Abstract Introduction: Neuromonitoring (electroencephalogram [EEG] and cerebral oximetry) is essential for appropriate anesthesia and neuroprotection assessment during pediatric cardiac surgery. Methods: We describe the intraoperative pediatric multimodal and multiparametric neuromonitoring pattern of the software system Neuron-Spectrum (Kandel®) that consists of continuous electroencephalogram (cEEG), spectral analysis, amplitude-integrated electroencephalogram (aEEG), depth of anesthesia monitor (NINDEX), and regional cerebral and somatic oximetry (near-infrared spectroscopy-INVOS™). A physiological algorithm for management using neuromonitoring and physiological data is also described. Results: Visual data examples are presented for interpretation of the cerebral perfusion and oxygenation, neurophysiological state, anesthesia depth, possible neurologic predictions, and identification of cerebral drug effects (EEG signature). Conclusion: The neuromonitoring model can be an effective tool for anesthesia control and to provide adequate cerebral oxygenation during surgery.

Abstract Atrial septal aneurysm (ASA) is an uncommon but well-recognized cardiac abnormality. This educational text reviews the case of a 54-year-old female presenting an ASA related to a small ostium secundum atrial septal defect. The considerable signs and symptoms, interestingly, have not been justified by the clinical and hemodynamic investigations. So, we opted for a better imaging investigation with cardiac catheterization and transesophageal echocardiography. The surgical process was earlier indicated and performed with aid of cardiopulmonary bypass. (ASA wellrecognized well recognized abnormality 54yearold yearold 54 year old defect symptoms interestingly investigations So echocardiography bypass 5

Abstract This article describes our proposal for routine anesthesia, intraoperative medical management, cerebral and physiological monitoring during pediatric cardiac surgery with cardiopulmonary bypass that intend to provide appropriate anesthesia (analgesia, hypnosis), neuroprotection, adequate cerebral and systemic oxygen supply, and preventing against drugs neurotoxicity. A concise retrospective data is presented.

Abstract Nonvalvular atrial fibrillation is associated with a 4- to 5-fold strokes increase and may be responsible for 15% to 20% of all strokes in the elderly. In this scenario, the left atrial appendage thrombus would be the associated with 90% of cases. The use of anticoagulants, percutaneous devices, and the left atrial appendage surgical exclusion is still an open discussion. For left atrial appendage procedures, relevant anatomic spatial relationships have to be emphasized, besides the chance of the normal physiological functioning would be eliminated with the proceedings. There are evidences that the left atrial appendage closure during routine cardiac surgery is significantly associated with an increased risk of early postoperative atrial fibrillation. Therefore, the purpose of this review is to focus basic aspects for continuous medical education. In summary, the rationale of this text is to emphasize anatomical and pharmacological aspects involved in the simple surgical exclusion of left atrial appendage under cardiopulmonary bypass. There are several operative techniques, but to conclude this revision it will present one of them based on the discussed basic sciences.

Abstract Scientific progress shall ultimately boost the current acceptance level for conservative aortic valve surgery. The present text aimed to report the 23-year long-term follow-up of one patient operated with bovine pericardium cusp extension. Growing confidence in the efficacy of the operation will allow a more expeditious indication for surgical treatment, as is already the case in mitral valve repair. This change of attitude will certainly make it possible for patients to be sent for operation in mild aortic valve regurgitation. The present report reinforces the concept and highlights the impression that the aortic valvoplasty, independent of the progressive bovine pericardium degeneration, may positively change the natural history of the aortic valve insufficiency.

