Reconstruction of stenotic or nonconfluent pulmonary arteries simultaneously with a Blalock-Taussig shunt.

Stenosis or discontinuity of the pulmonary arteries associated with congenital cardiac defects was repaired in 12 patients, in conjunction with the Blalock-Taussig shunt. This approach was based on the following concepts: (1) The shunted blood is more uniformly distributed to both lungs, which avoids predominance of flow to the ipsilateral lung and long-term pulmonary vascular damage; (2) because adequate blood flow is maintained, the contralateral lung growth will be near normal; (3) the possibility of future surgical correction is enhanced. The ages of the patients ranged from 2 to 24 months. Five had a primary diagnosis of tetralogy of Fallot, three had double outlet of the right ventricle, three had single ventricle, and one had a truncus type anomaly. All operations were performed without cardiopulmonary bypass. Dilation of the stenotic segment was performed in two patients, enlargement of the stenotic segment in three, and resection of the segment and end-to-end anastomosis in four. Nonconfluent pulmonary arteries were corrected in three patients. In one, the stenotic segment was resected and an anastomosis was made between the left pulmonary artery and pulmonary trunk. In another patient, a segment of the right subclavian artery was interposed between the pulmonary trunk and intrahilar left pulmonary artery. In the third patient, the right pulmonary artery was disconnected from the aorta and a tube was interposed between the right and left pulmonary arteries. There were no intraoperative or late deaths, and postoperative angiographic evaluations were satisfactory. We believe that in infants needing a Blalock-Taussig shunt the pulmonary artery anomalies, if present, should be corrected simultaneously.

Postinfarction ventricular septal defect. An efficacious technique for early surgical repair.

Between December 1982 and June 1987, seven consecutive patients (52 to 77 years old) underwent early surgical repair of postinfarction ventricular septal defect. The defect was diagnosed 3 to 10 days after the myocardial infarction. A new repair technique was used which stresses that no part of the infarcted septum be resected. This technique consists of a transinfarction incision in the left ventricle, placement of a fine Dacron fabric patch that covers all the infarcted septum and closes the ventricular septal defect, and placement of a second Dacron fabric patch that reinforces the infarcted anterior wall of the heart and supports the buttressed double suture closure of the left ventriculotomy. One very ill patient of this series died during the operation (mortality rate 14.3%). Three patients required the help of intraaortic balloon counterpulsation postoperatively, and five needed inotropic drug support. None of the patients had excessive bleeding. Two initial patients had a small left-to-right interventricular shunt. Postoperative angiographic studies and Doppler echocardiography confirmed the existence of a nonsignificant residual ventricular septal defect in these two patients and showed good geometry of the left ventricle with no aneurysm formation in all six survivors. This technique seems to be efficacious. It can be expeditiously performed, and the risks of postoperative complications related to the technique appear to be minimal.

Acquired ventricular septal defect and tricuspid valve disruption as a complication of infective endocarditis of the aortic valve.

Ventricular septal defect is a rare complication of infective endocarditis. This is a case report of a 48-year-old man with chronic alcoholism without known previous heart disease who developed a ventricular septal defect and a tricuspid valve disruption in the course of a fatal infective endocarditis of the aortic valve.

Long-term results of mammary artery implants.

Eighty out of eighty-six patients (93%) with mammary artery implants were followed postoperatively for an average of three and a half years. The immediate mortality rate was 7% (6 cases), and the late mortality was 6% (5 cases). All had angina preoperatively. Twenty-four had a history of myocardial infarction and thirty-one were on limited physical activity, because of the pain. After surgery, thirty-three (45%) became asymptomatic. The angina improved significantly in thirty-five (47%) and remained unchanged in six (8%). Improvement in ventricular repolarization on ECG was observed in 69% of the patients. Postoperative cineangiography was performed in twenty-three patients; thirteen with single and ten with double implants. Out of the total of thirty-three implants, four (12%) were obstructed and twenty-seven patent (82%); twenty were in two cases of double implant, only one implant could be satisfactorily studied effectively functioning (61%). No obstructions were seen in the single implants. Non functioning implants were found in five (38%) of the thirteen single implants and in two of the twenty double ones (10%). The highest incidence of obstruction or non-functioning implants occurred in the group that did not show improvement (43%). This rate fell to 40% in the group that had some improvement and to 29% in those that were completely asymptomatic. Twelve of the eighteen patent mammary implants (67%) on the anterior wall of the left ventricle and eight of nine (89%) on the lateroinferior wall, established collateral circulation to the coronaries. Indication for surgery was considered satisfactory for nineteen out of the twenty-three patients and poor in four. There were two cases of obstruction of the implant (7%) in the group where surgery was correctly indicated and three of the twenty-three (11%) patent implants were non-functioning. Clinical improvement of the angina occurred in 84% in the first group and 50% in the other. In conclusion, this technique of indirect revascularization of the myocardium is valid for patients with severe diffuse lesions of the coronaries with a collateral network and preserved myocardial contractility.

Anomalous origin of the left coronary artery from the pulmonary artery. Surgical repair of an unusual form.

