Surgery for obstructive hypertrophic cardiomyopathy: challenge and future / 中华外科杂志

After more than 60 years of development, with the deepening of the pathophysiological understanding of obstructive hypertrophic cardiomyopathy, the extent and resection thickness of myectomy have increased significantly. Myectomy combined with the correction of anomalies of the mitral valve apparatus has become the standard treatment of obstructive hypertrophic cardiomyopathy. Only a few centers worldwide can routinely perform it due to the difficulty. Because of the advances of new drugs and interventional therapy, the development of surgical treatment faces many challenges. At the same time, generations of cardiovascular surgeons are constantly trying to promote septal myectomy, including developing devices and the surgical field, as well as improving surgical planning by advanced technology. At present, the superior long-term efficacy of septal myectomy has been confirmed. It is necessary to work together to promote the treatment of hypertrophic obstructive cardiomyopathy, so as to guard people's health.

Efficacy of alcohol septal ablation in mildly symptomatic or severely symptomatic patients with hypertrophic obstructive cardiomyopathy / 中华心血管病杂志

Objective: To compare the prognosis of mildly or severely symptomatic patients with obstructive hypertrophic cardiomyopathy (OHCM) who underwent alcohol septal ablation (ASA). Methods: This retrospective study cohort consisted of patients with OHCM who received ASA treatment in Beijing Anzhen Hospital, Capital Medical University from March 2001 to August 2021. These patients were divided into mildly and severely symptomatic groups according to the severity of clinical symptoms. Long-term follow-up was conducted, and the following data were collected: duration of follow-up, postoperatire treatment, New York Heart Association (NYHA) classification, arrhythmia events and pacemaker implantation, echocardiographic parameters, and cause of death. Overall survival and survival free from OHCM-related death were observed, and the improvement of clinical symptoms and resting left ventricular outflow tract gradient (LVOTG) and the incidence of new-onset atrial fibrillation were evaluated. The Kaplan-Meier method and log-rank test were used to determine and compare the cumulative survival rates of the different groups. Cox regression analysis models were used to determine predictors of clinical events. Results: A total of 189 OHCM patients were included in this study, including 68 in the mildly symptomatic group and 121 in the severely symptomatic group. The median follow-up of the study was 6.0 (2.7, 10.6) years. There was no statistical difference in overall survival between the mildly symptomatic group (5-year and 10-year overall survival were 97.0% and 94.4%, respectively) and the severely symptomatic group (5-year and 10-year overall survival were 94.2% and 83.9%, respectively, P=0.405); there was also no statistical difference in survival free from OHCM-related death between the mildly symptomatic group (5-year and 10-year survival free from HCM-related death were 97.0% and 94.4%, respectively) and the severely symptomatic group (5-year and 10-year survival free from HCM-related death were 95.2% and 92.6%, respectively, P=0.846). In the mildly symptomatic group, NYHA classification was improved after ASA (P<0.001), among which 37 patients (54.4%) were in NYHA class Ⅰ, and the resting left ventricular outflow tract gradient (LVOTG) decreased from 67.6 (42.7, 90.1) mmHg (1 mmHg=0.133 kPa) to 24.4 (11.7, 35.6) mmHg (P<0.001). In severely symptomatic group, NYHA classification was also improved post ASA (P<0.001), among which 96 patients (79.3%) improved by at least one NYHA classification, and the resting LVOTG decreased from 69.6 (38.4, 96.1) mmHg to 19.0 (10.6, 39.8) mmHg (P<0.001). The incidence of new-onset atrial fibrillation was similar between the mildly and severely symptomatic groups (10.2% vs. 13.3%, P=0.565). Cox multivariate regression analysis showed that age was an independent predictor of all-cause mortality in OHCM patients post ASA (HR=1.068, 95%CI 1.002-1.139, P=0.042). Conclusions: Among patients with OHCM treated with ASA, overall survival and survival free from HCM-related death were similar between mildly symptomatic group and severely symptomatic group. ASA therapy can effectively relieve resting LVOTG and improve clinical symptoms in mildly or severely symptomatic patients with OHCM. Age was an independent predictor of all-cause mortality in OHCM patients post ASA.

Therapeutic effects of alcohol septal ablation in mildly symptomatic patients with hypertrophic obstructive cardiomyopathy / 中华心血管病杂志

