Implante transcateter de valva aórtica sem a necessidade de marca-passo definitivo em uma série de casos consecutivos: é possível predizer o risco de bloqueio atrioventricular? / Transcatheter aortic valve implantatation without permanent pacemacker in a series of consecutive cases: is it possible to predict the risk of atrioventricular block?

Introdução: Embora os stents farmacológicos tenham reduzido de forma inconteste o crescimento neointimal e sua consequência clínica direta, a reestenose, questionamentos acerca de sua segurança a longo prazo têm motivado o desenvolvimento de novas tecnologias. A aplicação sistêmica de fármacos antiproliferativos teria o potencial de solucionar o problema da reestenose e ao mesmo tempo amenizar a questão da segurança tardia inerente aos polímeros sintéticos. Recentemente, estudo investigando a administração intravenosa de uma solução de paclitaxel ligado à albumina (ABI-007) produziu efeito discreto na redução da formação de tecido neointimal. Este trabalho teve como objetivo avaliar, por meio da angiografia e do ultrassom intracoronário (USIC) seriados, a efetividade da aplicação intracoronária do ABI-007 na supressão da hiperplasia neointimal após implante de stents não-farmacológicos. Método: Entre novembro de 2006 e maio de 2007, pacientes portadores de lesões coronárias de novo, com extensão < 18 mm, em vasos nativos de 2,5 mm a 3,5 mm de diâmetro, foram submetidos a intervenção coronária percutânea com implante de stents não-farmacológicos, seguida de injeção intracoronária de 70 mg/m² de ABI-007. Avaliação com angiografia e USIC foi programada para todos os pacientes imediatamente após o procedimento e aos seis meses de seguimento. Desfecho primário era a perda luminal tardia (QCA) e o porcentual de obstrução volumétrica gerado pela hiperplasia neointimal (USIC) aos seis meses...

Background: Transcatheter aortic valve implantation (TAVI) is increasingly reported as a valid alternative therapeutic option for patients with aortic valve stenosis with highsurgical risk. Although effective and relatively safe, TAVI is currently associated to the need of permanent pacemaker in 20% to 30% of the cases, with a number of predictors of this complication already described in the literature. Method: We report a series of 8 consecutive patients with aortic stenosis treated with TAVI (Corevalve Revalving, Medtronic Inc., USA). Results: The study population had ahigh surgical risk (on average, STS Score = 22.9% and EuroSCORE = 27.2%). All cases presented at least onehigh-risk predictor for post-procedure high grade atrioventricular block. The interventional procedure was successfully accomplished in all but one patient who presented a cardiac tamponade and in-hospital death. The transaortic pressure gradient was reduced from 91.3 ± 26.9 mmHg to19.4 ± 6.3 mmHg. After hospital discharge, the follow-up time ranged from 4 weeks to 12 months. During follow-up, there were no deaths and none of the patients had a new 2nd or 3rd degree atrioventricular block and permanent pacemaker was not required in any of the cases. Conclusion: Although the lack of a permanent pacemaker in the study population may have occurred by chance, our initial experience suggests that the need of pacemaker following TAVI is not readily predictable with the currently described high-risk predictors.

Mini-sternotomy for the treatment of aortic valve lesions

OBJECTIVE: To compare inverted-L mini-sternotomy performed above the sternal furcula with conventional sternotomy in patients with aortic valve diseases who undergo surgical treatment. METHODS: We operated upon 30 patients who had aortic valve lesions that had clinical and hemodynamic findings. All patients underwent inverted-L sternotomy, which extended from above the manubrium of the sternum to the 3rd right intercostal space, without opening the pleural cavity. Their ages ranged from 32 to 76 years, and 18 were males and 12 were females. We used negative pressure in a venous »-inch cannula, and the patients were maintained in Trendelemburg's position. Twenty-seven patients received bioprostheses with diameters ranging from 23 to 29mm. Three patients underwent only removal of the calcifications of the aortic valve leaflets and aortic commissurotomy. RESULTS: The mean duration of anoxic cardiac arrest was 63.11min. Access was considered good in all patients. One death was due to pulmonary and renal problems not related to the incision. All patients had a better recovery in the intensive care unit, got out of bed sooner, coughed more easily, and performed prophylactic physiotherapeutic maneuvers for respiratory problems more easily and with less pain in the incision. Early ambulation was more easily carried out by all patients. CONCLUSION: Mini-sternotomy proved to be better than the conventional sternotomy because it provided morecomfort for the patients in the early postoperative period, with less pain and greater desire for early ambulation and all its inherent advantages

