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Abstract Introduction: Left ventricular dysfunction after surgical treatment of mitral stenosis is uncommon. We intend to determine the pattern of left ventricular remodeling, shortly after open mitral valve replacement for rheumatic mitral stenosis, with in-hospital postoperative outcomes and the determinants of postoperative worsening of left ventricular ejection fraction. Methods: From January 2008 to January 2015, 107 adult patients with rheumatic mitral stenosis were submitted to open mitral valve replacement. Their mean age was 45±11 years and 93 (86.9%) were women. Left ventricular morphology and function were studied longitudinally with echocardiography. The end point was postoperative worsening of left ventricular ejection fraction, defined by a decrease of 10% compared to preoperative basal assessment. Determinants of worsening left ventricular ejection fraction were determined by multivariable logistic regression analysis. Results: The end point occurred in 18 patients (16.8%). We tested clinical and echocardiographic parameters to verify independent variables related to the decrease in postoperative ejection fraction. Lower body weight (P=0.005; odds ratio [OR]=0.89) and smaller preoperative mitral valve area (P=0.02; OR=0.02) were independent predictors of left ventricular dysfunction. These patients presented higher mortality and morbidity rates. Conclusion: Left ventricular remodeling patterns differed among patients with predominant rheumatic mitral stenosis undergoing open mitral valve replacement. Lower preoperative body weight and mitral valve area were independent determinants of deteriorating ejection fraction with increased end-systolic volumes, indicating that this specific problem may occur in anthropometric smaller patients with more extensive rheumatic disease.

OBJETIVO: Avaliar a morbidade e mortalidade da endarterectomia de carótida realizada sob bloqueio cervical regional, tendo como variáveis o tempo cirúrgico, uso de shunt, conversão para anestesia geral, complicações cirúrgicas, tempo de permanência dos pacientes na unidade de tratamento intensivo (UTI) e no hospital, e evolução dos pacientes durante um ano. MÉTODO: Durante o período de junho de 1998 a janeiro de 2004, foram realizadas 67 operações em 61 pacientes, com 70% ou mais de estenose de carótida interna, diagnosticada por Doppler e confirmada por angiografia carotídea. A monitorização cerebral intra-operatória consistiu na análise do nível de consciência e da atividade motora dos pacientes. A média de idade dos pacientes foi 69,7 anos. Quanto às doenças concomitantes, 45 (47%) eram hipertensos; 21 (22%), coronariopatas; 17 (18%), diabéticos; 12 (13%), pneumopatas. RESULTADOS: Houve três (4,48%) casos de doença carotídea bilateral, sendo a operação realizada em dois tempos. O tempo médio de operação foi de 120 minutos. Foi necessário uso de shunt em seis (8,95%) casos e conversão para anestesia geral em dois (2,98%). Dois (2,98%) pacientes apresentaram confusão mental no pós-operatório e um (1,49%) apresentou infecção da ferida operatória. Ocorreu reestenose de carótida em três (4,48%) casos. Os tempos médios de permanência na UTI e no hospital foram, respectivamente, 1,34 e 4,20 dias. Não houve morte, acidente vascular cerebral ou infarto agudo do miocárdio. CONCLUSÃO: A endarterectomia de carótida com o paciente acordado é uma boa alternativa para pacientes selecionados de alto risco cirúrgico para anestesia geral.OBJECTIVE: To evaluate morbidity and mortality of carotid endarterectomy performed under regional cervical block, taking into account duration of surgery, use of shunt, conversion to general anesthesia, surgical complications, stay of patients inthe intensive care unit (ICU) and in the hospital, and patients' evolution over one year. METHODS: From June 1998 to January 2004, 67 operations were performed in 61 patients, with 70% or greater internal carotid stenosis, diagnosed by Doppler and confirmed by carotid angiography. Neurologic monitoring consisted of continuous assessment of alertness and motor activity of patients during the operation. The mean age was 69.7 years old. Regarding concomitant pathologies, 45 (47%) had hipertension; 21 (22%), coronary artery disease; 17 (18%), diabetes; 12 (13%), pneumopathy. RESULTS: There were three (4.48%) cases of bilateral carotid disease, for which surgery was performed at different times. The mean duration of surgery was 120 minutes. The use of a shunt was necessary in six (8.95%) cases and to convert to general anesthesia in two (2.98%). Two (2.98%) patients evolved with mental confusion after surgery and one (1.49%) presented infection of surgical site. Restenosis occurred in three (4.48%) cases. The mean times of stay in the ICU and hospital were 1.34 and 4.20 days, respectively. There were no deaths, strokes or acute myocardial infarctions. CONCLUSION: Carotid endarterectomy with conscious patient is a good alternative for selected patients at high surgical risk for general anesthesia.