Objective: To observe the therapeutic effects of alcohol septal ablation (ASA) in mildly symptomatic patients (NYHA class Ⅱ) with hypertrophic obstructive cardiomyopathy(HOCM). Methods: This retrospective study included 150 mildly symptomatic patients with HOCM hospitalized in Beijing Anzhen Hospital affiliated to Capital Medical University from March 2001 to December 2017, consisting of medical therapy group (n=102) and ASA group (n=48). Baseline clinical data were collected, patients were followed up to a mean of 6.0 (3.5, 8.1) years. Overall and HCM-related mortality events (including chronic heart failure, atrial fibrillation related stroke, sudden cardiac death) were observed in the two groups. Moreover, the improvement of NYHA function classification and left ventricular outflow tract gradient (LVOTG) were also evaluated. Survival analysis was performed by Kaplan-Meier method. Results: Age of this cohort was (52.9±14.5)years, 92 cases(61.3%) were male. In the follow-up, LVOTG was reduced from (85.8±35.4)mmHg (1 mmHg=0.133 kPa) to (27.7±19.8)mmHg (P<0.001) in the ASA group, and from (66.3±35.0)mmHg to (56.5±27.7)mmHg in medical therapy group(P<0.01). At the last clinical follow-up, there were 32 patients (66.7%) whose LVOTG were<30 mmHg, septal thickness decreased from (20.3±3.8)mm to (16.1±3.4)mm (P<0.001), NYHA classification was also remarkably improved (P<0.001). New-onset atrial fibrillation tended to be lower in the ASA group compared to medical therapy group (9.3%(4/43) vs. 20.8%(20/96),P=0.096). Eleven patients (10.8%) in the medical therapy group and 2 patients (4.2%) in the ASA group died during the follow-up. One patient received pacemaker during the peri-procedural period, 1 patient was implanted with two-chamber pacemaker due to Ⅲ° atrioventricular block at 10 years after operation in the ASA group. Survival free of all-cause mortality of ASA group at 5 and 10 years was 97.9% and 97.9%, respectively, which was comparable to the medical therapy group (P=0.231). Survival free of HCM-related mortality was similar between the two groups (P=0.397). Conclusions: Compared with medical therapy in mildly symptomatic patients with HOCM, long-term survival rate is similar after ASA. Meanwhile, ASA can remarkably reduce LVOTG and improve the clinical status of the patients. Therefore, ASA may be used as an alternative therapy for mildly symptomatic HOCM patients.

Comparison of superior septal approach with left atriotomy in mitral valve surgery / Comparação da abordagem septal superior com atriotomia esquerda em cirurgia valvar mitral

Objective: In this study, we aimed to compare clinical outcomes of superior transseptal approach with the conventional left atriotomy in patients undergoing mitral valve surgery. Methods: Between January 2010 and November 2012, a total of 91 consecutive adult patients (39 males, 52 females; mean age: 54.0±15.4 years; range, 16 to 82 years) who underwent mitral valve surgery in the Division of Cardiovascular Surgery at Koşuyolu Training Hospital were included. The patients were randomized to either superior transseptal approach (n=47) or conventional left atriotomy (n=44). Demographic characteristics of the patients, comorbidities, additional interventions, intraoperational data, pre- and postoperative electrophysiological study findings, and postoperative complications were recorded. Results: Of all patients, 86.7% (n=79) were in New York Heart Association Class III, while 12 were in New York Heart Association Class IV. All patients underwent annuloplasty (42.9%) or valve replacement surgery (57.1%). There was no significant difference in pre- and postoperative electrocardiogram findings between the groups. Change from baseline in the cardiac rhythm was statistically significant in superior transseptal approach group alone (P<0.001). There was no statistically significant difference in mortality rate between the groups. Permanent pacemaker implantation was performed in 10.6% of the patients in superior transseptal approach group and 4.5% in the conventional left atriotomy group. No statistically significant difference in bleeding, total length of hospital and intensive care unit stay, the presence of low cardiac output syndrome was observed between the groups. Conclusion: Our study results suggest that superior transseptal approach does not lead to serious or fatal adverse effects on sinus node function or atrial vulnerability, compared to conventional approach. .

Objetivo: O objetivo deste estudo é comparar os resultados clínicos da abordagem septal superior com a atriotomia esquerda convencional em pacientes submetidos à cirurgia valvar mitral. Métodos: Entre janeiro de 2010 e novembro de 2012, foi incluído um total de 91 pacientes adultos consecutivos (intervalo de 16 a 82 anos, média 54,0±15,4 anos; 39 homens, 52 mulheres) submetidos à cirurgia valvar mitral no Serviço de Cirurgia Cardiovascular no Hospital Training Koşuyolu. Os pacientes foram randomizados para abordagem septal superior (n=47) ou atriotomia esquerda convencional (n=44). Foram registradas características demográficas dos pacientes, comorbidades, intervenções adicionais, dados intraoperatórios, achados do estudo eletrofisiológico pré e pós-operatório e complicações pós-operatórias. Resultados: Do total de pacientes, 86,7% (n=79) estavam na Classe III e 12 na Classe IV da New York Heart Association. Todos os pacientes foram submetidos à anuloplastia (42,9%) ou cirurgia de troca valvar (57,1%). Não houve diferença significativa nos resultados do eletrocardiograma pré e pós-operatórios entre os grupos. Mudança da linha de base no ritmo cardíaco foi estatisticamente significativa apenas no grupo abordagem septal superior (P<0,001). Não houve diferença estatisticamente significativa na taxa de mortalidade entre os grupos. Marca-passo definitivo foi implantado em 10,6% dos pacientes no grupo abordagem septal superior e em 4,5% dos pacientes no grupo atriotomia esquerda convencional. Não houve diferença estatisticamente significativa no sangramento, tempo total de internação e de permanência na UTI, tendo sido observada síndrome de baixo débito cardíaco entre os grupos. Conclusão: Nossos resultados sugerem que a ...

Hypertrophic cardiomyopathy part II - Anesthetic and surgical considerations.

Hypertrophic cardiomyopathy (HCM) poses many unique challenges regarding the conduct of anesthesia and surgery. Adequate preload, control of sympathetic stimulation, heart rate, and increased afterload are required to decrease the left ventricular outfl ow tract obstruction. Comprehensive intraoperative transesophageal echocardiography (TEE) examination confi rms the diagnosis, elucidates the pathophysiology, and identifi es the various anomalies of mitral valve apparatus and allows assessment of the adequacy of surgery. In this review, we focus on the preoperative assessment, conduct of anesthesia and comprehensive TEE examination of patients presenting for surgery with HCM. The various surgical options are extended myectomy and resection, plication and release.