Resultados da cirurgia da estenose aórtica em pacientes com disfunção ventricular grave / Results of Aortic Valve Surgery in Patients with Severe Left Ventricular Dysfunction

PURPOSE: To study the short and long term clinical course of patients with severe aortic stenosis after surgical treatment of the valvular lesion. METHODS: Thirty survivors among 31 consecutive patients with severe left ventricular dysfunction (LVD) due to aortic stenosis (AS) were submitted to clinical and echocardiographic follow-up during a mean of 30 months after surgical treatment of the valvular lesion. Twenty five (83.3) patients were male with a mean age of 50 years (25 to 74). Before operation the following parameters were obtained: diastolic left ventricular diameter (DLVD), shortening fraction (SF), left ventricular ejection fraction (LVEF), aortic valve area (AVA), left ventricular-aortic pressure gradient (PG) and NYHA functional class (FC). During the follow up, after the surgical procedure, FC, DLVD, LVEF and SF could be analysed and compared with previous data. RESULTS: A significant rise in SF (p = 0.001) and LVEF (p = 0.0001), as well as a decrease in DLVD (p = 0.001) were observed in the follow up. Symptoms lessened in severity in the majority of patients. Three of our patients died with progressive LVD and heart failure, after at least 36 months of follow-up. These results indicate that when operation is carried out in patients with AS and left ventricular failure, a significant improvement in left ventricular function and in symptoms takes place. Although the risk of surgical treatment is increased in this group of patients, LVD should not be considered a contraindication to the procedure. CONCLUSION: The left ventricular dysfunction is not a contraindiction for the surgical treatment of the aortic stenosis.

Objetivo - Estudar a evolução imediata e tardia de portadores de estenose aórtica, com disfunção ventricular grave submetidos à cirurgia. Métodos - Estudamos clínica e ecodopplercardio graficamente, por período médio de 30 meses, a evolução pós-operatória de 30 sobreviventes dentre 31 pacientes (mortalidade imediata 3,2%) com estenose aórtica e disfunção grave de ventrículo esquerdo (VE) submetidos consecutivamente à troca valvar aórtica. A idade média foi de 50 (25 a 74) anos, sendo 25 (83,3%) do sexo masculino. A comparação pré e pós-operatória compreendeu fundamentalmente a análise do ∆ D%, diâmetro diastólico do ventrículo esquerdo (DDVE) e classe funcional (CF) de insuficiência cardíaca. No pré-operatório foram analisados também a área valvar aórtica (AVA) e o gradiente de pressão (GP) sistólica entre VE e aorta. Resultados - Houve, no pós-operatório (PO) tardio significativa (p= 0,001) elevação média de ∆ D%, assim como da fração de ejeção do VE (p= 0,0001) e queda da média de DDVE (p= 0,001), bem como regressão para CFI/II em 27 (90%) casos. Ocorreram três (9,6%) óbitos tardios, todos após pelo menos três anos de PO, causados por disfunção ventricular esquerda progressiva. Observamos que nos portadores de estenose aórtica e disfunção ventricular, existe, no PO, melhora significativa das condições clínicas e da função ventricular, o que justifica o tratamento cirúrgico da valva aórtica nestes casos. Conclusão - A disfunção ventricular esquerda não constitui contra-indicação ao tratamento cirúrgico da estenose aórtica.

