Partial left ventriculectomy: preoperative risk factors for perioperative mortality.

This study aimed at determining risk factors for perioperative mortality for patients undergoing partial left ventriculectomy. Fourteen patients with end-stage congestive heart failure underwent partial ventriculectomy at our institution from February, 1995 to October, 1997. Mean age was 48+/-11 years, symptoms duration 44+/-34 months, New York Heart Association symptoms score 4+/-0, systolic blood pressure 97.69+/-20.06 mmHg, diastolic blood pressure 65.38+/-13.91 mmHg, heart rate 91+/-15 beats/min, furosemide daily dose 121.66+/-96.65 mg and captopril daily dose 68.75+/-76.76 mg. Seven (50%) patients needed inotropic support for hemodynamic stabilization. On echocardiography, left ventricular diastolic dimension was 81.71+/-11.92 mm. Left ventricular ejection fraction determined by radionuclide ventriculography or echocardiography was 16.71+/-5.13. At heart catheterization, mean right atrial pressure was 12.50+/-7.72 mmHg, mean pulmonary capillary wedge pressure 23.60+/-7.79 mmHg, and mean pulmonary artery pressure 34.10+/-12.81 mmHg. Twelve patients had idiopathic dilated cardiomyopathy and two patients had a globally dilated heart with single vessel coronary artery disease. Aneurysmectomy, mitral valve surgery or coronary artery bypass surgery were not performed in any patient. Four (28%) patients died: three in the operating theatre and one from low output syndrome 2 days after surgery. The proportion of patients operated on with cardiogenic shock was four (100%) in nonsurvivors and 0% in survivors (P=0.001). Inotropic support was necessary in three (30%) survivors and in four (100%) nonsurvivors (P=0.06). Thus, preoperative hemodynamic instability may be associated with perioperative mortality after partial left ventriculectomy.

[Clinical course of patients treated with partial left ventriculectomy]. / Evolução clínica de pacientes submetidos à ventriculectomia esquerda parcial.

OBJECTIVE: To assess the efficacy of partial left ventriculectomy as a treatment for patients with end-stage heart failure. METHODS: From February to June 1995, 7 patients with end-stage heart failure underwent partial left ventriculectomy. Subsequently, patients underwent clinical evaluation every 2 months, and 2-dimensional echocardiography at the 6th and 12th months after cardiac surgery. All patients were given digitalis and diuretics at conventional doses, and captopril or enalapril at maximal tolerated doses. RESULTS: Two (28%) patients died; 1 from cardiac arrhythmia associated with gastrointestinal hemorrhage, and the other suddenly. One (14%) patient developed an embolic cerebrovascular accident. Four (57%) patients were hospitalized for congestive heart failure; all of them had either decreased the daily dose of captopril or enalapril or discontinued the drugs by themselves. Twelve months after ventriculectomy, left ventricular ejection fraction values were greater and left ventricular diastolic dimension and functional class values lower than those found before cardiac operation. CONCLUSION: Beneficial effects of partial left ventriculectomy are observed one year after the surgical procedure. This technique, therefore, can be useful for the treatment of patients with end-stage heart failure.

[Initial experience with partial left ventriculectomy as a treatment for end-stage heart failure]. / Experiência inicial com a ventriculectomia parcial esquerda no tratamento da insuficiência cardíaca terminal.

PURPOSE: To evaluate the efficacy of left ventriculectomy, on a short term basis, as a treatment for patients with end-stage heart failure. METHODS: From February to June 1995, 7 patients with end-stage heart failure underwent partial left ventriculectomy. Before the surgical procedure, 7 (100%) patients were in functional class IV. Three (42%) patients needed inotropic support for hemodynamic stability. The mean daily dose of furosemide was l48.67 +/- 128.27 mg, of captopril 87.50 +/- 95.20 mg and of digoxin 0.23 +/- 0.04. Mean left ventricular diastolic dimension determined by 2-D echocardiography was 78.29 +/- 12.63 mm, mean left ventricular ejection fraction, determined by radionuclide ventriculography, was 0.15 +/- 0.05 whereas mean transpulmonary gradient and pulmonary vascular resistance in Wood units, determined by right heart catheterization, were 16.80 +/- 8.80 and 6.57 +/- 3.22, respectively. RESULTS: Sixty days after the surgery, the mean functional class was 1.71 +/- 0.48 (p = 0.009), the mean left ventricular diastolic dimension 64.67 +/- 11.41 mm (p = 0.02) and the mean left ventricular ejection fraction 0.22 +/- 0.04 (p = 0.02). CONCLUSION: The left ventriculectomy is a promising treatment for patients with end-stage heart failure.

[Surgical approach in bacterial endocarditis of the tricuspid valve in children. Report of 2 cases]. / Abordagem cirúrgica na endocardite bacteriana da valva tricúspide em crianças. Relato de dois casos.

The two techniques usually employed for the surgical treatment of tricuspid valve endocarditis are valve replacement or simple valve excision without valve replacement. A third more conservative procedure consists of resection of the vegetation ("vegetectomy") and leaflet repair, if necessary. Valve excision without valve replacement is described in adult patients especially in addicts of intravenous drugs, with normal ventricular function. Two cases of tricuspid valve endocarditis in children with interventricular communication successfully treated by "vegetectomy" and valve excision without valve replacement are reported. In the first case, surgery was performed during acute infection. Contrarily in the other case there was evidence that cure had been obtained, but still the prosthesis was not implanted due to the excellent hemodynamic status at the moment, and to abbreviate bypass time due to the preoperative conditions of the child. The uncommon approach to these two cases of tricuspid valve endocarditis in childhood motivated this presentation.