Aneurisma del seno de valsalva derecho no roto con disección hacia el tabique interventricular. Presentación de un caso / Aneurysm of an unruptured right valsalva sinus with dissection into the interventricular septum. Case presentation

Los aneurismas de los senos de valsalva (ASV) son una rara enfermedad. Algunos de estos aneurismas, aún más raros, disecan, rompiéndose o no, hacia el tabique interventricular. Presentamosen este trabajo un paciente masculino de 32 años de edad, de raza negra que se le diagnosticó un aneurisma de seno de valsalva que disecó hacia el tabique interventricular y que fue remitido a nuestro hospital en clase funcional IV (NYHA), con insuficiencia aórtica moderada, bloqueo auriculo ventricular y con disfunción ventricular. Se realizó el diagnóstico de la enfermedad porecocardiografía. Se le colocó un marcapaso permanente y se operó realizándosele plicación dela cavidad aneurismática, cierre del orificio de comunicación y plastia valvular aórtica. Evolución post-operatoria satisfactoria.

Os aneurismas dos seios de valsalva (ASV) são considerados uma doença rara. Alguns destes aneurismas, ainda mais raros, dissecam, rompendo-se ou não, atingindo o tabique interventricular. Apresentamos neste trabalho um paciente masculino de 32 anos de idade, de raça negra, que foi diagnosticado com um aneurisma de seio de valsalva que dissecou atingindo o tabique interventricular e que foi remetido ao nosso hospital em classe funcional IV (NYHA), com insuficiência aórtica moderada, bloqueio auriculo ventricular e disfunção ventricular. Realizou-se o diagnóstico da doença por ecocardiografia. Colocou-se um marcapasso permanente e foi operado, realizandose aplicação da cavidade aneurismática, fechamento do orificio de comunicação e plastia valvularaórtica. Evolução pós operatória satisfatória.

Aneurysms of the sinus of valsalva (ASV) are a rare defect. Some of these aneurysms, though rare, dissect, rupturing or not, into the interventricular septum. This paper describes a 32 year-old man, black race, with the diagnosis of a sinus of valsalva aneurysm which dissected into the interventricular septum and who was referred to our hospital in functional class IV (NYHA), with moderate aortic failure, AV block and ventricular insufficiency. The disease was diagnosed with ultrasound. An indwelling pacemaker was inserted and the operation consisted of the plication of the aneurysmal cavity, closure of the septal defect and aortic valvuloplasty. Post-op was satisfactory.

Resultados a longo prazo da miectomia septal no tratamento da cardiomiopatia hipertrófica / Long term results of septal myectomy in the treatment of obstructive hypertrophic cardiomyopathy

OBJETIVO: Avaliação clínica e ecocardiográfica tardia da miectomia septal cirúrgica de pacientes com cardiomiopatia hipertrófica obstrutiva (CMHO). MÉTODOS: Foram analisados, retrospectivamente, 34 pacientes adultos (média de 55,7±15,2 anos) portadores de CMHO operados consecutivamente na instituição entre 1988 e 2008. Apenas quatro (11,8%) pacientes tinham conhecimento de história familiar para CMHO. Nove (26,5%) pacientes apresentavam insuficiência cardíaca (NYHA) classe funcional IV. Trinta (88,2%) pacientes apresentavam CMHO isolada e, em quatro (11,8%), a CMHO estava associada à insuficiência coronária. A técnica cirúrgica utilizada em todos os casos foi a miectomia septal transaórtica. RESULTADOS: Em 26 (76,5%) pacientes, a insuficiência mitral decorrente do movimento anterior sistólico regrediu após a miectomia. Em oito (23,5%) pacientes, houve necessidade de abordagem da valva mitral. Houve um (2,9%) óbito hospitalar. Dois (5,9%) pacientes necessitaram de marcapasso definitivo no pós-operatório. Em média, o gradiente de pico pré-operatório na via de saída do ventrículo esquerdo, que era de 84,9±29,0 mmHg, diminuiu para 27,8±12,9 mmHg no pós-operatório inicial e caiu para 19,2±11,2 mmHg no pós-operatório tardio (49,0±33,0 meses). A classe funcional (NYHA) que, em média, era de 3,1±0,8 passou para 1,4±0,5 no pós-operatório. Com seguimento médio de 9,6±8,4 anos, a sobrevida foi de 87,9% e a sobrevida livre de eventos cardiovasculares foi de 77,7%. CONCLUSÃO: A miectomia septal cirúrgica pode ser realizada de modo seguro, com excelente sobrevida, melhora dos sintomas e alívio da obstrução na via de saída do ventrículo esquerdo em pacientes com CMHO. Os benefícios iniciais se mantiveram a longo prazo.