Evolução pós-operatória da função ventricular esquerda na insuficiência aórtica / Postoperative Left Ventricular Function Evolution in Aortic Insufficiency

PURPOSE--To analyze the follow-up of left ventricular function (LVF) after surgical correction of severe chronic aortic insufficiency (AI). METHODS--Twenty-one out of 68 patients with AI, initially asymptomatic and that developed symptoms during the follow-up period of 24-36 months, were studied. Relationship between symptoms and LVF by echocardiogram and radioisotopic ventriculography at rest and in isotonic exercise were studied. Three clinical moments (CM) were assumed: CM-0- at the beginning of the study, when all patients were asymptomatic; CM-1- manifestation of the symptoms during 24-36 months; CM-2- corresponding to the late post-operative period of 8 months of 20 out of 21 patients (one refused the surgery). The analysis did not show any significant differences between the mean values of all echocardiographic variables (diastolic and systolic diameters, shortening fraction, final systolic stress, volume-mass ratio, contractility index) and the ejection fraction of the left ventricle (EF) obtained by the radioisotope ventriculography at rest and, including exercise, between clinical moments 0 and 1. RESULTS--In the CM-2, involution was verified for functional class I/II in all cases and absence of expressive complications or immediate or late postoperative mortality. Comparison between CM-2 and 0 showed expressive regression of the diameters at rest in the postoperative period and with significant improvement in the means mainly the percentual variation of the EF and total time of effort. CONCLUSION--Symptoms assembled patients with more advanced eccentric hypertrophy and did not coincide with any immediate change in findings studied at rest and at exercise. It represented a point of reference for surgical indication compatible with late postoperative involution of chronic adaptation of AI.

Objetivo - Analisar a evolução da função ventricular esquerda (FVE) após correção cirúrgica da insuficiência aórtica crônica grave (IAo). Métodos - Dentre 68 portadores de IAo, inicialmente assintomáticos, selecionamos 21 que desenvolveram sintomas durante período de observação de 24-36 meses. Estudamos a FVE através do ecodopplercardiograma e da ventriculografia radioisotópica em repouso e em exercício isotônico em três momentos clínicos (MC): MC-0 - ao início do estudo e todos os pacientes eram assintomáticos; MC-1 - manifestação de sintomas no decorrer de 24-36 meses; MC-2 - período pós-operatório tardio de 8 meses de 20 dos 21 casos (houve uma recusa à cirurgia). Não havia diferenças significantes entre as médias de todas as variáveis ecocardiográficas estudadas (diâmetro diastólico, diâmetro sistólico, fração de encurtamento, estresse sistólico final, relação volume-massa, índice de contratilidade) e da fração de ejeção do ventrículo esquerdo (FE) obtida pela ventriculografia radioisotópica em repouso e, inclusive ao exercicio, entre os MC - 0 e 1. Resultados - No MC-2 constatou -se involução para classe funcional I/II em todos os casos e ausência de mortalidade pós-operatória imediata e tardia. Da comparação entre os MC - 2 e 0, houve expressiva regressão dos diâmetros em repouso no pós-operatório e com melhora significante entre as médias, principalmente da variação percentual da FE e do tempo total de esforço. Conclusão - A manifestação de sintomas reuniu pacientes com hipertrofia excêntrica avançada, não coincidiu com nenhuma mudança imediata dos marcadores laboratoriais estudados ao repouso e ao exercício, e representou ponto de referência de indicação cirúrgica compatível com involução pós-operatória tardia das conseqüências da adaptação IAo

Eritrocitoferese pré-operatória em portador de hemoglobinopatia sc e estenose mitral / Preoperative Eritrocytopheresis in a Patient with Hemoglobinopathy SC and Mitral Stenosis

Hemoglobinopathies are associated with thrombotic complications, when exposed to cardiopulmonary bypass. A 54-year old, black woman with hemoglobinopathy SC and severe mitral stenosis was submitted to eritrocytopheresis 48 hours before mitral commissurotomy surgery. The therapeutic determined appearance of the percentual hemoglobin A of 68 with reduction the hemoglobin S of 48 to 15 and the hemoglobin C of 51 to 17. No complications occurred during postoperative period. To best of our knowledge, that is the first report about application the eritrocytopheresis in the pre operative extra corporeal circulation care in surgical treatment of patients with chronic rheumatic heart disease and hemoglobinopathy SC.