OBJETIVO: O objetivo deste estudo é analisar a experiência do Instituto do Coração com a utilização de próteses mecânicas de duplo folheto. CASUÍSTICA E MÉTODOS: No período compreendido entre junho de 1989 e agosto de 1998, foram implantadas 323 próteses mecânicas de duplo folheto em 300 pacientes. A idade média foi de 38,7 ± 18,4 anos. Cento e noventa e um (63,7%) pacientes eram do sexo masculino. A etiologia foi reumática em 161 (53,7%) pacientes. Foram realizadas 186 substituições da valva aórtica, 89 da valva mitral, 2 da valva tricúspide, 22 substituições mitro-aórticas e 1 mitro-tricuspídea. Quanto à classe funcional (CF), 73 (24,3%) pacientes se encontravam em CF IV, 165 (55,4%) em CF III e 61 (20,3%) em CF II. RESULTADOS: A mortalidade hospitalar foi de 9% (27 pacientes), sendo de 13,5% no grupo mitral, 7,5% no grupo aórtico e 4,5% no mitro-aórtico. As taxas linearizadas dos eventos no pós-operatório tardio são: 0,2% pacientes/ano (pac./ano) para endocardite, 0,3% pac./ano para escape paravalvar, 0,2% pac./ano para hemorragia relacionada à anticoagulação e 1,0% pac./ano para tromboembolismo. No pós-operatório tardio 213 (91%) pacientes encontram-se em classe funcional I ,16 (6,8%) em CF II e 4 (1,7%) em CF III e 1 (0,5%) em CF IV. A sobrevida actuarial em 9 anos foi de 68,1 ± 15,5% para a posição mitral e 67,5 ± 10,8% para a aórtica. CONCLUSÃO: Concluímos que os resultados com a utilização das próteses mecânicas de duplo folheto são satisfatórios.

Relatamos o caso de uma paciente de 46 anos, cor branca, hipertensa há 20 anos, com suspeita de endocardite infecciosa. Foi realizado ecocardiograma transtorácico, o qual levou à hipótese de mixoma de átrio direito. A paciente foi submetida à cirurgia, observando-se massa tumoral de aspecto muco-gelatinoso friável. A massa foi submetida a congelação para exame anatomopatológico, com laudo sugestivo de tumor maligno mesenquimal. Foi realizado exame imunohistoquímico compatível com condrossarcoma mixóide. A paciente evoluiu com remissão espontânea do quadro após ressecção completa da neoplasia. Realizou acompanhamento ambulatorial por 14 meses, sem apresentar sinais de recidiva do tumor.We report a case of a 46 years-old woman, Caucasian, with hypertension and a primary dianosis of infectious endocarditis. A transthoracic echocardiogram was performed suggesting right atrium myxoma. The patient was submitted to surgery, which found a tumor mass with a jelly-like exterior. The mass was sent to anatomo-pathological analysis which diagnosed a myxoid chondrosarcoma tumor. After surgical resection, the patient achieved complete recovery with no signs of recidivation after 14 months.

ABSTRACT BACKGROUND: The aim of this study was to describe the experience of treatment of early prosthetic valve endocarditis at a heart center. DESIGN AND SETTING: Retrospective single-center study on data collected from electronic medical records covering the period from January 2009 to December 2015. METHODS: Over the study period, 1,557 consecutive valve operations were performed on adult patients. The study population comprised 32 patients (2%) who were diagnosed with prosthetic valve endocarditis within 12 months after the index surgery. Medical records were retrieved from electronic hospital records, retrospectively. Descriptive clinical, echocardiographic, microbiological and treatment-type data were used. Risk factors for early mortality were studied through univariate and multivariate analyses. RESULTS: The main clinical manifestation of infective endocarditis was fever, and this was present in all patients. Most of the prostheses were affected in the aortic position (40.6% of cases). The most commonly cultured microorganisms were Staphylococcus epidermidis and Staphylococcus aureus. Twenty-six patients (81.3%) underwent surgical treatment and six (18.7%) underwent exclusive clinical treatment. The prevalence of postoperative complications was 31.3% and hospital mortality occurred in seven cases (21.9%). The mortality rate was 50% among the patients who underwent medical treatment and 15.4% among those who underwent surgery. There were no independent risk factors for mortality. CONCLUSION: Prosthetic valve endocarditis is an infrequent complication of valve replacement. Surgical treatment has mortality rates compatible with the severity of patients’ conditions. Surgical indication should not be delayed when clinical treatment has been ineffective