OBJECTIVE: This study analyzed the clinical and echocardiographic late outcomes of surgical septal myectomy in patients with obstructive hypertrophic cardiomyopathy (OHCM). METHODS: We examined, retrospectively, 34 consecutive adult patients (age 55.7±15.2 years) with OHCM operated on in our institution from 1988 to 2008. Only four (11.8%) patients had family history of OHCM. Nine (26.5%) patients were in New York Heart Association (NYHA) funcional class IV. Thirty (88.2%) patients had solely OHCM, and four (11.8%) had OHCM associated with coronary insufficiency. The surgical technique used in all patients was septal myectomy performed through an aortotomy. RESULTS: In 26 (76.5%) patients the mitral insufficiency due to systolic anterior motion, decreased after the myectomy. Eight (23.5%) patients had mitral valve procedures. There was one hospitalar death (2.9%). Two (5.9%) patients required permanent pacemaker for complete heart block after the myectomy. The mean peak preoperative left ventricular outflow tract (LVOT) obstruction gradient was 84.9±29.0 mmHg, and decreased to 27.8±12.9 mmHg in the early postoperative and it was 19.2±11.2 mmHg in the late postoperative period (49.0±33.0 months). The NYHA functional class improved from 3.1±0.8 to 1.4±0.5 in the postoperative period. Survival free from death was 87.9% and survival free from cardiovascular events was 77.7% with mean follow-up 9.6±8.4 years. CONCLUSION: Surgical septal myectomy can be performed safely, with excellent survival, improvement from symptoms and relief for LVOT obstruction in patients with OHCM. The early benefits were remained at long term.

Avaliação intraoperatória e planejamento cirúrgico na cardiomiopatia hipertrófica / Intraoperative evaluation and surgical planning in the hypertrophic cardiomyopathy / Evaluación intraoperatoria y planeamiento quirúrgico en la cardiomiopatía hipertrófica

Paciente de 45 anos do sexo masculino, com diagnóstico de cardiomiopatia hipertrófica septal assimétrica, tendo sido submetido a implante de cardiodesfibrilador no passado. Apesar do tratamento clínico otimizado, evoluiu com progressiva deterioração clínica suscitando tratamento invasivo. Entretanto, não havia gradiente importante na via de saída do ventrículo esquerdo (VSVE) ao ecocardiograma de repouso e o teste provocativo com dobutamina foi inconclusivo por não atingir a frequência cardíaca preconizada. A avaliação intraoperatória com ecocardiograma transesofágico em uso de isoproterenol foi fundamental no diagnóstico de obstrução da VSVE. A miectomia septal foi realizada com sucesso e o paciente apresentou boa evolução pós-operatória.

A male, 45 year old patient, with diagnosis of septum hypertrophic cardiomyopathy, having undergone a cardiofibrilator implant in the past. Despite the optimized clinical treatment, he evolved to a progressive clinical deterioration that led to invasive treatment. However, there was not an important gradient in the exit pathway of the left ventricle (EPLV) at the echocardiogram in rest and the challenging test with dobutamine was non conclusive because it did not reach the preconized cardiac frequency. The intraoperative evaluation with a transesophageal echocardiogram using isoproterenol was fundamental for the diagnosis of the EPLV obstruction. The septum myectomy was performed successfully and the patient presented good post-operative evolution.

Paciente de 45 años del sexo masculino, con diagnóstico de cardiomiopatía hipertrófica septal asimétrica, habiendo sido sometido a implante de cardiodesfibrilador en el pasado. A pesar del tratamiento clínico optimizado, evolucionó con progresivo deterioro clínico suscitando tratamiento invasivo. Entre tanto, no había gradiente importante en la vía de salida del ventrículo izquierdo (VSVI) al ecocardiograma de reposo y el test provocativo con dobutamina fue inconclusivo por no alcanzar la frecuencia cardíaca preconizada. La evaluación intraoperatoria con ecocardiograma transesofágico en uso de isoproterenol fue fundamental en el diagnóstico de obstrucción de la VSVI. La miectomía septal fue realizada con éxito y el paciente presentó buena evolución postoperatoria.

Ressecção de lipoma do septo interventricular / Lipoma resection of the interventricular septum

Relatamos o caso de um homem de 43 anos, assintomático, portador de um lipoma do septo interventricular, diagnosticado durante exame médico de rotina, por meio de ecocardiograma bidimensional e confirmado por tomografia computadorizada e ressonância magnética. O paciente foi submetido, com sucesso, à ressecção do tumor.

We report the case of an asymptomatic 43-year-old-man with a lipoma of the interventricular septum. Diagnosis was established during routine medical examination by 2-dimensional echocardiography and confirmed by computed tomography and magnetic resonance imaging. The patient underwent successful resection of the tumor.

Evaluación de resultados quirúrgicos de la miectomía como tratamiento de la miocardiopatía hipertrófica obstructiva: experiencia de un centro en Uruguay / Evaluation of surgical results of myectomy in the treatment of hypertrophic obstructive cardiomyopathy: experience of a single center in Uruguay