Relação entre função ventricular esquerda e desencadeamento de sintomas na insuficiência aórtica crônica severa / The relationship between left ventricular function and the precipitation of symptoms in severe chronic aortic insufficiency

PURPOSE--To study the relationship between symptoms and left ventricular function in 68 patients with severe chronic aortic regurgitation using echocardiogram and radionuclide left ventriculography at rest. METHODS--Three stages of natural history are assumed: the 1st, at the beginning of the study, when all patients were asymptomatic (clinical stage 0); the 2nd, at the end of 36 month persistence of asymptomatic (clinical stage 1), consisting of 45 patients (group AA); the 3rd, on occasion of manifestation of the symptoms during this period of time (clinical stage 2), consisting of 21 patients (group AS-PRE), with two fatalities not related to valvopathy. RESULTS--The comparison between the groups resulted in similarities in the mean ages, mean time of knowledge of the disease, predominance of males and rheumatic etiology. The profile analysis showed that the significant initial differences between the average of all echocardiographic variables (diastolic diameter, systolic diameter, shortening fraction, final systolic stress, volume-mass ratio, contractility index) and of the ejection fraction of the left ventricle obtained by the radionuclide ventriculography at rest, remained during the study. CONCLUSION--Development of symptoms grouped patients with more advanced excentric hypertrophy, did not coincide with any immediate change in the laboratory markers studied at rest and it was used as a referential for surgical therapy.

Cardiopatia reumática crônica em portador de hemofilia submetido com sucesso a tratamento cirúrgico / Chronic Rheumatic Cardiopathy and Hemophilia in a Patient Submitted to Successful Surgical Treatment

Homem com 52 anos, portador de cardiopatia reumática crônica e homofilia foi submetido a substituiçäo da valva aórtica e comissurotomia mitral. Havia história de reaçäo alérgica a crioprecipitado e para realizaçäo da cirurgia, o valor ideal de fator VIII foi estipulado em 100 por cento. Para tanto, foram infundidas aproximadamente 2.500UI de fator VIII:C, o que proporcionou, contudo, acréscimo no valor de fator VIII:C de 20 por cento para 58 por cento. Durante o ato operatório foram administradas 1.500UI de fator VIII:C associadas à infusäo de 3.500.000U de aprotinina (TrasylolR), iniciada na induçäo anestésica e mantida durante a cirurgia. O valor de fator VIII:C sérico obtido ao término da cirurgia foi de 220 por cento. O paciente teve alta no 11§ dia de pós-operatório e näo houve nenhuma complicaçäo hemorrágica

Defeito do septo interventricular adquirido no curso de endocardite infecciosa / Acquired ventricular septal defect during infective endocarditis

We studied five patients with acquired ventricular septal defect during the course of an infective endocarditis. All patients were male and had a previous aortic valve disease associated with an aortic ring abscess. Clinical examination was useful for the diagnosis of 4 cases, emphasizing the following findings: systolic murmur and/or left paraesternal thrill and right-heart failure. Incidence of congestive heart failure was 60//, while 40//of all patients died during the in-hospital course. No specific etiologic agent was detected. Therefore, acquired ventricular septal defect should be suspected in patients with infective endocarditis of the aortic valve that evolve with a systolic murmur and/or paraesternal thrill and right-heart failure. Immediate surgical treatment is mandatory in these cases

Prevencao de recorrencia de fibrilacao atrial apos cardioversao / Prevention of atrial fibrilation recurrence after cardioversion