ABSTRACT Objective: To examine if methylene blue (MB) can counteract or prevent protamine (P) cardiovascular effects. Methods: The protocol included five heparinized pig groups: Group Sham -without any drug; Group MB - MB 3 mg/kg infusion; Group P - protamine; Group P/MB - MB after protamine; Group MB/P - MB before protamine. Nitric oxide levels were obtained by the nitric oxide/ozone chemiluminescence method, performed using the Nitric Oxide Analizer 280i (Sievers, Boulder, CO, USA). Malondialdehyde plasma levels were estimated using the thiobarbiturate technique. Results: 1) Groups Sham and MB presented unchanged parameters; 2) Group P - a) Intravenous protamine infusion caused mean arterial pressure decrease and recovery trend after 25-30 minutes, b) Cardiac output decreased and remained stable until the end of protamine injection, and c) Sustained systemic vascular resistance increased until the end of protamine injection; 3) Methylene blue infusion after protamine (Group P/MB) - a) Marked mean arterial pressure decreased after protamine, but recovery after methylene blue injection, b) Cardiac output decreased after protamine infusion, recovering after methylene blue infusion, and c) Sustained systemic vascular resistance increased after protamine infusion and methylene blue injections; 4) Methylene blue infusion before protamine (Group MB/P) - a) Mean arterial pressure decrease was less severe with rapid recovery, b) After methylene blue, there was a progressive cardiac output increase up to protamine injection, when cardiac output decreased, and c) Sustained systemic vascular resistance decreased after protamine, followed by immediate Sustained systemic vascular resistance increase; 5) Plasma nitrite/nitrate and malondialdehyde values did not differ among the experimental groups. Conclusion: Reviewing these experimental results and our clinical experience, we suggest methylene blue safely prevents and treats hemodynamic protamine complications, from the endothelium function point of view.

Objetivo: O presente estudo foi realizado com a finalidade de reavaliar conceitos estabelecidos em 20 anos, com ênfase nos últimos 5 anos, sobre a utilização do azul de metileno no tratamento da síndrome vasoplégica em cirurgia cardíaca. Métodos: Foram considerados dados da literatura utilizando-se três bases de dados (MEDLINE, SCOPUS e ISI Web of Science). Resultados: Os conceitos reavaliados e reafirmados foram: 1) Nas doses recomendadas o AM é seguro (a dose letal é de 40 mg/kg); 2) O AM não causa disfunção endotelial; 3) O efeito do AM só aparece em caso de supra nivelamento do NO; 4) O AM não é um vasoconstritor, pelo bloqueio da via GMPc ele libera a via do AMPc, facilitando o efeito vasoconstritor da norepinefrina; 5) A dosagem mais utilizada é de 2 mg/kg, como bolus EV, seguida de infusão contínua porque as concentrações plasmáticas decaem fortemente nos primeiros 40 minutos, e; 6) Existe uma "janela de oportunidade" precoce para efetividade do AM. Nos últimos cinco anos, os principais desafios foram: 1) Observações de efeitos colaterais; 2) A necessidade de diretrizes, e; 3) A necessidade da determinação de uma janela terapêutica para o uso do AM em humanos. Conclusão: O efeito do AM no tratamento da SV é dependente do tempo, portanto, o grande desafio atual é a necessidade do estabelecimento da janela terapêutica do AM em humanos. Esse seria o primeiro passo para a sistematização de uma diretriz a ser seguida por possíveis estudos multicêntricos.

Objective: This study was conducted to reassess the concepts established over the past 20 years, in particular in the last 5 years, about the use of methylene blue in the treatment of vasoplegic syndrome in cardiac surgery. Methods: A wide literature review was carried out using the data extracted from: MEDLINE, SCOPUS and ISI WEB OF SCIENCE. Results: The reassessed and reaffirmed concepts were 1) MB is safe in the recommended doses (the lethal dose is 40 mg/kg); 2) MB does not cause endothelial dysfunction; 3) The MB effect appears in cases of NO up-regulation; 4) MB is not a vasoconstrictor, by blocking the cGMP pathway it releases the cAMP pathway, facilitating the norepinephrine vasoconstrictor effect; 5) The most used dosage is 2 mg/kg as IV bolus, followed by the same continuous infusion because plasma concentrations sharply decrease in the first 40 minutes; and 6) There is a possible "window of opportunity" for MB's effectiveness. In the last five years, major challenges were: 1) Observations about side effects; 2) The need for prophylactic and therapeutic guidelines, and; 3) The need for the establishment of the MB therapeutic window in humans. Conclusion: MB action to treat vasoplegic syndrome is time-dependent. Therefore, the great challenge is the need, for the establishment the MB therapeutic window in humans. This would be the first step towards a systematic guideline to be followed by possible multicenter studies.