Introducción: la miectomía quirúrgica del septum interventricular es el gold standard en el tratamiento de la miocardiopatía hipertrófica (MH) que requiere cirugía para alivio sintomático. No se encontró publicada ninguna serie de pacientes tratados mediante miectomía en Uruguay, lo que motivó analizar una serie de nuestro centro, valorando variables para su comparación con series de referencia. Material y método: se incluyeron todos los pacientes con miectomía entre enero de 2001 y enero de 2008. Se consignaron variables demográficas, ecocardiográficas y sobrevida a los 18 y 72 meses. Resultados: se incluyeron 23 pacientes, 14 mujeres. Edad promedio 59 años. Siete presentaban familiar de primer grado con MH. Seis presentaban lesiones coronarias significativas. El promedio del gradiente intraventricular máximo fue 96,32 mmHg, SIVD 21,4 mm y FEVI 66%. 17 tenían SAM, y de ellos, 15 presentaban insuficiencia mitral severa. En el preoperatorio, 14 presentaban CF NYHA III y nueve CF IV; 20 recibieron algún procedimiento asociado. La mortalidad operatoria fue de 8,7% (dos pacientes). El gradiente máximo postoperatorio promedio fue 12 mmHg, SIVD 16,65 mm y FEVI 64%. A los 18 meses, 20 estaban vivos y en CF I. La sobrevida actuarial a seis años fue 76,7%. Conclusiones: en 20 de los 23 pacientes se asoció otro procedimiento, mayormente sustitución valvular mitral. La miectomía redujo significativamente los gradientes intraventriculares, el espesor del SIVD y los síntomas en todos los pacientes (p < 0,0001). La mortalidad operatoria fue de 8,7% (dos pacientes) y la sobrevida actuarial a seis años de 76,7%. Estos resultados se equiparan a series de referencia.

Introduction: surgical septum myectomy remains the gold standard for the treatment of obstructive hypertrophic cardiomyopathy requiring surgery forsymptomatic relief. Wasn’t found in the literature, any series of patients underwent myectomy in Uruguay.Our objetive was the analysis of our center series, assessing variables for comparison with reference series.Materials and methods: were included all patients with myectomy from january 2001 to 2008. Demographicsand ultrasonographics variables, and survival at 18 and 72 months were consignated. Results: Were included 23 patients, 14 women. Mean age 59 years. Seven with a first grade relativeaffected of hypertrophic cardiomyopathy (HM). Six with coronary lessions. The mean maximum intraventricular gradient was 96,32 mmHg, dyastolic interventricular septum wide 21,4 mm, EF 66%. 17with systolic anterior motion, 15 with severe mitral insufficience. Before surgery, 14 shows NYHA functionalclass (FC) III, and 9 FCIV. 20 with one additional surgical procedure. Operative mortality was 8,7% (two patients). The mean maximum intraventriculargradient after surgery was 12 mmHg, dyastolic interventricular septum wide 16,65mmand EF 64%. At 18 months, survival was 20 patients, all in FC I. Actuarial survival at 6 years was 76,7%. Conclussions: 20 of 23 patients with an additional procedure, mainly mitral valve substitution. Myectomyimproved intraventricular gradients, DIVS wide and symptoms in all patients (p<0,0001). Operative mortality was 8,7% (two patients), and actuarialsurvival at 6 years was 76,7%. This results are comparable with reference series.

Remodelamento reverso cirúrgico do ventrículo esquerdo: seguimento de 111 meses / Surgical reverse remodelling of the left ventricle: 111 months of follow-up

Objetivo: Apresentar a experiência do Instituto de Cirurgia Cardiovascular do Oeste do Paraná (ICCOP) com o tratamento de aneurismas de ventrículo esquerdo, com a técnica de endoventriculoplastia com exclusão septal (EVES), imediata e o seguimento por 111 meses. Métodos: No período de abril de 1999 a 2006, 28 pacientes foram submetidos a EVES, pelo autor. Foram analisadas, retrospectivamente, variáveis clínicas e ecocardiográficas pré, trans e pós-operatórias tardias. A idade média era de 59,0 ± 9,5 anos, sendo 23 pacientes do sexo masculino. Dezessete pacientes estavam em classe funcional IV e o EuroScore médio foi 8,2 ± 2,3. Os valores pré-operatórios de fração de ejeção, volumes sistólico e diastólico finais do ventrículo esquerdo foram, respectivamente, 32,3 ± 9,2 por cento, 113,9 ± 36,0 ml e 179,2 ± 48,4 ml. Foi aplicada a versão brasileira do questionário de qualidade de vida SF36 no pós-operatório tardio. Resultados: A mortalidade imediata foi de quatro pacientes por síndrome de baixo débito e arritmia. O tempo médio de seguimento pós-operatório foi 5,6 ± 3,2 anos. A fração de ejeção de ventrículo esquerdo foi fator significativo na mortalidade imediata (P=0,0222) e o tempo de parada cardíaca anóxica na tardia (P=0,0123). A análise atuarial de sobrevivência demonstrou uma sobrevida de 82,1 ± 7,2 por cento, e 54,7 ± 22,9 por cento, respectivamente, antes e depois de 107 meses, de seguimento. Conclusões: A cirurgia da EVES é efetiva no tratamento desse grupo de pacientes, com melhora da função ventricular esquerda (de 32,3 para 46,4 por cento) e da qualidade de vida dos pacientes.