A fibrilacao atrial e arritmia frequent com alto indice de recorrencia apos reversao para ritmo sinusal. O uso de drogas antiarritmicas para a manutencao do ritmo sinusal e considerado benefico se comparado com placebo. Essas drogas geralmente sao as mesmas empregadas na reversao, incluindo, entre as disponiveis em nosso meio, quinidina, amiodarona, disopiramida e sotalol. Digital, outros betabloqueadores e bloqueadores de canal de calcio parecem mais efetivos para diminuicao da resposta ventricular. O beneficio do digital e indubitavel na reversao e provavelmente na namutencao do ritmo sinusal . Usamos com frequencia quinidina, associada ou nao a digital, como primeira opcao, principalmente quando foram eficazes na reversao. Amiodarona parece mais efetiva na prevencao de recorrencia de fibrilacao atrial; entretanto seus efeitos colaterais a longo prazo sao mais frequentes e mais graves. Nos portadores de disfuncao ventricular importante, ou naqueles que durante os paroxismos de fibrilacao atrial apresentam instabilidade hemodinamica ou fenomenos embolicos, nos quais a manutencao do ritmo sinusal e altamente desejavel e necessaria, a amiodarona e a droga de primeira escolha. Algumas doencas cardiacas ou extracardiacas e alguns fatores desencadeantes de recorrencias devem ser analisados e tratados antes ou concomitantemente ao uso de antiarritmicos. A conveniencia da manutencoa do ritmo sinusal e consideracoa que deve ser feita nos casos que apresentam alto indice de paroxismos ou nos propensos a efeitos pro-arritmicos, nos quais o custo/beneficio e alto.

Eventos neurológicos na endocardite infecciosa / Neurologicol Events in Infective Endocorditis

PURPOSE--The study of frequency, modalities and course of neurological complications of infective endocarditis (IE), as well as the current indication and value of supplementary examinations. METHODS--Sixty-three patients with IE, 39 with native valve and 24 with valvar prosthesis, were prospectively studied; the mean age was 42 years and 45 (71.4 per cent ) were males. Two groups were formed: A) 41 patients without neurological events and B) 22 patients who presented 28 neurological events before or during hospitalization: ischemic cerebrovascular accident 20, hemorrhagic cerebrovascular accident 2, meningeal hemorrhage 2, meningitis 2, brain abscess 1 and seizure 1. All patients were submitted to neurological clinical examination; 57 computerized tomographies of the cranium, 28 arteriographies and 32 cerebrospinal fluid analysis were performed. RESULTS--The incidence of neurological events corresponded to 34.92 per cent of IE patients, with a clear predominance (85.71 per cent ) of vascular as compared to infectious manifestations. Mortality was 2.32 times higher in group B patients (22.73 per cent x 9.76 per cent ), albeit p = 0.256, and was not related to staphylococcal etiology. The neurological events were not related to sex, age and presence of valvar prosthesis. The presence of neurological complications was greater (p = 0.047) in patients with simultaneous infections in two valves (mitral and aortic) and also (p = 0.00884) in those with IE in prosthesis implanted for less than three months. All supplementary neurological examinations in group A were normal. CONCLUSION--1) Occurrence of neurological events is a factor which influences the prognosis of IE; 2) supplementary neurological examinations did not reveal subclinical neurological complications; 3) neurological complications were significantly more frequent in patients with simultaneous mitral and aortic valve IE; 4) IE in prosthesis implanted for less than 3 months has a greater probability to develop a neurological picture as compared to IE in prosthesis implanted for more than 3 months

Purpose - The study of frequency, modalities and course of neurological complications of infective endocartitis (IE), as well as the current indication and value of suplementary examinations. Methods - Sixty-three patients with IE, 39 with native valve and 24 with valvar prosthesis, were prospectively studied; the mean age was 42 years and 45 (71,4%) were males. Two groups were formed: A) 41 patients without neurological events and B) 22 patients who presented 28 neurological events before or during hospitalization: ischemic cerebrovascular accident 20, hemorrhagic cerebrovascular accident 2, meningeal hemorrhage 2, meningitis 2, brain abscess 1 and seizure 1. All patients were submitted to neurological clinical examination; 57 computerized tomographies of the cranium, 28 arteriographies and 32 cerebrospinal fluid analysis were performed. Results - The incidence of neurological events corresponded to 34.92% of IE patients, with a clear predominance (85.71%) of vascular as compared to infectious manifestations. Mortality was 2.32 times higher in group B patients (22.73% x 9.76%), albeit p=0.256, and was not related to staphilococcal etiology. The neurological events were not related to sex, age and presence of valvar prosthesis. The presence of neurological complications was greater (p=0.047) in patients with simultaneous infections in two valves (mitral and aortic) and also (p=0.00884) in those with IE in prosthesis implanted for less than three months. All supplementary neurological examinations in group A were normal. Conclusion - 1) Occurrence of neurological events is a factor which influences the prognosis of IE; 2) supplementary neurological examinations did not reveal subclinical neurological complications; 3) neurological complications were signifcantly more frequent in patients with simultaneous mitral and aortic valve IE; 4) IE in prosthesis implanted for less than 3 months has a greater probability to develop a neurological picture as compared to IE in prosthesis implanted for more than 3 months

