OBJETIVO: Revisar a experiência de correção de defeitos cardíacos congênitos por meio de minitoracotomias. MÉTODOS: No período de janeiro de 1998 a março de 2005, 98 pacientes foram submetidos a correção de defeitos congênitos simples, por meio de minitoracotomias, em nosso serviço. A idade variou de 14 meses a 16 anos (média de 4,6 anos), todos do sexo feminino e com peso variando de 8 kg a 58 kg (média de 20 kg). O diagnóstico incluiu defeito do septo atrial em 78 casos (seis associados com drenagem anômala das veias pulmonares parcial e quatro com estenose pulmonar valvar) e defeito do septo ventricular perimembranoso em 20. Todos tiveram confirmação do diagnóstico pela ecocardiografia, não necessitando de cateterismo cardíaco. Em 10 pacientes foi utilizada minitoracotomia submamária direita e em 88, minitoracotomia com esternotomia mediana parcial. RESULTADOS: Todos os defeitos foram corrigidos com sucesso, com exposição satisfatória. O tempo médio de circulação extracorpórea foi de oito a 30 minutos (média de 10 minutos) e o tempo de clampeamento aórtico, de cinco a 22 minutos (média de 12 minutos). Todos os pacientes foram extubados na sala de operação e o tempo médio de permanência hospitalar foi de três a sete dias (média de cinco dias). Não houve mortalidade operatória nem complicações pós-operatórias graves. Não foi observado nenhum defeito residual. CONCLUSÃO: Nossa experiência demonstrou que as minitoracotomias são tecnicamente possíveis, sendo procedimentos seguros e efetivos em alternativa à esternotomia mediana para correção de defeitos cardíacos congênitos simples e seletivos. As vantagens dessas abordagens incluíram menor dano e manutenção tanto da continuidade como da integridade do esterno, parcial ou total, prevenindo defeito do tipo peito de pombo pós-operatório. O resultado estético foi superior ao obtido por esternotomia mediana.

OBJECTIVE: To evaluate the repair of congenital heart defects through minithoracotomies. METHODS: Between January 1998 and March 2005, 98 patients underwent minithoracotomies for simple congenital heart defect repairs at our institution. All patients were female between the ages of 14 months and 16 years (mean 4.6) with weights ranging from 8 to 58 Kg (mean 20). Diagnoses included 78 cases of atrial septal defects (ASD) (six with associated partial anomalous pulmonary venous drainage and four with pulmonary valve stenosis) and 20 cases of perimembranous ventricular septal defects (PVSD). All diagnoses were confirmed with an echocardiogram; therefore, cardiac catheterization was not required. A right submammary minithoracotomy was performed on 10 patients and a minithoracotomy with a partial median sternotomy was performed on 88 patients. RESULTS: All defects were corrected successfully with satisfactory exposure. Cardiopulmonary bypass times ranged from 8 to 30 min (mean 10) and aortic clamping times ranged from 5 to 22 min (mean 12). All patients were extubated in the operating room and hospital stays ranged from 3 to 7 days (mean 5). There were no deaths during the operation or severe postoperative complications. No residual shunts were observed. CONCLUSION: Our study demonstrated that the minithoracotomy is a safe effective and technically viable alternative to a median sternotomy to correct selected simple congenital heart defects. The advantages of this approach include less trauma, partial or complete preservation of sternum continuity and integrity, and elimination of postoperative deformities such as pectus carinatum. The cosmetic outcome was superior to a median sternotomy.

OBJETIVO: Analisar os resultados iniciais da utilização do enxerto tubular orgânico, utilizados para anastomoses sistêmico-pulmonares. MÉTODOS: De março/2002 a abril/2003, 10 pacientes foram submetidos à realização de shunt sistêmico pulmonar tipo Blalock-Taussig modificado utilizando um novo tipo de enxerto biológico originado da artéria mesentérica bovina tratada com poliglicol denominado L-D-Hydro. A idade variou de 3 dias a 7 anos e 60% dos pacientes eram do sexo masculino. O diagnóstico das cardiopatias foi determinado pela ecocardiografia, todos apresentando sinais clínicos de hipóxia severa (cianose). As cardiopatias foram: tetralogia de Fallot (40%), atresia tricúspide (50%), defeito do septo atrioventricular (10%). RESULTADOS: Em 10 pacientes, ocorreu um óbito por sepse e em nove houve melhora imediata na saturação de O2 ao oxímetro de pulso e da pressão parcial de oxigênio à gasometria arterial. Nenhum paciente apresentou obstrução do shunt no pós-operatório imediato ou qualquer outra complicação. Todos os pacientes mostraram shunt pérvio ao exame ecocardiográfico no pós-operatório imediato e tardio, realizado no 3º mês de pós-operatório. Nenhum paciente apresentou sangramento no intra e pós-operatório. CONCLUSÃO: O enxerto tubular L-D-HYDRO demonstrou ser promissor para a realização de shunt sistêmico pulmonar, como alternativa para produtos inorgânicos existentes no mercado, entretanto, temos de ter maior número de implantes e acompanhamento tardio para uma avaliação definitiva.

