Use of bovine pericardial tissue for aortic valve and aortic root replacement: long-term results.

BACKGROUND AND AIMS OF THE STUDY: The study aimed to determine the clinical performance of bovine pericardial aldehyde-treated products alone or in combination with aortic leaflets of porcine origin. These included a composite porcine stentless aortic valve attached to a scalloped pericardial tube (BSAV), and valved and non-valved bovine pericardial conduits for use in left-sided heart lesions (BPG). METHODS: For BSAV grafts, between January 1990 and August 1996, 163 patients (119 males) had their aortic valves replaced by SJM Biocor BASV. Mean age was 37.9 +/- 17.6 years (range: 1 to 76 years). Rheumatic heart disease sequelae (n = 72) and replacement of a prosthetic heart valve (n = 46) were predominant. Preoperative NYHA functional class showed 90 patients (55.2%) in class III and 50 (30.7%) in class IV. BPVC and NVPC grafts were used in 166 patients: acute aortic dissection was the main indication in 52 (31.3%) and chronic in 36 (21/7%). The ascending aorta was involved in 141 patients (84.9%); grafts were seldom used at other sites. In most patients the graft implanted was either a non-valved (n = 79) or a valved (n = 75) pericardial conduit. Twelve patients had a localized lesion and required a patch repair. RESULTS: For BASV grafts, the non-valve-related hospital mortality rate was 4.9%. There were 14.7% non-fatal complications with full recovery of all patients. Mean follow up in 141 patients was 3.0 +/- 1.4 years (range: 1 month to 7.2 years); 14 patients were lost to follow up. Late, non-conduit-related, mortality occurred in seven patients (4.9%). Eight patients underwent reoperation. The current clinical follow up of 127 patients has shown 118 (92.9%) with competent valves and nine (7.0%) with mild stable aortic insufficiency. For BPVC and NVPC grafts, hospital mortality rate was 16.9%, death being related to poor preoperative clinical condition. Postoperative follow up was accomplished in 125 patients; reoperation was necessary in seven patients. Histology showed good tissue preservation up to five years; echocardiography revealed satisfactory findings. No valved conduit had to be reoperated for valve or pericardial tissue wear. CONCLUSIONS: Clinical results of left-sided heterologous pericardial grafts have shown excellent performance over time. The BASV (over seven years) and BPVC and NVPC (eight years) have demonstrated superior results as aortic valves alone or in combination with a pericardial conduit.

Fibrilação; ventricular em pacientes com forma permanente da taquicardia juncional reciprocante / Ventricular fibrillation in a patient with the permanent form of junctional reciprocating tachycardia

Homem de 20 anos, portador de taquicardia de apresentaçäo incessante há longos anos, sem resposta a medicaçöes antiarrítmicas. Seis meses antecedendo a admissäo referia paroxismos de taquicardia mais rápida, de duraçäo curta, autolimitada. Na admissäo apresentava flutter atrial com conduçäo 1:1 (250 bpm) que degenerou em fibrilaçäo ventricular, revertida com 350J. O estudo eletrofisiológico identificou taquicardia atrioventricular, utilizando conexäo anômala "oculta" de localizaçäo póstero-septal deita com conduçäo lenta e propriedade decremental, conduçäo atrioventricular acelerada, observando-se precipitaçäo de fibrilaçäo atrial com resposta rápida pós-atropinizaçäo. Foi submetido a ablaçäo por cateter pro radiofrequência com sucesso. Esta assintomático, 18 meses após o procedimento.

[Atriofascicular connection with slow conduction and longitudinal dissociation. Electrophysiologic evidence and clinical implications]. / Conexão átrio-fascicular com condução lenta e dissociação longitudinal. Comprovação eletrofisiológica e implicações clínicas.

We report on a patient with paroxysmal left bundle branch block-like tachycardia with electrophysiologic findings suggestive of nodoventricular pathway (ventricular pre-excitation dependent on slowing of AV conduction, and accessory pathway with exclusive anterograde conduction). There was no pre-excitation during sinus rhythm but it was brought on by intravenous verapamil. Atrioventricular node conduction curves showed no signs of duality. Diagnosis of an atriofascicular pathway with decremental properties was based on the following findings: 1) absence of AV dissociation during reciprocating tachycardia; 2) absence of fusion beats or narrowing QRS complexes during tachycardia; 3) advancement of right ventricular activation with late atrial extrastimuli delivered during antidromic tachycardia at a time of low right atrium refractoriness; 4) observation that earliest ventricular endocardial electrogram during tachycardia (activation mapping) was simultaneous with the right bundle potential; 5) surgical ablation of the accessory pathway by endocardial incision at the right anterior aspect of the tricuspid ring, far away from the AV node region. Evidences showing anterograde longitudinal dissociation of the accessory pathway included cycle length alternation during tachycardia and duality of accessory pathway conduction times and refractory periods. We hypothesize that reentry occurring in such AV node-like structure could give to a pre-excited tachycardia with AV dissociation mimicking antidromic tachycardia associated with nodoventricular pathway.