Objetivo: Apresentar uma variante técnica para correção de aneurismas do ventrículo. Métodos: Após anestesia geral, circulação extracorpórea e proteção miocárdica com cardioplegia sanguínea tépida hiperpotassêmica: 1) O ventrículo esquerdo é aberto através da área de infarto e procede-se a uma cerclagem do endocárdio (polipropileno 2-0) em torno da zona de transição entre a cicatriz e tecido normal; 2) No passo seguinte, o tecido cicatricial é circularmente plicado com pontos grosseiros e profundos, utilizando o mesmo fio de sutura, tomando cuidado para eliminar toda a cicatriz septal; 3) A seguir, uma segunda cerclagem completa a oclusão do aneurisma, e; 4) Finalmente, o tecido cicatricial restante é submetido a uma sutura invaginante para garantir a hemostasia. Terminada a correção do aneurisma, realiza-se a revascularização do miocárdio. Todos os pacientes foram operados pelo mesmo cirurgião. Resultados: Em relação ao tempo de evolução pós-cirúrgica 4 pacientes (40%) superaram o tempo de 8 anos, 2 pacientes (20%) foram operados há mais de 6 anos e 1 paciente (10%) foi operado há mais de 5 anos. Três pacientes estão em classe funcional I (30%), 2 pacientes em classe II (20%) e 2 em classe III (20%) da NYHA. Ocorreram 3 óbitos (30%) em curto prazo (4 dias, 15 dias e 8 meses) em pacientes septuagenários, infarto agudo do miocárdio menos de 30 dias, diabetes e enfisema pulmonar. Conclusão: A técnica é segura, tecnicamente fácil, e pode ser uma opção para a correção de aneurismas do ventrículo esquerdo.

Objective: To present a surgical variant technique to repair left ventricular aneurysms. Methods: After anesthesia, cardiopulmonary bypass, and myocardial protection with hyperkalemic tepic blood cardioplegia: 1) The left ventricle is opened through the infarct and an endocardial encircling suture is placed at the transitional zone between the scarred and normal tissue; 2) Next, the scar tissue is circumferentially plicated with deep stitches using the same suture thread, taking care to eliminate the entire septal scar; 3) Then, a second encircling suture is placed, completing the occlusion of the aneurysm, and; 4) Finally, the remaining scar tissue is oversewn with an invaginating suture, to ensure hemostasis. Myocardium revascularization is performed after correction of the left ventricle aneurysm. The same surgeon performed all the operations. Results: Regarding the post-surgical outcome 4 patients (40%) had surgery 8 eight years ago, 2 patients (20%) were operated on over 6 years ago, and 1 patient (10%) was operated on more than 5 years ago. Three patients (30%) were in functional class I, class II in 2 patients (20%) and 2 patients (20%) with severe comorbidities remains in class III of the NYHA. There were three deaths (at four days, 15 days and eight months) in septuagenarians with acute myocardial infarction, diabetes and pulmonary emphysema. Conclusion: The technique is easy to perform, safe and it can be an option for the correction of left ventricle aneurysms.

Vivenciamos a experiência de reoperar uma paciente por estenose degenerativa de uma prótese biológica de pericárdio bovino, após 24 anos de implante. Essa prótese degenerada havia sido implantada devido à destruição da valva tricúspide por endocardite bacteriana estafilocócica após aborto séptico.

We were challenged by the experience of one patient reoperation for a bioprosthetic bovine pericardium degenerative stenosis, 24 years after implantation. This bioprosthesis was implanted due to tricuspid valve bacterial staphylococcal endocarditis after septic abortion.