OBJECTIVE: To analyze the initial results of the use of an organic tubular graft for systemic-pulmonary anastomoses. METHODS: From March 2002 to April 2003, 10 patients underwent systemic-pulmonary shunt of the modified Blalock-Taussig type, using a new type of biological graft originating from the bovine mesenteric artery treated with polyglycol, the so-called L-D-Hydro. The patients' ages ranged from 3 days to 7 years, and 60% of them were of the male sex. The diagnoses of heart disease were determined on echocardiography. All patients had clinical signs of severe hypoxia (cyanosis). The heart diseases were as follows: tetralogy of Fallot (40%), tricuspid atresia (50%), and atrioventricular septal defect (10%). RESULTS: One patient died due to sepsis and 9 had an immediate improvement in O2 saturation on pulse oximetry and in the partial oxygen pressure on arterial blood gas analysis. The intensive care unit length of stay ranged from 2 to 6 days. No patient had obstruction of the shunt on the immediate postoperative period or any other complication. All patients had a patent shunt on the echocardiographic studies performed in the immediate postoperative period and later, in the third postoperative month. No bleeding occurred during surgery or in the postoperative period. CONCLUSION: The tubular L-D-Hydro graft proved to be promising for performing systemic-pulmonary shunt as an alternative for the inorganic products available in the market, however, we need a greater number of implantations and late follow-up for definitive assessment.

The patient is a 54-year-old asymptomatic male with a tumor in the right atrium that was diagnosed on transesophageal echocardiography and confirmed as a lipoma of the right atrium on computerized tomography. The patient underwent surgical repair with extracorporeal circulation. The tumor was resected, and its base of implantation in the atrium was repaired with a flap of bovine pericardium. The diagnosis of lipoma was confirmed on histopathological examination. Locating of the tumor with the aid of transesophageal echocardiography was very useful in the strategy of cannulation of the venae cava for installation of the circuit of extracorporeal circulation. The patient had a good postoperative evolution.

OBJECTIVE: Left ventricular aneurysm is a complication of myocardial infarction that can best be treated by reconstructive surgeries that can restore ventricular geometry. We analyzed immediate results in a group of consecutive patients who underwent surgical correction of left ventricular aneurysms. METHODS: From January '90 to August '99, 94 patients - mean age 58.4 (ranging from 36 to 73 years), 65 (69.1%) males and 9 ( 30.8%) females - were operated upon. Pre-operative ejection fraction ranged from 0.22 to 0.58 (mean = 0.52), and the aneurysm was located in the antero-lateral area in 90.4% of the cases. Functional class III and IV (NYHA) was present in 82 (87.2%) patients, and 12 (12.7%) were in functional class I and II. Congestive heart failure was the most frequent cause (77.6%), occurring in isolation in 24.4% or associated with coronary artery diseases in 53.2%. RESULTS: Short-term follow-up showed a 7.4% mortality, and low cardiac output was the main cause of death. Coming off pump was uneventful in 73 patients (77.6%), with a 3.2% mortality and with the use of inotropics in 20 (21.3%). One patient (1%) did not come off the pump. CONCLUSION: Surgical correction was adequate in the immediate follow-up of operated patients, and mortality was higher in patients with higher functional class.

OBJETIVO: Atualmente existe uma tendência mundial para a realização de cirurgias através de incisões mínimas, denominadas minimamente invasivas, tornando o ato operatório cada vez menos agressivo. A introdução desta nova técnica possibilita a dissecção da artéria torácica interna esquerda (ATIE) e sua anastomose com a artéria interventricular anterior (AIA), através de uma minitoracotomia esquerda. MÉTODOS: De maio/96 a outubro/97, 11 portadores de insuficiência coronária, com lesão única e proximal da AIA, foram submetidos a revascularização do miocárdio (RM). A abordagem cirúrgica consistiu de uma toracotomia ântero-lateral esquerda, de aproximadamente 10cm, através do 4º espaço intercostal esquerdo, e nos últimos 6 casos com ressecção de parte da cartilagem da 4ª e 5ª costelas, dissecção da ATIE, abertura e reparo do pericárdio adjacente à AIA. Todos pacientes receberam ponte única para AIA com enxerto da ATIE, sem auxílio de circulação extracorpórea (CEC). RESULTADOS: A idade variou de 46 a 76 (média = 58,55) anos, sendo 10 (90,90%) pacientes do sexo masculino e 1 (9,09%) feminino. O tempo de permanência hospitalar variou de 4 a 8 (média de 5,2) dias. Nenhum paciente apresentou alteração eletrocardiográfica no pós-operatório imediato. Um paciente apresentou no controle, trombose no 1/3 distal da ATIE com comprometimento importante de fluxo e, outro, estenose ao nível da anastomose, sendo ambos submetidos a angioplastia com sucesso. Não houve mortalidade no grupo estudado. CONCLUSÃO: A ausência de mortalidade, sugere que a cirurgia de RM através de cirurgia minimamente invasiva, em grupos selecionados, é uma excelente alternativa de revascularização da AIA.