[Surgery for Wolff-Parkinson-White syndrome in the first year of life]. / Cirurgia para síndrome de Wolff-Parkinson-White no 1. ano de vida.

A case of surgical treatment for reentrant atrioventricular tachycardia in a 7 months old child is reported. Episodes of tachycardia were repetitive and long-lasting, often leading to signs of hemodynamic impairement, and were not controlled by antiarrhythmic drugs. The electrophysiologic study showed a circus-movement tachycardia utilizing a concealed accessory pathway located at the anterior septal aspect of tricuspid anulus. The child underwent successful surgical treatment by the endocardial technique. Few minutes after weaning from extracorporeal circulation, developed T wave inversion followed by acute right ventricular dysfunction and ventricular fibrillation. Others ischemic like episodes, maybe as a result of coronary artery spasm, occurring in the next 6 hours were successfully treated with isosorbide dinitrate. At 18 months follow-up, the child is free of tachycardia and has normal atrioventricular conduction.

[Transcoronary chemical ablation of ventricular tachycardia in a patient with chronic chagas cardiomyopathy]. / Ablação química transcoronária de taquicardia ventricular em portador de cardiopatia chagásica crônica.

A case of recurrent ventricular tachycardia in the setting of chronic chagasic heart disease refractory to conventional antiarrhythmic agents as well as high doses of amiodarone (600 mg/day) is reported. Left ventriculography disclosed an apical aneurysm and a filling defect image suggestive of a thrombus. Sustained monomorphic ventricular tachycardia with the same QRS configuration as "clinical" tachycardia could be induced by means of right ventricular programmed electrical stimulation. The risk of systemic embolization precluded endocardial activation mapping of ventricular tachycardia. Intracoronary cold saline injections were done during induced ventricular tachycardia looking for a coronary artery branch related to the arrhythmogenic substrate. Cold saline mapping results pointed to an apical site of origin. Next step was intracoronary injection of ethyl alcohol in the distal part of the left anterior descending artery leading to a small and uncomplicated myocardial infarction. Control programmed stimulation was unable to reinduce ventricular tachycardia. Clinical outcome was uneventful and there was no recurrence of clinical arrhythmia in 6 months of follow-up.

[Cardiomyopathy induced by incessant ventricular tachycardia ("tachycardiomyopathy"): cure after control of arrhythmia]. / Miocardiopatia induzida por taquicardia ventricular incessante ("taquicardiomiopatia"). Cura após controle da arritmia.

A case of severe dilated cardiomyopathy in a young boy presenting with incessant ventricular tachycardia, who had been referred for heart transplantation is reported. Complete resolution of dilated cardiomyopathy followed arrhythmia control with oral amiodarone. Such evolution strongly suggests a cause-effect relationship between incessant ventricular tachycardia and dilated cardiomyopathy in this particular case.

Clinical results with the Biocor porcine bioprosthesis.

In order to evaluate our clinical results with the use of the Biocor prosthesis, a total of 1,101 patients were studied. Follow-up was from 1 to 96 months (mean 48); cumulative follow-up in the aortic group (385 patients) was 1,230 patient years and in the mitral group (716 patients) 3,018 patient years. Mitral patients had 102 late complications (14.24%), and aortic patients had 51 (13.2%). A total of 220 patients were under 20 years of age (176 mitral, 44 aortic). Intrinsic valve failure in this subgroup was found in 43% of mitral patients and 29% of aortic patients. Prosthetic endocarditis was more frequent in the aortic group (45%) than in the mitral group (29.9%). Sixty-two patients were reoperated, with a hospital mortality of 12.6%. Reoperation was more frequent in the mitral group and in patients under 20 years of age. The actuarial curve free mortality related to the bioprosthesis was 97.1% (32 patients). At the 8-year follow-up, 96.9% of the aortic versus 95.2% of the mitral group were free of valve dysfunction, and the majority were in Classes I or II of the New York Heart Association (NYHA) classification. The incidence of reoperation, although significant, is acceptable, especially since the bioprosthesis offers a safer alternative than mechanical prostheses followed for similar periods. Analysis of our results suggests the need for continued research for an ideal bioprosthesis.