OBJETIVO: Verificar se a administração de azul de metileno (AM) previne e/ou reverte o choque anafilático induzido por composto 48/80 (C48/80) em suínos. MÉTODOS: Porcos fêmeas Dalland foram anestesiados e tiveram os parâmetros hemodinâmicos registados durante o tempo necessário para administrar algumas drogas e observar seu efeito. Os animais foram aleatoriamente destribuídos em um dos cinco grupos: 1) controle, 2) AM: os animais receberam uma injeção em bolus de AM (2mg/kg), seguido de infusão contínua de AM (2,66mg/Kg /h por bomba de infusão de seringa); 3) C48/80: os animais receberam uma injeção em bolus de C48/80 (4mg/kg); 4) C48/80 + AM: os animais receberam uma injeção em bolus de C48/80 (4mg/kg) e 10 minutos após a administração de C48/80 os animais receberam uma injeção em bolus de AM (2mg/kg), seguido de infusão contínua de AM (2,66mg/kg/h por bomba de infusão de seringa); 5) AM+C48/80: os animais receberam uma injeção em bolus de AM (2mg/kg) e três minutos depois, receberam uma injeção em bolus de C48/80 (4mg/kg). RESULTADOS: A infusão intravenosa de AM não causou mudanças na pressão arterial média (PAM), mostrando que a dose de AM administrada foi segura neste modelo experimental. O C48/80 foi eficaz na indução do choque anafilático experimental, uma vez que foi observada redução na PAM e débito cardíaco (DC), após a sua administração. O AM não preveniu ou reverte o choque anafilático induzido por C48/80 neste modelo. Na verdade, a PAM dos animais com choque anafilático tratados com AM diminuiu mais do que o PAM dos animais do grupo C48/80. Por outro lado, as alterações epidérmicas induzidas pelo C48/80 desapareceu após a infusão do AM. CONCLUSÃO: Apesar dos resultados a melhora clínica das manifestações anafiláticas permite considerar a possibilidade do azul de metileno como opção terapêutica no tratamento do choque anafilático.

PURPOSE: To verify if the methylene blue (MB) administration prevents and/or reverses the compound 48/80 (C48/80)-induced anaphylactic shock in pigs. METHODS: Female Dalland pigs were anesthetized and had the hemodynamic parameters recorded during the necessary time to administer some drugs and observe their effect. The animals were randomly assigned to one of the five groups: 1) control; 2) MB: the animals received a bolus injection of MB (2 mg/kg) followed by continuous infusion of MB (2.66 mg/Kg/h delivered by syringe infusion pump); 3) C48/80: the animals received a bolus injection of C48/80 (4 mg/kg); 4) C48/80+MB: the animals received a bolus injection of C48/80 (4 mg/kg) and 10 minutes after the C48/80 administration the animals received a bolus injection of MB (2 mg/kg) followed by continuous infusion of MB (2.66 mg/Kg/h delivered by syringe infusion pump); 5) MB+C48/80: the animals received a bolus injection of MB (2 mg/kg) and 3 minutes later they received a bolus injection of C48/80 (4 mg/kg). RESULTS: The intravenous infusion of MB alone caused no changes in the mean arterial pressure (MAP) showing that the administered MB dose was safe in this experimental model. The C48/80 was effective in producing experimental anaphylactic shock since it was observed a decrease in both MAP and cardiac output (CO) after its administration. The MB did not prevent or reverse the C48/80-induced anaphylactic shock in this model. In fact, the MAP of the animals with anaphylactic shock treated with MB decreased even more than the MAP of the animals from the C48/80 group. On the other hand, the C48/80-induced epidermal alterations disappeared after the MB infusion. CONCLUSION: Despite our data, the clinical manifestations improvement brings some optimism and does not allow excluding the MB as a possible therapeutic option in the anaphylactic shock.

