Economic longitudinal lateral posterior thoracothomy. Minimally invasive option in pulmonary resections.

BACKGROUND: Pulmonary resections are usually performed through posterolateral thoracotomy. However this approach has been associated largely with early and late incidence of postoperative morbidity. Several lateral chest approaches have been reported in the medical literature with the objective to decrease morbidity due to thoracotomy. The aim of this study was to evaluate the results of pulmonary resection, performed by means of a minor thoracotomy in the posterior axillary region. METHODS: The skin incision was longitudinal and scapular; shoulder and chest wall muscles were not cut, a subperiosteally lateral portion of rib was removed and the thoracic wall was opened in the rib bed. The approach in this place allowed a smaller skin incision, skin flaps were not necessary and the chest wall opening stayed in a better position in relation to the pulmonary hilum, facilitating the exposition of its anterior and posterior faces. From January 1994 to December 1996 seventy-eight consecutively non-selected patients underwent eighty surgical procedures for several kinds of pulmonary resections. RESULTS: All surgical procedures occurred without difficulties and with a lower number of postoperative complications. A very good aesthetic result was reached. CONCLUSIONS: We believe this chest approach may be a good choice for pulmonary resection.

Direct myocardial revascularization without extracorporeal circulation: technique and initial results.

In a 10-month period, 68 patients underwent saphenous vein bypass revascularization without extracorporeal circulation. Distal sutures were performed with interruption of coronary flow without any devices for perfusion of the coronary artery; the proximal sutures were completed with tangential clamping of the aorta. Most frequently, the anterior descending and the distal right coronary arteries were revascularized; of 225 patients who underwent bypass surgery, this technique was possible in 68 cases (30.2%). The 30-day hospital mortality was 1.5%, and perioperative myocardial infarction, as determined by daily electrocardiograms (ECGs) and creatine phosphokinase isoenzyme (CKMB), occurred in two patients. Control hemodynamic studies were performed in 22 of the 68 patients (32.4%) with a patency rate of 84.2% in the grafts restudied.

Modified Blalock-Taussig shunt with an umbilical vein graft.

We describe a modification of the Blalock Taussig anastomosis, with the interposition of a glutaraldehyde-tanned umbilical vein graft between the subclavian and pulmonary arteries. This operation was performed in 64 children: 11 were less than 1 month of age (17.2%), and 23 were between 1 and 6 months of age (34.9%). Hospital deaths occurred in six patients-all less than 6 months of age (9.4%). There was no instance of shunt occlusion noted. The clinical course was uneventful among survivors, except for one patient who died of endocarditis in the late postoperative follow-up. The shunt procedure may be performed very rapidly, with minimal dissection, allowing the use of a graft larger than the diameter of the subclavian artery. This modification of the Blalock Taussig operation compares favorably with our previous experience with other shunt procedures and may be considered a valuable alternative in the palliative surgical treatment of several malformations with severe pulmonary oligemia.

[Effect of total++ time of extracorporeal circulation in in myocardial revascularization surgery on urinary urea nitrogen loss]. / Efeito do tempo total de circulação extracorpórea em cirurgia de revascularização miocárdica sobre a perda urinária de nitrogênio na forma de uréia.

Cardiopulmonary bypass probably should be an important factor increasing surgical stress when heart surgery is focused. This study was undertaken in order to evaluate the role of cardiopulmonary bypass in proteic catabolism. Study group consisted of patients who underwent cardiac aortic bypass graft as an isolated procedure. Inclusion criteria were elective surgery and absence of comorbidities after a rigorous preoperatory evaluation. One hundred and five patients were studied prospectively and urinary nitrogen loss was measured in the first 24 hour postoperative period. Operations performed were standard cardiopulmonary bypass procedures, under cardiopulmonary bypass, moderate hypothermia and hemodilution. Saphenous veins and mammary artery grafts were performed in all cases. Correlation and multiple linear regression were used. There was found no correlation between urinary nitrogen loss and age, gender and time under cardiopulmonary bypass. A positive correlation was found between number of grafts and increased urinary nitrogen loss. Further studies comparing cardiac aortic bypass graft with and without cardiopulmonary bypass are suggested.

[Assessment of pulmonary arterial pressure in adults with Doppler echocardiography]. / Avaliação da pressão arterial pulmonar em adultos pela Eco-Dopplercardiografia.