PURPOSE: There is, today, a global tendency towards a surgical approach privileging very small incisions, the so-called minimally invasive intervention, which results in a less aggressive action. The introduction of this new technique makes it possible to dissect the left internal thoracic artery (LITA) and to perform in the anastomosis with the anterior interventricular artery (AIA) through a left minithoracotomy. METHODS: From May of 1996 to october of 1997, 11 patients with ischemic heart disease and a single proximal lesion of the AIA were submitted to a myocardial revascularization (MR). The surgical approach consisted of a left anterolateral thoracotomy through the 4th left intercostal space, of approximatly 10cm, and in the last 6 cases, resection of part of the cartilage of the 4th and 5th ribs, dissection of the LITA, as well as opening and repair of the pericardium adjacent to the AIA was done. All patients received a single bypass to the AIA with a graft of the LITA, without extracorporeal circulation. RESULTS: The patients' age varied between 46 and 76 years (mean = 58,55). Ten patients (90,90%) were males and 1 (9,09%) was a female. Hospital stay ranged from 4 to 8 days, with the average of 5,2 days. None of the patients presented any electrocardiographic change in the immediate post-operatory period. During the control period one patient developed a clot in the distal LITA, with important compromise of the flow. In another patient the stenosis was at the level of the anastomosis. Both were successfully submitted to angioplasty. There were no deaths in the groups studied. CONCLUSION: The absence of deaths suggests to us that MR surgery carried out with this minimally invasive technique, in selected groups and is an excellent alternative to the revascularization of the AIA.

É relatada a retirada cirúrgica de trombos em próteses mecânicas em dois pacientes, manobra rara e inédita em nossa Instituição. O primeiro paciente, do sexo masculino, de 19 anos de idade, com história de doença reumática na infância, tendo sido submetido a duas duplas trocas mitro-aórticas, com duas próteses metálicas na última operação, realizada em 1988. Tendo descontinuado o uso de anticoagulantes por conta própria, deu entrada no pronto-socorro em edema agudo dos pulmões, com diagnóstico de trombose nas próteses. Foi levado ao centro cirúrgico, optando-se pela limpeza cirúrgica das próteses, diminuindo, desta forma, o tempo de circulação extracorpórea em paciente de extrema gravidade. Outra paciente, de 2 anos e 6 meses de idade, com diagnóstico de insuficiência mitral por degeneração mixomatosa, foi submetida a troca da valva mitral por prótese mecânica em 13/10/92. Apesar de bem anticoagulada, apresentou trombose da prótese e, no dia 12/1/93, foi submetida a trombectomia cirúrgica. Os dois pacientes apresentaram boa evolução pós-operatória, sendo que a segunda paciente, 3 meses após a trombectomia, apresentou nova trombose aguda, sendo administrada estreptoquinase, com sucesso. A trombectomia cirúrgica pode ser uma boa opção em pacientes com alto risco e portadores de trombose de próteses metálicas.

We report the surgical procedure which was adopted in two patients exhibiting thrombosis of mechanical prosthesis, a rare procedure and unprecedent in our Institution. A 19 years old male patient with a history of rheumatic fever in childhood, who had been submitted to two mitro-aortic substitutions, two metalic prostheses, having been introduced in the last surgery, which occurred in 1988. The patient, having of his own free will discontinued taking the anticoagulant, was admitted into the Emergency Department whith a condition of acute pulmonary oedema, with a diagnosis of thrombosis of the prosthesis. He was directed to the Surgical Centre where surgical depletion of the prosthesis was opted for, thus reducing the period of extracorporeal circulation of the patient in an extemely critical condition. Another patient, a two and a half years old female with a diagnosis of mitral insufficiency resulting from mixomatous degeneration, underwent mitral valve substitution for a mechanical prosthesis, on October 13, 1992. Despite satisfactory anticoagulation, the patient exhibited thrombosis of the prosthesis on January 12, 1993, and was also submitted to surgical thrombectomy. Both patients presented satisfactory pastoperative evolution. Three months following the thrombectomy, the second above mentioned patient exhibited a further acute thrombosis, which was followed by sucessful streptokinase. Surgical thrombectomy could be a satisfactory surgical option in high risk surgical patients exhibiting thrombi in metal prosthesis.