The authors present a case of a 24-year-old woman with anomalous left coronary artery originating from the pulmonary artery. Surgical correction was performed by the direct transposition of the anomalous left coronary artery from the pulmonary artery to the ascending aorta, without interposed graft. Pre- and postoperative evaluations, including angiograms and cycloergometer stress test are presented. The advantages of this technique are discussed, emphasizing the creation of a two-coronary system without the use of prosthetic, arterial or venous grafts. In the present case the left coronary artery originated from the right posterior sinus of the pulmonary artery. The patient is doing well 23 months after operation.

Direct myocardial revascularization in young patients: analysis of 100 consecutive cases without operative mortality.

The authors studied a series of 100 patients submitted to direct myocardial revascularization before 40 years of age. One hundred and seventy-three saphenous vein by-passes and 4 mammary artery left descending coronary artery anastomoses were performed. There was no operative mortality and the late mortality was 2%. The period of postoperative clinical evaluation of the patients varied from 12 to 60 months (mean 32.0 months).

Surgical treatment of the congenital fistulae of coronary arteries.

Six cases of coronary artery fistulae surgically treated are presented. All patient but one was male; the ages varied from 4 to 44 years. The fistulae originated from the left coronary artery in three cases from the right in two cases and from both arteries in one case. The draining heart chambers were the right atrium in three, the right ventricle in two and the pulmonary artery in one case. Associated lesions were present in three cases. One patient died on the early postoperative period and the evolution was satisfactory in five cases.

Vascular anastomosis by argon laser beam.

Twenty-four mongrel dogs, weighing 13 to 24 kg, were used to study the effectiveness of anastomosis by Argon Laser beam. After anesthesia, intubation and controlled ventilation, they were submitted to three types of vascular anastomoses: saphenous vein intercarotid artery bypass; left mammary artery/left anterior descending coronary artery bypass; and veno-venous anastomosis. In all groups, 0.8 to 1.5 watts of Argon Laser power were applied for a total time of 90 to 300 seconds. The lower power was for veno-venous anastomoses and the greater was applied for arterial anastomoses. The mean values of resistance of the laser anastomosis to pressure-induced repture were 730 mm Hg in the immediate postoperative study, but increased to 2,500 mm Hg 30 days after surgery. No signs of occlusion were demonstrated at the anastomotic sites by the angiographic and anatomopathological studies performed.

[Excimer laser in the treatment of obstructive coronary disease. Initial experience]. / Excimer laser no tratamento da doença coronária obstrutiva. Experiência inicial.

The aim of this study is to evaluate a group of four male patients aged between 47 and 77 years (mean 52 +/- 4.5) with coronary artery disease who underwent excimer laser with classical indication for this method. The vessels considered were the left anterior descending artery in three patients and the right coronary artery in one. Conventional percutaneous transluminal coronary angioplasty (PTCA) was applied in all patients after the laser procedure. Reduction to 50% or less of the internal diameter was considered a satisfactory result. Early success (laser plus PTCA) was obtained in 100%. There were a decreasing in number of obstruction from 75-100% (mean of 80 +/- 8.5%) to 0-50% (mean of 20 +/- 6%) after the procedure (laser plus PTCA). During hospitalization no complication have been found. In conclusion, we certified that excimer laser has been applied in special situation (complex lesions) with high rate of success than conventional angioplasty but these results will require further studies.

[Doppler echocardiographic evaluation of heart transplantation]. / Avaliação ecodopplercardiográfica do transplante cardíaco.

In order to evaluate major Doppler-Echocardiographic parameters for the diagnosis of acute cardiac allograft rejection episodes a serial of 54 Doppler Echocardiograms were performed simultaneously with endomyocardial biopsy in five patients (mean age = 40.2 y/o). Measurements included: right and left chambers diameters, left ventricular (LV) myocardial diastolic thickness, LV systolic function parameters, LV mass, LV volume/mass ratio, LV isovolumic relaxation time, mitral flow peak velocities and pressure half-time. Episodes with acute rejection histopathologic findings, Billingham class III or IV, were associated to increase in LV free wall thickness and LV mass (p less than 0,005) as well as decreased isovolumic relaxation time and pressure half-time (p less than 0,001). Left ventricular systolic function parameters and heart rate were no different comparing rejection and no rejection episodes. However, in each patient, progressive lower values of LV ejection fraction were associated to higher incidence of acute rejection episodes. Isovolumic relaxation time increased promptly following immunosuppressive therapy. Thus, Doppler Echocardiography is a reliable method for early detection of acute cardiac allograft rejection and monitoring of the cardiac transplant recipient.

[Directional coronary atherectomy. The initial experience]. / Aterectomia coronária direcional. Experiência inicial.

Four male patients, 38 to 59 years old (mean 49 +/- 2.5), with angina and the angiographic features has been the classical indications for the method, underwent directional coronary atherectomy. Vessels treated were, respectively, left anterior descending artery (LAD), right coronary artery (RCA), saphenous vein graft (SVG) to LAD and SVG to left marginal branch. Reductions to 50% or less of the internal diameter was considered a satisfactory result. Early success was obtained in all four patients. Obstructions of 75 to 95% (mean of 83 +/- 7.5%) were reduced to 0-25% (mean 12 +/- 5%) after atherectomy. Only one patient died suddenly five days after de procedure. So, directional coronary atherectomy may represent a reliable and safe method for special situations.