[Postoperative atrial fibrillation in myocardial revascularization]. / Fibrilação atrial pós-operatória na revascularização do miocárdio.

Many studies have demonstrated fairly high incidence of supraventricular arrhythmias after coronary artery bypass surgery, and have tried to identify preoperative, operative and postoperative factors related to their appearance. The present paper analysed 186 patients submitted to coronary artery bypass and reported a incidence of atrial fibrillation of 6.04% (11 cases). The male sex was dominant (81.2%) with ages varying from 49 to 73 (mean 54.58) years. The preoperative incidence of diabetes, smoking and systemic hypertension were, respectively, 18.2%, 54.51% and 36.4%. The mean number of vessels bypassed was 2.42 +/- 1.19 and the left circumflex artery was involved in 81.20% of these cases. Cardiopulmonary bypass time was 100 +/- 39.6 min and ischemic arrest time of 79.6 +/- 37.7 min. Single double stage cannulae for venous drainage were used in 45.5% of the patients and ventricular fibrillation and cardiac overdistention occurred in 63.60% immediately after CPB. Atrial fibrillation presented around 1.66 +/- 2.17 days in the postoperative period and 45.5% of the patients had more than one distinct episode of the arrhythmia. Treatment constituted of cardioversion in 25%, atenolol oral in 18.75% and digitalis associated to quinidine in 56.25%. These numbers permit us to suggest that some of the above factors may contribute to the genesis of arrhythmias, such as single double stage cannulation for venous drainage, inadequate myocardial protection, overdistention and cardiac fibrillation and, mainly, the presence of proximal circumflex artery obstructions responsible for atrial ischemia before and during surgery.

Surgical excision of the vegetation as treatment of tricuspid valve endocarditis.

The usual surgical treatment of tricuspid endocarditis is valve replacement or valve excision alone without valve replacement. 'Vegetectomy', i.e. local excision of the vegetation and leaflet repair, has been previously described and can be applied to cases with well-circumscribed vegetations and little or no valve damage. A case of tricuspid valve endocarditis successfully managed by surgical excision of the vegetation is reported.

A simple mechanical system for pulsatile cardiopulmonary bypass.

The authors present a mechanical system for pulsatile cardiopulmonary bypass. Its major advantages are: simplicity, low cost and the synchronization of pulse generation with the arterial roller. This system has been used clinically since 1981.

Late surgical repair of ventricular septal defect due to nonpenetrating chest trauma: review and report of two contrasting cases.

Traumatic rupture of the interventricular septum is a rare condition usually presenting in infancy and childhood. This report describes two cases: a 3-year-old boy operated on soon after the diagnosis was made, and a 15-year-old girl operated on 12 years following the causative accident. Both patients had the diagnosis confirmed by cardiac catheterization. The typical appearance of a traumatic ventricular septal defect (VSD) was seen during surgical repair that was successfully carried out in both patients. The protracted clinical course of the second patient, eventually requiring corrective intervention, contributes to the understanding of natural history of traumatic VSD.

Níveis séricos de digoxina em pacientes submetidos à cirurgia cardíaca com circulação extracorpórea / Serum digoxin levels in patients subjected to cardiac surgery with extracorporeal circulation

Determinou-se por metodo imunienzimatico, o nivel serico digoxina antes, durante e apos a circulacao extracorporea (CEC) para correcao de valvopatias, em 21 pacientes que fizeram uso de 0,25mg/dia do medicamento ate o dia anterior a operacao.Os resultados medios das dosagens foram, respectivamente, 1,95 +/- 0,94; 1,46 +/- 0,82 e 162 +/- 0,74 ng/ml, com diminuicao estatisticamente significante durante a CEC (p < 0,01) e nao significante quando se compararam os valores obtidos antes e apos a CEC. Conclui-se que a CEC nao influiu nos niveis sericos de digoxina, sendo as pequenas variacoes atribuidas a hemodiluicao. Nao se observaram arritmias ventriculares importantes depois da CEC a no pos-operatorio imediato/

Fluxo pulsátil em circulação extracorpórea. Apresentação de um sistema mecânico com estudos preliminares hemodinâmicos e do transporte de oxigênio / Pulsatile flow in extracorporeal circulation. Presentation of a mechanical system with preliminary hemodynamic and oxygen transport studies

Estudaram-se 20 pacientes submetidos a cirurgia cardiaca com circulacao extracorporea (CEC) e hipotermia, 10 deles perfundidos com um novo sistema mecanico para obtencao de fluxo pulsatil. Os resultados obtidos para cada grupo, pelo estudo das variaveis do transporte de oxigenio, nao foram significantemente diferentes. Por outro lado, observou-se diminuicao da resistencia vascular sistemica nos pacientes perfundidos com fluxo pulsatil. Concluiuse que o sistema para obtencao do fluxo pulsatil em CEC e simples, seguro, estando em andamento outros estudos sobre o metod