from 50 to 100 mmHg (mean = 73.5).The patients were operated on with extracorporeal circulation, moderate hypothermia, crystalloid cardioplegia in the 7 first cases and bloody cardioplegia in the 3 last ones. The ascending aorta was widely dissected till the supra-aortic vessels. After the aorta total transection and the resection of the stenosis f ibrotic tissue, longitudinal incisions were performed at the edge of the aortic proximal portion till the bottom of the Valsalva sinuses. Next to it, longitudinal incisions were performed in the distal portion, in the regions corresponding to the comissural points, in such a way that each stretching of the distal aorta may widen a bottom of Valsalva sinus, in this way obtaining an aortic root with an anatomic aspect and regular sizes. Presently, no death has occurred in a post-operative period from 3 months to 4 years and 5 months. All the patients are asymptomatic, having a satisfactory evolution, checked by Doppler Echocardiogram, Magnetic Nuclear Ressonance and Hemodynamic study. These results allow us to conclude that this technique is suitable to the surgical correction of the localized supravalvar aortic stenosis, by the point of not using artificial grafts and accomplishing the aorta suture in a sinusoidal line, avoiding reestenosis.