Objective: To present the Instituto de Cirurgia Cardiovascular do Oeste do Paraná' (ICCOP) surgical experience, on the treatment of left ventricle aneurysms, by endoventriculoplasty, with septal exclusion (EVSE), and a 111 months follow-up. Methods: Between April 1999 and April 2006, 28 patients were submitted to EVSE, by the author. Pre, trans and late post clinical and echocardiographic variables were analyzed retrospectively. Mean age was 59.0 ± 9.5 years, being 23 male patients. Seventeen patients were in NYHA functional class IV and the mean EuroScore was 8.2 ± 2.3. The mean pre-operative values for ejection fraction, end systolic and diastolic left ventricular volumes were 32.3 ± 9.2 percent, 113.9 ± 36.0 ml e 179.2 ± 48.4 ml, respectively. The BraziliAnVErsion of the SF36 quality of life questionnaire was applied in the late follow up period. Results: Four patients died in the immediate post-operative period, being the major cause of morbidity low cardiac output syndrome and arrhythmias. The mean follow-up period was 5.6 ± 3.2 years. Left ventricle's ejection fraction and aortic cross clamping time were the significant factors for hospital and late mortality with P = 0.0222 and P = 0.0123, respectively. Actuarial survival curve showed a survival of 82.1 ± 7.2 percent, and 54.7 ± 22.9 percent, pre and post 107 months, of follow-up. Conclusion: EVSE' surgery is an effective option to treat this group of patients, with improvement of left ventricular function (from 32.3 to 46.4 percent) and patients' quality of life.

Resultados da abordagem transeptal para a valva mitral com coração batendo / Results of beating heart mitral valve surgery via the trans-septal approach

OBJETIVO: A cirurgia da valva mitral pode ser feita via transatrial ou transeptal. Embora a transatrial seja a preferida, a via transeptal tem sido utilizada mais recentemente e tido um grande valor nas operações com o coração batendo. Mostramos a nossa experiência na cirurgia da valva mitral via transeptal com coração batendo e discutimos seus benefícios e problemas. MÉTODOS: Entre 2000 e 2007, 214 pacientes consecutivos foram operados com o coração batendo. A operação foi feita por via transeptal sem pinçamento da aorta, com o coração batendo e eletrocardiograma normal e em ritmo sinusal. RESULTADOS: A idade média foi de 56,03 ± 13,93 anos (intervalo: 19-86 anos; mediana: 56 anos). Havia 131 (61,2 por cento) pacientes do sexo masculino e 83 (38,8 por cento), do feminino. Foram utilizadas 108 (50,5 por cento) próteses biológicas e 39 (18,2 por cento) mecânicas. Reparo da valva foi feito em 67 (31,3 por cento) pacientes. A estadia hospitalar foi de 17,4 ± 20,0 dias (intervalo: 3-135 dias; mediana: 11 dias). Balão intra-aórtico foi utilizado em 12 (5,6 por cento) pacientes. A mortalidade hospitalar foi de 7,4 por cento. Reoperação para revisão de hemostasia foi necessária em 15 pacientes. CONCLUSÃO: A operação com o coração batendo é uma opção para proteção miocárdica em pacientes submetidos a cirurgia da valva mitral. A técnica é facilitada ao se usar a via transeptal, reduzindo a insuficiência aórtica e melhorando a visualização do aparato mitral.

OBJECTIVE: Mitral valve surgery can be performed through the trans-atrial or the trans-septal approach. Although the trans-atrial is the preferred method, the trans-septal approach has also been used recently and has a particular value in beating-heart mitral valve surgery. Herein we report our experience with beating-heart mitral valve surgery via trans-septal approach, and discuss its advantages and pitfalls. METHODS: Between 2000 and 2007, 214 consecutive patients were operated upon utilizing beating heart technique for mitral valve surgery. The operation was performed via transseptal approach with the aorta unclamped, the heart beating, with normal electrocardiogram and in sinus rhythm. RESULTS: Mean age was 56.03 ± 13.93 years (range: 19-86 years; median: 56 years). There were 131 (61.2 percent) males and 83 (38.8 percent) females. Of the prostheses used, 108 (50.5 percent) were biological, and 39 (18.2 percent) were mechanical. Mitral repairs were performed in 67 (31.3 percent) patients. Mean hospital stay was 17.4 ± 20.0 days (range: 3-135 days; median: 11 days). Intra-aortic balloon pump (IABP) utilization was required in 12 (5.6 percent) of 214 patients. One-month mortality was 7.4 percent, and re-operation for bleeding was needed in 15 (7 percent) patients. CONCLUSIONS: Beating-heart mitral valve surgery is an option for myocardial protection in patients undergoing mitral valve surgery. This technique is facilitated by the trans-septal approach due to reduced aortic insufficiency and improved visualization of the mitral apparatus.

Experience of percutaneous mechanical mitral commissurotomy using metallic commissurotome in patients with mitral stenosis at chest disease institute.

BACKGROUND: Percutaneous metallic mitral commissurotomy (PMMC) has been accepted as an alternative to the traditional balloon technique. The advantage of the metallic commissurotome is that it is designed for several reuse and resterization and it is an interesting tool as seen by the authors. OBJECTIVE: To evaluate the efficacy and safety of PMMC among a wide range of patients with severe mitral stenosis. MATERIAL AND METHOD: Between July 2000 and August 2003, patients with severe mitral stenosis who underwent PMMC were enrolled Interatrial septum was punctured under transesophageal echocardiography guidance in all cases. Demographic data and baseline characteristics were collected Mitral valve area (MVA) was evaluated by echocardiography and hemodynamic parameters pre and post PMMC were compared RESULTS: PMMC was performed in 304 patients with a broad range of severe mitral stenosis. Mean age was 38.7 +/- 10. 9 years and 79% was female. Most were in functional class 11 (94%) and 43 patients (14%) had prior commissurotomy. Atrial fibrillation was found in 41%. Twenty-six patients were crossed over to the Inoue balloon technique. The rate of success was 81% in all patients (246/304) and 89% in patients when PMMC was actually done (246/278). The MVA increased from 84 +/- 22 to 170 +/- 36 mm2 (p < 0.0001). Transvalvular gradient decreased from 17 +/- 6 to 7 +/- 4 mmHg (p < 0.0001) and mean left atrial pressure from 26 +/- 7 to 15 +/- 6 mmHg (p < 0.0001). Separation of both commissures was found in 25% and 61% had symptom relief by a reduction in functional class at least one level (p < 0.0001). Complications developed in 16 patients (5.3%) including three serious events, one death caused by severe mitral regurgitation followed by emergency surgery, another survivor after surgical repair of left ventricular free wall rupture and the last one with surgical removal of the malfunctioned device stuck in the left atrium. CONCLUSION: Results of PMMC is not as encouraging as shown in previous studies. The risk of cardiac tamponade is minimized by interatrial septal puncture using transesophageal echocardiography (TEE) monitoring but this technique increased the possibility of crossover. Deterioration of the metallic commissurotome after a few procedures is demonstrated in the author's real practice.