PURPOSE: To assess the role of pulsed Doppler echocardiography (PDE) in the indirect assessment of pulmonary artery (PA) pressure (P), analysing the pulmonary velocity blood flow curves (PVBFC) profile. PATIENTS AND METHODS: Sixty-one adults with several kinds of heart disease were submitted to heart catheterization to obtain PAP (systolic, diastolic, mean), and other hemodynamic variables. A PDE examination was performed in all to obtain the PVBFC at the level of the pulmonic annulus. Qualitative features of the curve were analysed (morphological pattern, presence of pulmonic regurgitation) as well as quantitative data (acceleration time = AT, right ventricle ejection time = RVET index, AT/RVET index AT corrected for heart rate = ATC), which were compared to the invasive measurements. RESULTS: An abnormal rapid acceleration of the PVBFC, with triangular configuration, was noted in patient with pulmonary hypertension (PH), in contrast to the dome-like shape of the PVBFC in normal PAP. Pulmonary regurgitation was more frequent (p < 0.05) in patients with severe PH (mean PAP > or = 40 mmHg), comparing with patients with PAP < 40 mmHg. Inverse linear correlations were observed between AT and mean PAP, particularly when sinus rhythm was present (r = 0.89; p < 0.05) excluding patients with atrial fibrillation (19 cases). CONCLUSION: PDE is an useful and noninvasive method for indirect evaluation of PAP in adults, especially during stable sinus rhythm, in heart rate range from 60 to 115 bpm.

[Pulmonary artery pressure evaluation in adults by Doppler echocardiography]. / Avaliação da pressão arterial pulmonar em adultos pela ecodopplercardiografia.

PURPOSE: To assess the role of pulsed Doppler echocardiography (PDE) in the indirect assessment of pulmonary artery (PA) pressure (P), analysing the pulmonary velocity blood flow curves (PVBFC) profile. PATIENTS AND METHODS: Sixty-one adults with several kinds of heart disease were submitted to heart catheterization to obtain PAP (systolic, diastolic, mean), and other hemodynamic variables. A PDE examination was performed in all to obtain the PVBFC at the level of the pulmonic annulus. Qualitative features of the curve were analysed (morphological pattern, presence of pulmonic regurgitation) as well as quantitative data (acceleration time = AT, right ventricle ejection time = RVET index, AT/RVET index AT corrected for heart rate = ATC), which were compared to the invasive measurements. RESULTS: An abnormal rapid acceleration of the PVBFC, with triangular configuration, was noted in patient with pulmonary hypertension (PH), in contrast to the dome-like shape of the PVBFC in normal PAP. Pulmonary regurgitation was more frequent (p less than 0.05) in patients with severe PH (mean PAP greater than or equal to 40 mmHg), comparing with patients with PAP less than 40 mmHg. Inverse linear correlations were observed between AT and mean PAP, particularly when sinus rhythm was present (r = 0.89; p less than 0.05) excluding patients with atrial fibrilation (19 cases). CONCLUSION: PDE is an useful and noninvasive method for indirect evaluation of PAP in adults, especially during stable sinus rhythm, in heart rate range from 60 to 115 bpm.

[Systemic-pulmonary shunts in congenital heart diseases with decreased pulmonary blood flow: critical analysis of the surgical techniques and immediate results]. / Derivação sistêmico-pulmonar em cardiopatias congênitas com hipofluxo pulmonar: análise crítica da técnica cirúrgica e resultados imediatos.

PURPOSE: To evaluate immediate postoperative results in children with congenital heart disease and decreased pulmonary blood flow who underwent a systemic to pulmonary shunt. PATIENTS AND METHODS: Sixty-four patients underwent surgery, 46.8% (30) of them males with ages from 1 day to 17 years old. They were divided in three groups: I--13 pts (20.3%) who underwent classical Blalock-Taussig (BT) shunt; II--46 pts (71.8%) who underwent modified BT shunts, 34 of them with polytetrafluoroetylene (PTFE) and 12 of them with umbilical vein shunts; III--5 pts (7.8%) with central anastomosis that were made with three different types of graft; 3 PTFE, umbilical vein and bovine mammary artery in one each. The simultaneous procedures were: section and suture of PDA--2, closure of systemic-pulmonary collaterals--3, pulmonary valvotomy--3, right ventricular outflow patch--3, pulmonary branch stenosis (enlargement)--2. RESULTS: In group I there were 4 (30.7%) closures, with two immediate reoperation and a total mortality of 30.7%. In group II there were 4 closures (8.6%) and two reoperations with a mortality of 15.2% (7 cases). In group III there was one graft closure and an overall mortality of 80% (4 pts). When analysing deaths due to the shunt itself the mortality rate was respectively 15.3%, 8.6% and 40.0%. CONCLUSION: Modified BT operation was performed most frequently in our service; it was associated with less closure and mortality than the other types of shunt. It is considered our first alternative for a systemic-pulmonary shunt.