[Relationship of average level and variability of blood pressure with the geometry of the left ventricle in systemic hypertension]. / Relação do nível médio e variabilidade da pressão arterial com a geometria do ventrículo esquerdo na hipertensão arterial sistêmica.

PURPOSE: To study the relation between the average level and variability of blood pressure (VBP) obtained by ambulatory monitoring (AMBP) and the geometric pattern (GP) of the left ventricle (LV) obtained by echocardiography (ECHO) in patients with hypertension (Hy) METHODS: AMBP and ECHO were performed in 37 patients with Hy, divided into three groups: group A--11 women using antihypertensive therapy (AH); group B--15 men using AH and group C--7 male and 4 female without AH. The GP of LV was obtained by ECHO based on mass index (MI) and relative thickness of the wall (RTW). Mean systolic (MSBP) and diastolic (MDBP) were analyzed during daytime (DT) and nighttime (NT) periods. VBP was defined by mean standard deviation (SD) of mean pressures considered. RESULTS: In G-A, there was a significant association between the MI and both VBP and MSBP (r = 0.65 and p < 0.005, r = 0.61, and p < 0.005, respectively), and MSBP and VBP during the DP (r = 0.64 and p < 0.005, r = 0.75, and p < 0.005). In G-B, there was a relation between the LVRTW (r = 0.55 and p < 0.005), and MSBP during the DP (r = 0.65 and p < 0.005). In G-C, there was a significant association (p < 0.005) between the MI and the MDBP in the DP and with the MSBP in the NP (r valueS ranged from 0.51 to 0.66). There was also a significant relation (p < 0.005) between the LVRTW and the SD of all variables in both DP and NP (r ranged from 0.47 to 0.78 and mean diastolic in the wakeful period (r = 0.42 to 0.78) and MDBP in the DP (r = 0.42 and p < 0.05). CONCLUSION: Both the increase in VBP and the mean BP are involved in the changes of LVGP in Hy.

[Chronic active hepatitis and possible relationship with immunosuppressive therapy]. / Hepatite crônica ativa e possível relação com terapia imunossupressora.

A 54-year-old man with Chagas cardiomyopathy that was submitted to a heart transplantation and five months later presented a progressive increase in liver enzymes. Diagnosis of chronic active hepatitis was confirmed by histopathologic studies. A transitory interruption of treatment with azathioprine and the posterior re-introduction of small doses, as well as the use of lesser amounts of cyclosporin-A improved the clinical and laboratory pictures. Despite several investigations the pathogenesis of hepatitis remained undetermined, although some type of drug injury was presumed to be involved. The eventual role of viruses as the primary inciting event could not be completely ruled out.

[Coronary angioplasty in young patients]. / Angioplastia coronária em pacientes jovens.

PURPOSE: To evaluate the results of coronary angioplasty in patients at the age of 40 years old or under. METHODS: From July 1987 to July 1990, 878 coronary angioplasty procedures were performed. Sixty six patients (7.5%) were 40 years old or under. The coronary obstruction was considered significant when 70% or more of the arterial diameter was involved and the post angioplasty results were considered satisfactory when residual obstruction was less than the 50%. RESULTS: Fifty four patients (81.8%) were male with an average age of 37 years (ranging from 29 to 40). Forty four patients (67%) had stable angina, 18 (27%) unstable angina, 3 (4%) acute myocardial infarction (AMI) and one (1.5%) AMI after streptokinase treatment. Eight of these patients had previous report of AMI and 3 (4.5%) had undergone coronary bypass grafting surgery. Fifty five patients (83%) had single vessel disease and 11 (17%) had multivessel disease. Eighty coronary arteries had balloon dilatation. In 32 patients (58%) with single vessel artery, 12 (22%) in the RCA, 10 (18%) in the left circumflex and one (2%) into a saphenous vein bypass grafting. In 12 patients (48%) with multivessel disease it was performed in the LAD coronary artery, 8 (32%) in the RCA and 5 (20%) in the left circumflex. Angioplasty was successfully performed in 53 (96%) patients with single vessel disease and in 10 (01%) with multivessel disease. One of the patients died immediately after the procedure. A follow up of 11.6 months (ranged from 1 to 27 months) was possible in 63 patients. Re-stenosis was depicted in 10 (19%) of the 55 patients with single vessel disease and in 3 of the 11 patients (30%) with multivessel disease. Nine patients had a successful redilatation in the first group and 2 in the second one. The two remaining patients had undergone coronary bypass surgery. The clinical evaluation among patients who had been dilated as the first procedure and those who had redilatation (61 patients) showed: 92% were asymptomatic and 8% had mild angina. CONCLUSION: Coronary angioplasty performed in young patients is an effective procedure with very low rate of early complications and favorable clinical follow-up.