Valvoplastia mitral por cateter baläo: resultados imediatos e seguimento de 1 ano / Percutaneous mitral balloon valvuloplasty.early results and one year follow-up

Objetivo - Avaliar os resultados da valvoplastia mitral por cateter baläo (VMCB) a curto e a médio prazos. Métodos - Cento e quatro procedimentos em 103 pacientes, 89 (87%) mulheres e média etária de 33 anos. O diagnóstico foi estenose mitral (EM) em 95 (91%), reestenose mitral em 7 (7%) e bioprótese estenótica em 2(2%). Doze pacientes (10%) estavam em classe funcional (CF) II (NYHA), 73 (70%) em CF III e 19 (18%) em CF IV. Noventa e três (89%) estavam em ritmo sinusal, 10 (10%) em fibrilaçäo atrial e 1 (1%) em ritmo funcional. Em 99% dos casos a técnica empregada foi transeptal. Resultados hemodinâmicos comparativos entre pré X pós VMCB imediato foram: área valvar mitral (cm2) 0,75 ñ 0,27 x 1,68 ñ 0m48 (p < 0,0001), gradiente AE-VE médio (mmHg) 19,52 ñ 8,03 x 5,44 ñ 4,38 p < 0,0001); pressäo média de AE (mmHg) 24,72 ñ 8,76 x 9,63 ñ 6,11 (p < 0,0001); índice cardíaco (L/min/m*) 2,55 ñ 0,69 x 2,92 ñ 0,77 (p < 0,0001); pressäo média de AP (mmHg) 40,17 ñ 16,52 x 25,65 ñ 13,77 (p < 0,0001). Ao ecocardiograma os resultados comparativos entre pré-VMCB, pós-VMCB, controle de 6 meses e 12 meses pós-VMCB foram respectivamente: área valvar mitral (cm*) 0,89 ñ 0,23 x 1,87 ñ 0,41 x 1,72 ñ 0,43 x 1,64 ñ 0,44 e gradiente transvalvar mitral (mmHg) 13,12 ñ 4,66 x 6,44 ñ 2,93 x 7,72 ñ 3,24 x 8,30 ñ 4,17. Houve um óbito imediato pós-VMCB em paciente portadora de tromboembolismo pulmonar, 4 (4%) pacientes com insuficiência mitral importante (1 óbito no pós-operatório imediato) e 2 pacientes com reestenose mitral. Conclusäo - A VMCB mostra-se método eficaz e seguro ocorrendo persistência de bons resultados no período de 1 ano de acompanhamento

Purpose - To evaluate percutaneous mitral balloon valvuloplasty (PMBV) results immediately and one yearfollow-up. Methods - One hundred andfour procedures in 103 patients, 89 (87%) were women and mean age was 33. Ninety five (91%) had mitral stenosis, 7 (7%) mitral restenosis and 2 (2%) stenotic bioprosthesis. Twelve (10%) patients were in functional class (FC) II (NYHA), 73 (70%) in FC III and 19 (18%) in FC IV. Ninety three (89%) were in sinusal rhythm, 10 (10%) had atrialfibrilation and 1 (1%) junctional rhythm. In 99% cases the transeptal access was used. Results - The comparative haemodinamic results late x immediately after-PMBV were mitral valve area (cm2) 0.75 ± 0.27 x 1.68 ±0.48 (p < 0.0001), gradiente AE-VE average (mmHg) 19.52 ± 8.03 x 5.44 ± 4.38 (p < 0.0001); average pressure AE (mmHg) 24.72 ± 8.76 x 9.63 ± 6.11 (p < 0.0001), cardiac inde x (L/ min/m2) 2.55 ± 0.69 x 2.92 ± 0.77 (p < 0.0001); average pressure PA (mmHg) 40.17 ± 16.52 x 25.65 ± 13.77 (p < 0.0001). The echocardiography results pré-PMBV, post-PMBV, 6 and 12 months after PMBV were respectively: mitral valve area (cm2) 0.89 ± 0.23 x 1.87 ± 0.41 x 1.72 ± 0.43 x 1.64 ± 0.44 and mitral transvalvar gradient (mmHg) 13.12 ± 4.66 x 6.44 ± 2.93 x 7.72 ± 3.24 x 8.30 ± 4.17. There was one death immediately after-PMBV in a patient with pulmonar thromboembolism. Four (4%) had severe mitral regurgitation and went to surgery (1 death). There were 2 mitral reestenosis. Conclusion - For selected patients PMBVis a safe method and the good results are maintained in 1 year follow-up