Revascularização miocárdica e restauração ventricular por meio da pacopexia / Myocardial revascularization and ventricular restoration through pacopexy

OBJETIVO: Analisar o desempenho ventricular esquerdo após revascularização miocárdica associada à restauração da geometria ventricular pela "pacopexia", em pacientes portadores de miocardiopatia isquêmica com significativa disfunção ventricular, nos quais a restauração ventricular foi conseguida com técnica especial. MÉTODOS: Revascularização miocárdica associada à restauração da geometria ventricular através de técnica especial, sem utilização de próteses ou outros materiais sintéticos. RESULTADOS: Após o procedimento cirúrgico, foi observada melhora da classe funcional em 93,10 por cento dos pacientes. Houve um aumento significante na comparação pré e pós operatórias da fração de ejeção do ventrículo esquerdo e diminuição do diâmetro sistólico do ventrículo esquerdo. Não houve alteração significante do diâmetro diastólico do ventrículo esquerdo e do volume sistólico. O tempo de seguimento após a operação variou de 1 mês a 3 anos e 4 meses. CONCLUSÃO: A técnica de restauração ventricular através da pacopexia mostrou-se eficaz no tratamento da grave disfunção ventricular de origem isquêmica, com impacto sobretudo na melhora da classe funcional dos pacientes estudados.

OBJECTIVE: To analyze left ventricle performance after myocardial revascularization associated to ventricular geometrics restoration by "pacopexy" in schemic myocardiopathy patients with significant ventricular dysfunction in whom ventricular restoration was obtained through special technique. METHODS: Myocardial revascularization associated to ventricular geometrics restoration through special technique, with no use of prosthesis or other synthetic materials. RESULTS: PatientsÆ functional class was shown to have improved 93.10 percent after surgical procedure. Pre- and post-surgical comparison showed significant increase in left ventricle ejection fraction as well as decrease in left ventricle systolic diameter. No significant change was observed in left ventricle diastolic diameter or systolic volume. Post-surgical follow-up time length ranged from 1 month to 3 years and 4 months. CONCLUSION: Ventricular dysfunction restoration technique through pacopexy showed to be effective for the management of severe ventricular dysfunction from schemic causes. Major impact was observed in the functional class of patients under study.

Shunt direita-esquerda através de forame oval patente sem hipertensão pulmonar / Right to left shunt through a patent foramen ovale without pulmonary hypertension

Este artigo descreve um paciente que se apresentou com quadro de hipoxemia e platipnéia e cujo único achado na investigação foi a presença de um forame oval patente com shunt direita-esquerda sem hipertensão pulmonar, caracterizando uma síndrome rara conhecida como platipnéia-ortodeoxia, de interessantes características fisiopatológicas e com opções terapêuticas ainda não totalmente definidas.

This article describes a patient presenting with dyspnea and platypnea and whose only clinical finding was presence of patent foramen ovale with a right to left shunt, without pulmonary hypertension, characteristic of the rare Platypnea-Orthodeoxya Syndrome, with very interesting pathophysiological findings and with therapeutic alternatives not yet defined.

Ablação por cateter com radiofreqüência de vias acessórias esquerdas por abordagem transeptal / Radiofrequency catheter ablation of left accessory pathways by transeptal approach

OBJETIVO: Estudar uma série de pacientes submetidos a ablação por cateter, com radiofreqüência (RF) de vias acessórias (VA) esquerdas mediante abordagem transeptal (TS), comparando-os aos pacientes submetidos ao mesmo tipo de procedimento por abordagem arterial retrógrada (AR) convencional. MÉTODOS: Cem pacientes consecutivos (56 masculinos; 34,3 ± 11 anos de idade), portadores de 100 VA esquerdas (62 manifestas e 38 ocultas) foram submetidos a ablação por cateter por via TS (50 pacientes) e por via AR (50 pacientes), de forma alternada. A análise foi baseada na intenção de tratar. RESULTADOS: A punção transeptal foi realizada com sucesso em 48 (96 por cento) pacientes. Por esse acesso foi obtido sucesso primário na ablação em todos os pacientes e nenhuma complicação foi observada. Ao compararmos com o grupo AR não verificamos diferença em relação ao sucesso primário (p = 0,2), taxa de recorrências (p = 1,0), tempos de fluoroscopia (p = 0,63) e total (p = 0,47). No grupo AR um paciente apresentou complicação vascular. A abordagem TS proporcionou um menor tempo de ablação (p = 0,01) e número de aplicações de RF (p = 0,003) em relação à abordagem AR convencional. As recorrências e insucessos da primeira sessão de cada grupo foram submetidos a novo procedimento pela técnica oposta (cross-over), obtendo-se assim um sucesso final na ablação de 100 por cento. CONCLUSÃO: As abordagens TS e AR apresentam eficácia e segurança semelhantes para ablação de vias acessórias esquerdas. O tempo de ablação e o número de aplicações de RF foram menores com a abordagem TS. Quando as técnicas foram utilizadas de forma complementar, aumentaram a eficácia final da ablação.

