Relaciones biométricas del anillo atrioventricular izquierdo y las arterias coronarias en el hombre / Biometric relationships between the left atrioventricular ring and the coronary arteries in man

La relación de las arterias coronarias con los anillos atrioventriculares se torna importante en casos de reemplazo o plastía de la valva correspondiente. La proximidad de la rama circunfleja de la arteria coronaria izquierda al anillo atrioventricular izquierdo, a nivel de la comisura anterior, ha traído complicaciones quirúrgicas, en algunos casos con resultados fatales. Basado en lo anterior, estudiamos las relaciones biométricas entre las arterias coronarias y el anillo atrioventricular izquierdo. Utilizamos 58 corazones de individuos chilenos, 28 fijados en formaldehído al 10 por ciento y 30 frescos de individuos brasileños, de edades comprendidas entre 18 y 84 años, de ambos sexos y sin aparente cirugía cardíaca. Disecamos la región de ambos surcos coronarios, para luego clasificar las piezas según el tipo de dominancia coronaria. Luego, los atrios fueron resecados dejando visibles los anillos atrioventriculares y su relación con las arterias coronarias. Se efectuaron mediciones de la distancia de las arterias coronarias y sus ramas en relación al anillo atrioventricular izquierdo. Se establecieron 5 puntos en la porción posterior del anillo, distribuidos en sentido antihorario. Los puntos 1 y 5 localizados a nivel de las comisuras anterior y posterior, respectivamente. La menor distancia entre las ramas de las arterias coronarias y el anillo atrioventricular izquierdo se presentó en corazones con dominancia coronaria izquierda, y fue de 3,8 mm (corazones fijados) y 3,0 mm (corazones frescos).El tercio proximal de la rama circunfleja, asociado a una mayor proximidad al anillo mitral, constituye el área de mayor predisposición a una lesión iatrogénica durante un reemplazo y/o plastía valvar.

The relationships between the coronary arteries and the atrioventricular rings are important in cases of substitution or plastic of the corresponding valve. The vicinity of the circumflex branch of the left coronary artery to the left atrioventricular ring, at level of the previous corner, it has brought surgical complications, in some cases with fatal results. Due to this, we consider necessary to study the relationships biometric between the coronary arteries and the left atrioventricular ring. We use 58 hearts, 28 fixed hearts of Chilean individuals and 30 fresh hearts of Brazilian individuals, of ages between 18 and 84 years, of both sexes and without apparent heart surgery. The region of both coronary sulcus was dissected and we classified the pieces according to the type of coronary dominance. Later on, the atrium were dried up leaving visible the atrioventricular rings and their relationship with the coronary arteries. Measurement of the distances were made (in mm) of the coronary arteries and their branches, in relation to the left atrioventricular ring. Five points settled down in the later portion of the ring, distributed in having felt anti-timetable. The points 1 and 5 located at level of the previous and later corners, respectively. The smallest distance between the branches of the coronary arteries and the left atrioventricular ring was presented in hearts with left coronary dominance, and it was of 3,8 mm (fixed hearts) and 3,0 mm (fresh hearts).

Tratamento cirúrgico valvar concomitante a revascularizaçäo do miocárdio / Valvar surgical treatment concomitant to myocardial revascularization

Objetivo - Estudo da morbidade e da mortalidade decorrentes do tratamento cirúrgico valvar concomitante à revascularização do miocárdio. Métodos - Entre 1650 pacientes submetidos a tratamento cirúrgico da valva mitral ou aórtica, a revascularização do miocárdio foi realizada concomitantemente em 103 (6,24%). A insuficiência coronária estava associada à lesão da valva aórtica em 66 (64,0%) pacientes (grupo D, e à lesão da valva mitral em 37 (35,9%) pacientes (grupo II). O diagnóstico foi baseado na anamnese, exame físico, e confirmado através do estudo cinecoronariográfico. Resultados - I - Complicações no pós-operatório imediato: a) mortalidade - 11 (10,6%) pacientes, sendo 6 (9,09%) do grupo I e 5 (13,5%) do grupo II. As causas de óbito no grupo I foram: baixo débito cardíaco (3 pacientes); arritmia incontrolável (1), mediastinite (1), e infarto agudo do miocárdio seguido de choque cardiogênico (1). Dos 5 óbitos verificados no grupo II, 2 foram decorrentes de hemorragia incontrolável, 1 teve morte súbita por oclusão de ponte de safena, e 2 faleceram após insuficiência respiratória e sepses; b) intercorrências que puderam ser controladas, mas aumentaram o período de internação hospitalar: confusão mental (5 pacientes); acidente vascular cerebral (1), descompensação diabética (2); insuficiência renal crônica agudizada (1); hemorragia digestiva alta (1) e insuficiência respiratória (3). II - Complicações observadas no pós-operatório tardio dentre 77 (83,6%) pacientes seguidos de 4 a 60 meses: a) mortalidade: 3 (3,89%) pacientes, (2 por miocardiopatia) e 1 subitamente por infarto agudo do miocárdio; b) capacidade funcional III (NYHA) (6 pacientes, conseqüente a miocardiopatia); os demais 68 pacientes permaneceram em CF I/II. Recorrência de angina em 6 pacientes; 2 foram revascularizados ao final de 36 e 42 meses, respectivamente

Purpose - To study the morbidity and mortality due to valvar surgical treatment performed concomitantly to myocardial revascularization. Methods - From 1650 patients submitted to mitral or aortic valve surgical treatment, 103 (6.24%) had it associated to myocardial revascularization. Coronary insufficiency was associated to aortic valvar lesion in 66 (64.0%) patients, group I, with mean age of 62.3 ± 8 years; and in 37 (35.9%) patients with mitral valve lesion, group II, with mean age of 57.8 ± 5.8 years. Diagnosis was based upon the anamnese, physical examination and confirmed by cinecoronariographic findings. Results - I - Complications at the immediate postoperative: a) mortality 11 (10,6%) patients, 6 (9,09%) from group I: by low cardiac output 3, uncontrolled arrhythmia 1, mediastinitis 1; acute infarction with cardiogenic shock 1, and 5 (134,5%) of group II: uncontrolled hemorrhage 2, sudden death 1, saphenous vein graft occlusion, respiratory insufficiency and sepsis 2; b) controlled intercurrences that increased the time of hospitalization: mental disorder 5 patients; CVA 7, diabetis descompensation 2, worsening of chronic renal insufficciency 1, upper level digestive hemorrhage 1 and respiratory insufficiency 3 patients. II - late postoperative complications of 77 (83,6%) patients which could tee followed up during a period of 60 months: 1) mortalility: 3 (3,89%) patients; 2 due to cardiomyopathy and 1 by acute myocardial infarction; 2) late evolution - functionalcapacity III (NYHA) by cardiomiopathy 6; I/II 68 patients; mild angina 6 patients, 2 underwent revascularization at the end of final 36-42 months. Conclusion - The clinical improvement and mortality indexes statistically similar to the isolate surgical acts stimulate us to keep up with such associate procedures