[Congenital absence of left pericardium simulating tumor of the anterior mediastinum]. / Agenesia de pericárdio esquerdo simulando tumor de mediatino anterior.

The authors report a case of a patient presenting atypical dyspnea symptom. The physical examination, the chest roentgenogram and EKG were abnormal; the echocardiogram showed an abnormal mass compressing the outflow tract of the right ventricle (RV). These data were confirmed by a computerized tomography. The cardiac catheterization showed a heart deviation to the left and a RV outflow tract gradient of 10 mmHg. Consequently a surgery was necessary. The surgical findings presented an absence of the left pericardium and no tumor was found. This is a rare entity that may be misdiagnosed as other heart diseases but this is the first case in which a tumor of the anterior mediastinum was suspected.

[Tetralogy of Fallot associated with total anomalous drainage of the pulmonary veins. Report of 2 cases]. / Tetralogia de Fallot associada a drenagem anômala total de veias pulmonares. Relato de dois casos.

The authors report on two cases of tetralogy of Fallot (TF) associated with total anomalous pulmonary venous return to the coronary sinus. The clinical manifestations in both children were the same as of classical TF and diagnosis was confirmed by cineangiography. The patients underwent total surgical correction and the first one died in the immediate post-operative period. The second patient had an uneventful recovery. The rarity of this association is the main reason of this report where clinical and surgical findings are discussed.

Correção cirúrgica da estenose supra aórtica localizada. Relato de 2 casos / Surgical correction of localized supra-aortic stenosis. Report of 2 cases

Dois casos de estenose supra-aortica localizada foram submetidos a correcao cirurgica por tecnica de aortoplastia alargada.Um dos pacientes apresentava uma associacao rara de agenesia da arteria pulmonar direita, nao sendo encontrada nenhuma referencia a este repeito na literatura consultada. Ambos exibiam estenoses supra-aorticas severas com gradientes superiores a 90 mmHg e obtiveram excelente resultado pos-operatorio, comprovado pelo segmento clinico e estudo hemodinamico. Sao discutidos os aspectos relacionados com a tecnica empregada e suas vantagens perante os metodos tradicionais de correcao

Complicacoes vasculares nos transplantes renais. / Vascular complications in renal transplantation

Os autores apresentam analise de 115 casos de transplantes renais realizados pelo Grupo de Transplantes Renais do Hospital Felicio Rocho e Hospital das Clinicas da Faculdade de Medicina da Universidade Federal de Minas Gerais, com enfase as complicacoes vasculares. Dos 115 casos operados, tivemos 7 complicacoes vasculares.Dos valentes a uma percentagem de 6,0%. De maneira geral, os problemas vasculares quando aparecem no pos-operatorio imediato ou tardio, simulam um quadro de rejeicao. Encontramos frequentemente queda do volume urinario associado ou nao a elevacao ou estabelecimento de niveis tensionais altos A complicacao mais frequente em nosso estudo foi exatamente a oclusao da arteria renal (tres casos), seguida por ruptura renal (um caso), estenose de arteria renal (um caso), ruptura espontanea da arteria iliaca (um caso) e hemorragia hilar (um caso). As complicacoes vasculares estao en intima relacao a problemas tecnicos peroperatorios tais como a manipulacao renal durante a sua retirada, a perfusao renal e a confeccao das anastomoses. A atencao a estes detalhes nos proporcionara um numero reduzido de problemas pos-operatorios

Atresia pulmonar com comunicacao interventricular. Aspectos angiograficos e cirurgicos em sete pacientes. / Pulmonary atresia with ventricular intercommunication. Angiographic and surgical aspects in 7 patients

Sao estudados 7 casos de pacientes portadores de atresia pulmonar com comunicacao interventricular divididos em 2 grupos. No grupo A, constituido por 3 lactentes, o achado mais comum foi de um canal arterial persistente muito estenosado. Nesse grupo, 2 pacientes foram submetidos a cirurgias paliativas. O grupo B e composto por 4 pacientes com idade superior a 6 anos. Em 3 deles o fluxo pulmonar dependia fundamentalmente de arterias colaterais sistemico-pulmonares e no outro paciente, o ramo esquerdo da arteria pulmonar estava conectado a um canal arterial, que exibia severa estenose. Nesse grupo, 3 pacientes foram submetidos a cirurgias paliativas e em 2 deles, associou-se a ligadura de arterias colaterais sistemico-pulmonares. Discute-se a importancia da avaliacao angiografica nos casos de atresia pulmonar, com vistas a identificacao das arterias colaterais, bem como das arterias pulmonares. Comentam-se as suas implicacoes no tratamento cirurgico, corretivo ou paliativo