[Submitral left ventricular aneurysm in a Brazilian Indian]. / Aneurisma submitral do ventrículo esquerdo em um Indio Brasileiro.

Subvalvar left ventricular aneurysm is a rare disease of unknown etiology, that has been described most often in black Africans. A case of Brazilian indian with heart failure and a murmur of mitral regurgitation is reported. The chest x-ray showed a mild bulge in the left cardiac border and two-dimensional echocardiography demonstrated submitral left ventricular aneurysm, confirmed by left ventricular angiography. Surgical treatment consisted of resection of the aneurysm and mitral valvuloplasty. A perforation of the aneurysm, undetected neither by two-dimensional echocardiography nor by angiography was found at surgery.

[Early and late results of myocardial revascularization after coronary thrombolysis with intravenous streptokinase in the treatment of acute myocardial infarction]. / Resultados imediatos e tardios da revascularização cirúrgica do miocárdio pós-trombólise coronariana com estreptoquinase intravenosa no tratamento do infarto agudo do miocárdio.

PURPOSE: To study the early and late results of patients treated initially intravenous streptokinase and then with coronary artery bypass surgery. METHODS: One hundred and twenty one patients with acute myocardial infarction less than 6 hours duration were treated initially with intravenous streptokinase, and 1-38 days after (median 8.80 days) coronary artery bypass was undertaken. Ninety six patients were operated with extracorporeal circulation and 25 without it. RESULTS: Overall operative mortality was 3.30% (4/121). Reoperations due to bleeding was necessary in 3.30% (4/121). Late mortality was 5.40% with survival probability of 94.60% after 36 months and 92.30% after 70 months. Late morbidity events in terms of angina and cardiac insufficiency demonstrated that 7 patients had angina, 4 cardiac insufficiency and two angina and cardiac insufficiency; probability to be free from these events was 88.20% after 46 months and 66.40% after 70 months. CONCLUSION: Coronary artery bypass surgery after intravenous streptokinase can be undertaken with security and excellent early and late results.

[Polyalveolosis: pathogenesis of congenital lobar emphysema?]. / Polialveolose: patogênese do enfisema lobar congênito?

BACKGROUND: Congenital lobar emphysema is an unusual condition and its pathogenesis remains unknown. The variety of findings in pathology studies of the resected specimens led to increasing academic interest. About 50 per cent of the cases have no definitive diagnosis in pathology. The most recent theory proposes an increased number of alveoli within each acinus (polyalveolar lobe). PURPOSE: The aim of this paper is to report the morphometric measures of surgical specimens of 12 patients with congenital lobar emphysema, using the Emery and Mithal technique (radial alveolar count). METHODS: We made a case-control study, classifying the cases by age. Mann-Whitney's U test and linear regression techniques were used in data analysis: Mann-Whitney's U in comparing the cases and respective controls and linear regression to evaluate the influence of age in the measures found. RESULTS: The results revealed a significantly higher radial alveolar count than expected for the age group under 3 years; no difference was observed in the age group between 3 and 7 years and in children older than 7, the radial alveolar count was lower than expected. The normal development of the lung consists in an increasing number of alveoli increase from birth until adulthood, but this number remains constant, independent of age in congenital lobar emphysema. CONCLUSIONS: Such findings allow us to conclude that polyalveolar lobe can and must be diagnosed by a simple and practical method, such as the radial alveolar count, which decreases the incidence of the unknown etiology. The findings of an increased number of alveoli on patients younger than 3 is related to congenital lobar emphysema, since the number of alveoli does not increase in congenital lobar emphysema, just the opposite to what one would expect in the normal development of the lung.