Objetivo: Determinar a prevalência e as características de ateromatose da aorta ascendente e/ou arco aórtico em cirurgia cardiovascular, os fatores de risco de sua ocorrência e a implicação prognóstica imediata da mesma. Métodos: No período de janeiro de 2007 a junho de 2011, 2042 pacientes adultos consecutivos foram analisados, sem critérios de exclusão. A detecção de ateromatose da aorta foi realizada por meio de palpação durante o ato operatório. Os fatores de risco de ateromatose da aorta e a sua implicação prognóstica foram determinados por regressão logística multivariada. Resultados: A prevalência de ateromatose da aorta foi de 3,3% (68 pacientes). Os fatores de risco foram a idade > 61 anos (OR= 2,79; IC95%= 2,43 - 3,15; P

Objetivo: O EuroSCORE tem sido utilizado na estimativa de risco em cirurgia cardíaca, apesar de fatores importantes não serem considerados. O objetivo foi validar o EuroSCORE na predição de mortalidade em cirurgia cardiovascular num centro brasileiro, definindo a influência do tipo de procedimento e da equipe cirúrgica responsável pelo paciente. Métodos: No período de janeiro de 2006 a junho de 2011, 2320 pacientes adultos consecutivos foram estudados. De acordo com o EuroSCORE aditivo, os pacientes foram divididos em risco baixo (escore 12). A relação entre a mortalidade observada (O) sobre a esperada (E) de acordo com o EuroSCORE logístico foi calculada para cada um dos grupos, procedimentos e cirurgiões com > de 150 operações, e analisada por regressão logística. Resultados: O EuroSCORE calibrou com a mortalidade observada (O/E=0,94; P

Relatamos o caso de uma paciente de 58 anos com síndrome coronariana aguda, com acometimento triarterial. Em decorrência de angina refratária, foi indicada cirurgia de revascularização do miocárdio (RM) de urgência. Na avaliação pré-operatória, foram detectadas lesões obstrutivas na origem do tronco braquiocefálico, artérias carótida comum esquerda e carótida interna esquerda. A paciente foi submetida, concomitantemente, a RM e revascularização dos troncos supra-aórticos (bypass extra-anatômico), além de endarterectomia da artéria carótida interna esquerda. A paciente teve uma boa evolução, com alta hospitalar no sétimo dia pós-operatório. Atualmente, dois anos após o procedimento, encontra-se em acompanhamento ambulatorial, assintomática.We report the case of a 58-year-old patient, with a three vessel disease with unstable angina. Due to refractory angina, she was referred to urgent coronary artery bypass graft (CABG). In the preoperative evaluation were found severe obstructive lesions in the brachiocephalic trunk origin, left common carotid origin and left internal carotid artery. The patient underwent CABG, supra-aortic trunks revascularization (extra-anatomic bypass) and carotid endarterectomy in the same procedure. She presented an uneventful recovery and was discharged home on the seventh postoperative day. Currently, two years after the procedure, she continues under follow-up, symptomless.

Paciente do sexo masculino, de 66 anos, previamente hipertenso, com história de ortopneia, palpitações e dor precordial de início súbito, que teve o diagnóstico de avulsão espontânea de uma comissura valvar aórtica e consequente insuficiência aórtica aguda, evoluindo com insuficiência cardíaca esquerda refratária ao tratamento clínico. O paciente foi submetido precocemente à substituição cirúrgica da valva aórtica por uma bioprótese, e apresentou evolução pós-operatória satisfatória. Atualmente, quatro anos após o evento, continua em acompanhamento ambulatorial em classe funcional I.A 66-year-old male patient, prior hypertension, a history of orthopnea, palpitations and chest pain of sudden onset, which was diagnosed as spontaneous avulsion of aortic valve commissure and consequent aortic insufficiency progressing to acute left heart failure refractory to medical treatment. The patient underwent early surgical replacement of the aortic valve by a bioprosthesis, and presented satisfactory postoperative course. Currently, four years after the event, still in attendance in functional class I.

