Heart transplant in a patient with complete absence of the pericardium.

We report the case of a heart transplant in which the recipient patient had a total congenital absence of the pericardium. Associated with this, we found a major disproportion between the size of the recipient's mediastinal cavity and the size of the donor's heart. To prevent twisting of the great arteries, we placed the graft on the left diaphragm muscle and beneath the left lung, which resulted in an uneventful early and late postoperative course.

Partial tricuspid valve transfer for repair of mitral insufficiency due to ruptured chordae tendineae.

BACKGROUND: A new technique is suggested for the reconstructive surgical treatment of mitral regurgitation. It involves partial transfer of the tricuspid valve of the patient to the mitral valve, in order to provide chordae to correct anterior leaflet prolapse of the mitral valve, secondary to rupture of the chordae tendineae. METHODS: From January 1991 to May 1997, 20 patients with mitral insufficiency due to rupture of the chordae were operated on. The prevailing cause was myxomatous degeneration (70%). Patients were in New York Heart Association functional class III and IV. RESULTS: There were no hospital deaths. Two patients were reoperated on. Eighteen patients (90%) are alive with their own valves (class I and II). Doppler echocardiogram mean values were: ejection fraction, 0.65; left atrial diameter, 4.2 cm; mitral area, 2.4 cm2; mitral transvalvular gradient, 3.3 mm Hg. No regurgitation or mild regurgitation was observed in 16 (94.1%) of the 17 cases evaluated. Mean tricuspid valvular area was 3.3 cm2. In all cases, no tricuspid regurgitation was present or it was mild. CONCLUSIONS: Partial transfer of the tricuspid valve to the mitral valve is an effective procedure for the surgical treatment of mitral valve insufficiency secondary to ruptured chordae tendineae of the anterior leaflet.

[Immediate and late results of the surgical treatment of the aneurysms and dissections of the ascending aorta]. / Resultados imediatos e tardios do tratamento cirúrgico dos aneurismas e dissecções da aorta ascendente.

PURPOSE: To report our experience and results with the surgical treatment of aortic aneurysms and dissections of the ascending aorta as well as the techniques that have been used. METHODS: Between May 1982-May 1995, 54 patients were operated on and divided in two groups: group A was composed of 25 patients with aneurysms or chronic dissections of the ascending aorta. The Bentall and DeBonno procedure was performed in 18, five were submitted to prosthetic aortic graft associated with aortic valve replacement and two prosthetic aortic graft without aortic valve replacement. Group B had 29 patients with acute dissections of the ascending aorta (type A) who were submitted to 10 prosthetic graft alone, nine Bentall procedures, five prosthetic graft with aortic valve replacement, four aortic repair and one direct suture of the dissection. The survival curve was obtained by the Kaplan-Meier method. RESULTS: Total hospital mortality rate was 13% and the late was 18.5%. Group A-immediate mortality rate was 8% (two patients): Low cardiac output and stroke; late mortality rate was five (20%): sudden death in three, pulmonary embolism one and infectious endocardite one. Group B-hospital mortality rate was five (17.2%) patients: low cardiac output three, multiple organs failure one and stroke with pneumonia one; late mortality rate was five (17.2%), distal redissection in three, sudden death in two. The average survival time was 86 +/- 12 for group A and 75 +/- 13 months for group B. CONCLUSION: The surgery of the aneurysm and dissections of the ascending aorta has shown immediate favorable results and a thorough follow-up to get better late results is needed.

Cox maze operation without cryoablation for the treatment of chronic atrial fibrillation.

BACKGROUND: From August 1993 to May 1994, 20 patients (mean age, 43 years) with atrial fibrillation underwent the maze operation without cryoablation. Ten patients had mitral stenosis, 5 had mitral insufficiency, and 5 had a mixed mitral lesion. The mean left atrial diameter as measured on echocardiograms was 6.1 cm. The cause was rheumatic in 17 patients (85%) and degenerative in 3 (15%). Seven patients had had previous episodes of thromboembolism. METHODS: Mitral valvuloplasty was performed on 7 patients, mitral commissurotomy on 4, and mitral valve replacement on 9. Thrombi were found in the left atrium of 7 patients and also in the right atrium in 2. The mean cross-clamp time was 73 minutes (range, 52 to 108 minutes). RESULTS: Patients were discharged from the hospital in good condition. Hemodynamic studies and Doppler echocardiograms showed significant reduction in the left atrial diameter (mean diameter, 4.9 cm; p < 0.01) in 18 patients. The two-channel Holter monitor showed sinus rhythm in 15 patients, atrial ectopic rhythm in 4, and atrial fibrillation in 1. Eleven patients (55%) experienced atrial fibrillation (9 in the first 3 months postoperatively), which was reversed with quinidine. Ninety percent of patients had development of an effective, synchronous, atrial systole. Six to 15 months postoperatively (average follow-up, 10 months), all patients were in functional class I, and 18 were not on a regimen of antiarrhythmic medication. CONCLUSIONS: This simplification of the maze operation has been demonstrated to be an effective alternative for the treatment of chronic atrial fibrillation.

[Use of tranexamic acid for bleeding control in myocardial revascularization]. / Emprego do ácido tranexâmico para controle de sangramento em cirurgia de revascularização miocárdica.

PURPOSE: To compare two groups of 80 patients undergoing to myocardial revascularization with the use of antifibrinolytic drug tranexamic acid and its efficacy in reduce bleeding and blood transfusion. METHODS: Prospective analysis of two groups of 80 patients. Group A-no antifibrinolytic therapy (dec 91-may 92) and group B-fibrinolytic therapy-tranexamic acid-10g EV (jun-dec/92). Quantification of mediastinal drainage over 12h as well as the blood or derivatives received at the same time. RESULTS: Hospital mortality: group A-3.8%, group B-2.5%. Drainage (12h): group A-602 +/- 547 ml and group B-260 +/- 260 ml (p < 0.001). Blood transfusion (12h): group A-1,782 +/- 1,163 ml and group B-1,105 +/- 839 ml (p < 0.001). COMPLICATIONS: group A-two cases of intraoperative myocardial infarction, one episode of jaundice; group B-one case of intraoperative MI, one reoperation for bleeding control, one episode of jaundice, one of renal insufficiency, two mediastinitis and one seizure. The mean hospitalization time was ten days in both groups. CONCLUSION: Tranexamic acid was an effective drug in bleeding control and in reducing blood transfusion in the postoperative of patients submitted to myocardial revascularization.

Modified technique for total cavopulmonary connection.

The laterolateral anastomosis between the superior vena cava and the pulmonary artery trunk is presented as a modified technique for total cavopulmonary connection. This procedure was successfully performed on a 9-year-old girl, associated with the exclusion of the right atrium, for the treatment of tricuspid atresia and transposition of the great arteries.