Paralisia bilateral do diafragma no pós-operatório imediato de cirúrgia cardíaca / Immediate post-operative bilateral diaphragmatic paralysis after cardiac surgery

Homem de 56 anos, submetido a implante de prótese metálica em posiçäo aórtica, e a enxerto de safena para artéria coronária direita, evoluiu no pós-operatório imediato com insuficiência respiratória de difícil reconhecimento etiopatogênico, finalmente relacionada à paralisia bilateral do diafragma, diagnóstico confirmado através do exame ultrasonográfico de tórax. O paciente permaneceu sob assistência ventilatória com pressäo positiva por 75 dias, quando foi introduzido ventilador de pressäo negativa (VPN), tipo colete, permitindo o fechamento da traqueostomia e recuperaçäo da respiraçäo espontânea. Alta hospitalar no 90§ dia, com orientaçäo do uso de VPN no período noturon. Após 40 dias, o paciente retornou as suas atividades profissionais, sem qualquer apoio à respiraçäo

A 56 years old man was submitted to an aortic replacement with mechanical prosthesis and to saphenous vein graft to the right coronary artery. He developed respiratory insufficiency after surgery which was finally related to bilateral diaphragmatic paralysis whose diagnosis was confirmed through thorax ultrassonography. The patient remained under ventilatory assitance with positive pressure for 75 days. The introduction of thorax ventilatory negative pressure (VNP), jacket type, allowed the traqueostomy closure. The patient gradually recovered his spontaneous breathing and was discharged after 90 days with instructions to use VNP at night. He returned to his normal professional activities, without auxiliary respiratory support, 40 days after his discharge.

Estenose tricúspide: peculidades diagnósticas / Tricuspid stenosis: diagnostic peculiarities

Estudamos 24 pacientes portadores de estenose tricúspide (ET) associada à estenose mitral submetidos ao tratamento cirúrgico entre 1981 a 1986. Grupo I-16 (66%) pacientes com diagnóstico pré-operatório (clínico e/ou ecocardiográfico e/ou hemodinâmico), oito (50%) com insuficiência tricúspide (IT) associada, idade média de 32 anos, todos em classe funcional (CF, NYHA) III/IV, 12 (72%) com predomínio de insuficiência cardíaca direta (ICD). Foi realizada comissurotomia tricúspide em 13 (81%) pacientes, em três associada à plástica de De Vega. Em três pacientes procedeu-se a implante de prótese em posiçäo tricúspide (IVT). Os três pacientes sobmetidos a IVT faleceram. Doze (75%) pacientes receberam alta hospitalar CF/II e em período médio de 28 meses, dois (16%) apresentavam-se em CF III e os demais em CFI/II. Grupo II - oito (33%) pacientes cujo diagnóstico de ET foi apenas trans-operatório, todosIT associada, idade média de 31 anos, todos em CF III/IV, sete (87%) com predomínio de ICD. Na evoluçäo pós-operatória imediata, todos tiveram alta hospitalar em CFI/II. Em período pós-operatório tardio, houve um óbito, de causa desconhecida. Em conclusäo, a ET näo reconhecida do ponto de vista clínico pode ser perfeitamente identificada no ato operatório e deve ser uma possibilidade a ser pesquisada pelo cirurgiäo mesmo em caso admitidos com IT funcional no pré-operatório. Outrossim, a IT deve ser considerada como fator relevante de näo reconhecimento da ET