OBJETIVO: Existem fortes evidências de que o azul de metileno (AM), um inibidor da guanilato ciclase, é uma excelente opção terapêutica para o tratamento da síndrome vasoplégica (SV) em cirurgia cardíaca. O objetivo deste artigo é rever o papel terapêutico do AM no tratamento da SV. MÉTODOS: Revisão da literatura em período de 15 anos. RESULTADOS: 1) A heparina e inibidores da ECA são fatores de risco; 2) Nas doses preconizadas é droga segura (a dose letal é de 40 mg/kg); 3) O AM não causa disfunção endotelial; 4) O efeito do AM só aparece em caso de supra-regulação de óxido nítrico (NO); 5) O AM não é um vasoconstritor, pelo bloqueio do sistema GMPc ele "libera" o sistema AMPc, facilitando o efeito vasoconstritor da noradrenalina; 6) A dosagem mais utilizada é 2 mg/kg em bolus endovenosa, seguida de infusão contínua, pois a concentração plasmática decai acentuadamente nos primeiros 40 minutos; 7) Existe possível "janela de oportunidade" para efetividade do AM. CONCLUSÃO: Embora não existam estudos multicêntricos definitivos, a utilização do AM no tratamento da SV em cirurgia cardíaca é, na atualidade, a melhor, mais segura e barata opção, sendo contribuição brasileira

OBJECTIVE: There is strong evidence that methylene blue (MB), an inhibitor of guanylate cyclase, is an excellent therapeutic option for vasoplegic syndrome (VS) treatment in heart surgery. The aim of this article is to review the MB's therapeutic function in the vasoplegic syndrome treatment. METHODS: Fifteen years of literature review. RESULTS: 1) Heparin and ACE inhibitors are risk factors; 2) In the recommended doses it is safe (the lethal dose is 40 mg/kg); 3) The use of MB does not cause endothelial dysfunction; 4) The MB effect appears in cases of nitric oxide (NO) up-regulation; 5) MB is not a vasoconstrictor, by blocking of the GMPc system it releases the AMPc system, facilitating the norepinephrine vasoconstrictor effect; 6) The most used dosage is 2 mg/kg as IV bolus followed by the same continuous infusion because plasmatic concentrations strongly decays in the first 40 minutes; 7) There is a possible "window of opportunity" for the MB's effectiveness. CONCLUSIONS: Although there are no definitive multicentric studies, the MB used to treat heart surgery VS, at the present time, is the best, safest and cheapest option, being a Brazilian contribution for the heart surgery

OBJETIVO: Benefícios clínicos obtidos pelo azul de metileno (AM) no tratamento da vasoplegia induzida pela ação do óxido nítrico (NO) têm sido relatados na sepse, na síndrome da resposta inflamatória sistêmica (SIRS) em cirurgia cardíaca e no choque anafilático, mas a sua segurança é muitas vezes questionada, principalmente relacionada aos seus efeitos hemodinâmicos e à possibilidade de causar disfunção endotelial. O objetivo deste estudo foi examinar os efeitos hemodinâmicos e a função endotelial da infusão endovenosa in vivo do AM em porcos. MÉTODOS: O protocolo de estudo incluiu dois grupos experimentais de porcas fêmeas: Grupo I (Controle) - os animais (n = 6) não receberam AM; Grupo II (AM) - os animais receberam 3 mg/kg de AM em forma de bolus endovenoso. Após quinze minutos de registro dos parâmetros hemodinâmicos os animais foram sacrificados por exsangüinação, e os estudos in vitro foram conduzidos usando segmentos de artérias coronária, hepática, mesentérica superior, renal, para determinar o efeito do AM na função endotelial relacionada com a liberação de NO. Mediu-se também o NO plasmático nos dois grupos experimentais. RESULTADOS: Os resultados obtidos no presente estudo foram: 1) a infusão endovenosa de AM (3,0 mg/kg) não causou nenhuma alteração hemodinâmica significativa; 2) os valores absolutos e porcentuais e nitrito/nitrato plasmático (NOx) não apresentaram diferenças nos dois grupos experimentais; 3) o estudo in vitro dos segmentos arteriais (coronária, hepática, renal e mesentérica superior) não apresentou disfunção endotelial nos dois grupos. Os resultados sugerem que a injeção endovenosa de AM é segura. Esse dado concorda com dados clínicos no qual o AM foi utilizado para tratar a síndrome vasoplégica após circulação extracorpórea, síndrome da resposta infamatória sistêmica (SIRS) e anafilaxia. Os resultados não foram inesperados porque os animais não apresentavam vasoplegia, não se esperando que a inibição da guanilatociclase tenha algum efeito. CONCLUSÃO: A infusão em bolus endovenoso in vivo na dose investigada (3 mg/kg) não causou alterações hemodinâmicas e comprometimento da liberação in vitro de NO.