Trata-se de uma gestante de 20 semanas submetida à retroca de prótese de valva atrioventricular esquerda e troca da valva da aorta, ambas por prótese biológica, valvuloplastia de tricúspide e trombectomia de átrio esquerdo. O tempo de circulação extracorpórea foi de 105 minutos. A paciente recebeu alta do hospital em boas condiç��es gerais e o recémnascido permanece estável em Unidade de Terapia Intensiva. Por ser um procedimento de considerável complexidade e de alta mortalidade materna e fetal, este caso é de importante relevância no tratamento das doenças valvares durante o período gestacional, bem como a condução nos períodos intra e pós-operatório.We describe a woman with gestational age of 20 weeks, who was submitted to a complex procedure. She underwent replacement of the biological mitral and aortic valve, both by biological prosthesis, valvuloplasty of the tricuspid valve, as well as thrombectomy of the left atrium. Extracorporeal circulation (ECC) was used during 105 minutes. The patient was discharged from hospital in good health conditions and the newborn remained in the Neonatal Intensive Care Unit (NICU) in a stable state. This is a complex procedure with a high maternal and fetal mortality. Therefore, this is an important case regarding valve abnormalities treatment during pregnancy.

Background: Primary graft dysfunction is the main cause of early mortality after heart transplantation. Mechanical circulatory support has been used to treat this syndrome. Objective: Describe the experience with extracorporeal membrane oxygenation to treat post-transplant primary cardiac graft dysfunction. Methods: Between January 2007 and December 2013, a total of 71 orthotopic heart transplantations were performed in patients with advanced heart failure. Eleven (15.5%) of these patients who presented primary graft dysfunction constituted the population of this study. Primary graft dysfunction manifested in our population as failure to wean from cardiopulmonary bypass in six (54.5%) patients, severe hemodynamic instability in the immediate postoperative period with severe cardiac dysfunction in three (27.3%), and cardiac arrest (18.2%). The average ischemia time was 151 ± 82 minutes. Once the diagnosis of primary graft dysfunction was established, we installed a mechanical circulatory support to stabilize the severe hemodynamic condition of the patients and followed their progression longitudinally. Results: The average duration of extracorporeal membrane oxygenation support was 76 ± 47.4 hours (range 32 to 144 hours). Weaning with cardiac recovery was successful in nine (81.8%) patients. However, two patients who presented cardiac recovery did not survive to hospital discharge. Conclusion: Mechanical circulatory support with central extracorporeal membrane oxygenation promoted cardiac recovery within a few days in most patients.

Abstract Background: Cox-Maze III procedure is one of the surgical techniques used in the surgical treatment of atrial fibrillation (AF). Objectives: To determine late results of Cox-Maze III in terms of maintenance of sinus rhythm, and mortality and stroke rates. Methods: Between January 2006 and January 2013, 93 patients were submitted to the cut-and-sew Cox-Maze III procedure in combination with structural heart disease repair. Heart rhythm was determined by 24-hour Holter monitoring. Procedural success rates were determined by longitudinal methods and recurrence predictors by multivariate Cox regression models. Results: Thirteen patients that obtained hospital discharge alive were excluded due to lost follow-up. The remaining 80 patients were aged 49.9 ± 12 years and 47 (58.7%) of them were female. Involvement of mitral valve and rheumatic heart disease were found in 67 (83.7%) and 63 (78.7%) patients, respectively. Seventy patients (87.5%) had persistent or long-standing persistent AF. Mean follow-up with Holter monitoring was 27.5 months. There were no hospital deaths. Sinus rhythm maintenance rates were 88%, 85.1% and 80.6% at 6 months, 24 months and 36 months, respectively. Predictors of late recurrence of AF were female gender (HR 3.52; 95% CI 1.21-10.25; p = 0.02), coronary artery disease (HR 4.73 95% CI 1.37-16.36; p = 0.01) and greater left atrium diameter (HR 1.05; 95% CI 1.01-1.09; p = 0.02). Actuarial survival was 98.5% at 12, 24 and 48 months and actuarial freedom from stroke was 100%, 100% and 97.5% in the same time frames. Conclusions: The Cox-Maze III procedure, in our experience, is efficacious for sinus rhythm maintenance, with very low late mortality and stroke rates.