Spontaneous Closure of Iatrogenic Coronary Artery Fistula to Left Ventricle After Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy

Cases of iatrogenic coronary artery fistulas draining into the left ventricle after surgical myectomy for hypertrophic obstructive cardiomyopathy have been published as sporadic reports. However, its management scheme and prognosis are not clear because of the low incidence. A 46-yr-old woman was hospitalized for evaluation of chest pain and shortness of breath for 3 months. Transthoracic echocardiographic examination showed typical hypertrophic obstructive cardiomyopathy with a peak pressure gradient of 71 mmHg across the left ventricular outflow tract. The patient underwent surgical septal myectomy. Postoperative color Doppler imaging revealed a diastolic blood flow from the interventricular septal myocardium to the left ventricular cavity, i.e. iatrogenic coronary artery fistula to the left ventricle. Ten days later, the fistula closed spontaneously which was diagnosed by transthoracic echocardiography and confirmed by coronary angiography.

Estratégia cirúrgica na transposicão das grandes artérias com septo interventricular intacto após o período neonatal / Surgical strategy for transposition of the great arteries with intact ventricular septum after the neonatal period

OBJETIVO: Analisar o resultado cirúrgico em portadores de transposicão das grandes artérias com septo interventricular intacto, operados após o período neonatal. MÉTODOS: Entre janeiro de 1998 e marco de 2004 foram atendidas 121 criancas com transposicão das grandes artérias com septo interventricular intacto, sendo 29 (24 por cento) após o período neonatal. A selecão para tratamento cirúrgico foi baseada na avaliacão ecocardiográfica pelo cálculo da massa do ventrículo esquerdo e da configuracão do septo interventricular. Das 29 criancas, 12 foram selecionadas para correcão anatômica primária, 12 para correcão em dois estágios, após preparo cirúrgico do ventrículo esquerdo e 5 submetidas a correcão atrial. RESULTADOS: No grupo submetido à correcão anatômica primária houve 1 (8,3 por cento) óbito hospitalar por sepsis. No grupo de correcão em dois estágios, 5 pacientes foram submetidos ao preparo lento, com correcão 3-6 meses após o 1º estágio, ocorrendo 4 óbitos após o 1º estágio. Este fato determinou mudanca no nosso protocolo, adotando-se a técnica de preparo rápido nos outros 7 pacientes, tendo todos atingido o 2º estágio. Das 8 criancas submetidas ao 2º estágio houve 1 óbito hospitalar e outro óbito tardio. A evolucão clínica tardia das criancas de ambos os grupos é excelente. CONCLUSAO: A selecão ecocardiográfica adequada da transposicão de grandes artérias com septo interventricular intacto quando abordada após o período neonatal, permitiu uma orientacão segura da escolha da melhor abordagem cirúrgica nestes pacientes.

Abordagem terapêutica dos projéteis retidos no coração / Management of bullets lodged in the heart

Paciente do sexo masculino, 29 anos, apresentando ferimento por arma de fogo, com projétil alojado no coração e que chegou ao hospital hemodinamicamente estável. O diagnóstico, evidenciando a localização da bala, foi feito pelo ecocardiograma transesofágico(ET). Após 18 dias, foi submetido a cirurgia eletiva, sem circulação extracorpórea(CEC), para retirada do projétil encravado em parede anterior do ventrículo direito(VD) e septo interventricular(SIV), com sucesso. Os autores discutem a conduta terapêutica para os projéteis retidos no coração, com base na literatura consultada, concluindo que a cirurgia para remoção dos mesmos pode ser indicada em pacientes assintomáticos individualizados

Post-operative outcome of ventricular reshaping by septal exclusion in patients with severe left ventricular dysfunction.

BACKGROUND: Post-myocardial infarction, anteroseptal dysfunction or akinesia is treated by septal reshaping to improve the surgical outcome in patients with severe left ventricular dysfunction. METHODS AND RESULTS: Between February 2003 to December 2003, 30 consecutive patients with previous anterior wall myocardial infarction and severe ventricular dysfunction underwent septal reshaping. All the dyskinetic and akinetic septal areas were excluded using an oval dacron patch which was sutured from the healthy septal area to the anterior wall, resulting in formation of a new apex. There were two mortalities in the group. After a mean follow-up of 4.2 +/- 1.6 months (1-7 months) it was seen that this procedure resulted in significant reduction of ventricular volume, increase in ejection fraction, an improvement in New York Heart Association class from 2.9 +/- 1.1 to 1.7 +/- 0.3, and a better apical geometry. CONCLUSIONS: In selected patients with left anterior descending artery occlusion resulting in anteroseptal dyskinesia or akinesia, septal exclusion technique provides good clinical and morphological results with significant improvement in left ventricular function.