OBJECTIVE: Clinical benefit of methylene blue (MB) treating NO-induced vasoplegia has been reported in sepsis, systemic inflammatory response syndrome (SIRS) in cardiac surgery and anaphylactic shock, but its safety is sometimes questioned, mainly regarding its hemodynamic effects and the possibility of causing endothelium dysfunction. To examine the nitric oxide plasma levels and cardiovascular effects of the infusion of MB in vivo and its effects on endothelium-dependent and endothelium-independent in vitro vascular relaxation. METHODS: The study protocol included two experimental groups of female pigs: Group I (Control) - the animals (n=6) did not receive MB; Group II (MB) - the animals received 3 mg/kg of MB intravenous bolus infusion. After fifteen minutes of hemodynamic parameter recording the animals were sacrificed by exsanguination, and in vitro studies were conducted using segments of coronary, hepatic, superior mesenteric and renal arteries, to determine the effect of MB on the arterial endothelium function with regard to NO release. Nitric oxide plasma levels (NOx) were measured in each of the experimental groups. RESULTS: The results obtained in the present investigation were: 1) intravenous infusion of MB (3.0 mg/kg) caused no hemodynamic changes; 2) absolute and percent plasma NOx values did not differ between the experimental groups; and 3) in vitro study of vascular relaxation showed no significant difference between groups. These results show that MB intravenous infusion seems to be safe. This finding agrees with data from clinical experiments where MB was used to treat vasoplegic syndrome after cardiopulmonary bypass, systemic inflammatory response syndrome (SIRS) and anaphylaxis. These results were not unexpected because, as in healthy subjects, hemodynamics is only fine tuned and not fully under NO control; therefore, MB inhibiting guanylyl cyclase is not expected to do anything. CONCLUSION: Intravenous use of MB, at the investigated dose, did not cause any abnormal hemodynamic responses or impairment of endothelium-dependent relaxation.

Apresenta-se o caso de uma mulher, 44 anos, diabética, fumante crônica, em uso de anticoncepcional, com história prévia de possível isquemia cerebral. Foi atendida no departamento de emergências com infarto agudo do miocárdio. A coronariografia mostrou artérias coronárias normais com oclusão distal da artéria circunflexa. A aortografia e o ecocardiograma transesofágico revelaram uma estrutura pedunculada móvel, flutuante, aderida à parede posterior da aorta ascendente, a qual foi cirurgicamente ressecada. Tinha aspecto macroscópico de trombo recente confirmado pelo exame histológico. A paciente teve alta hospitalar em uso de anticoagulante.

We report the case of a 44-year-old diabetic woman who was a smoker using synthetic progestagen, with previous history of suspected thrombotic cerebral ischemia. She was admitted with clinical evidence of acute myocardial infarction. A coronary angiogram showed normal coronary arteries and distal occlusion of the left circumflex coronary artery. An ascending aorta angiogram and transesophageal echocardiography revealed a free floating mass attached to the aortic wall. The pedunculated thrombotic mass was surgically removed. Histological examination of the resected structure confirmed the macroscopic findings and revealed a recent thrombus. The patient was prescribed oral anticoagulant and released from hospital.

A case of left atrial myxoma is reported in a 14-year-old female patient with recurrent episodes of syncope. The patient was immediately referred to the cardiologist after an inconclusive neurological investigation. Syncope is a symptom thoroughly described as being associated with heart myxomas, but its specific association with adolescence is extremely rare. The authors discuss the clinical manifestations of the disease, emphasizing the diagnostic difficulties on the basis of the unspecific symptoms. As part of the analysis a Brazilian literature review was carried out. Also, the authors experience in the surgical treatment of the heart tumors is briefly presented.