Influence of the maze procedure on the treatment of rheumatic atrial fibrillation - evaluation of rhythm control and clinical outcome in a comparative study.

OBJECTIVE: The aim of this study was to evaluate the influence of the maze procedure on the treatment of rheumatic atrial fibrillation in patients with mitral valve disease. METHODS: Fifty-five patients (mean age 51 years; 47 females) with rheumatic mitral valve disease and associated atrial fibrillation in New York Heart Association functional class III or IV, preoperatively, were operated upon. Thirty-five had double dysfunction, 19 had stenosis, and one had mitral regurgitation. None had other associated heart diseases or previous operations. The patients were divided into two groups: GI, 20 patients were treated for mitral valve disease with associated maze procedure; GII, 35 patients were treated for mitral valve disease without the maze procedure. The preoperative echocardiogram showed a left atrial diameter in GI of 5.35 mm and in GII of 5.57 mm (P=0.779). The groups were considered clinically similar (P=0.759). Cardiopulmonary bypass was used in all patients. The mitral valve was replaced with a biological prosthesis in 24 patients and repaired in 31 patients. RESULTS: Three hospital deaths occurred, one in GI, two in GII. After cardiopulmonary bypass, 37.1% of patients in GII remained in atrial fibrillation. All patients in GI recovered regular rhythm (P<0.0001). In the ICU, atrial fibrillation was detected in 80% of patients in GII and maintained in 76.4% in a mean follow-up period of 38.5 months. In GI, atrial fibrillation occurred in 20% of patients in the ICU and maintained in 5.3% in 41 months of mean follow-up (P=0.0001). None of the patients in GI and 20.6% of patients in GII had a thromboembolic episode 1-63 months after the operation (P=0.041). Four late deaths occurred (two in each group), two being due to progression of valvular disease, one after an episode of pulmonary infection and one with no cardiac cause. CONCLUSION: The maze procedure is effective in treating atrial fibrillation in patients with rheumatic mitral valve disease. The results are sustained in the mid-term follow-up period, preventing postoperative thromboembolic episodes, and with acceptable morbidity and mortality.

Mycotic aneurysm of the celiac trunk and superior mesenteric artery in a case of infective endocarditis.

Mycotic aneurysms of the celiac artery are extremely rare, and in our review of the literature we found that in only one case was it due to infective endocarditis. In our case a 19-year-old female patient with culture-negative infective endocarditis presented with pain in the epigastric area. A celiac artery aneurysm was diagnosed by ultrasonography and confirmed on CT scan and angiography, which also demonstrated an associated aneurysm of the superior mesenteric artery. Since excellent collateral circulation was present, simple ligation of the two aneurysms was performed. The patient presented no major complications in the postoperative course.

Arterial distensibility as a possible compensatory mechanism in chronic aortic insufficiency.

OBJECTIVE: To evaluate elastic properties of conduit arteries in asymptomatic patients who have severe chronic aortic regurgitation. METHODS: Twelve healthy volunteers aged 30+/-1 years (control group) and 14 asymptomatic patients with severe aortic regurgitation aged 29+/-2 years and left ventricular ejection fraction of 0.61+/-0.02 (radioisotope ventriculography) were studied. High-resolution ultrasonography was performed to measure the systolic and diastolic diameters of the common carotid artery. Simultaneous measurement of blood pressure enabled the calculation of arterial compliance and distensibility. RESULTS: No differences were observed between patients with aortic regurgitation and the control group concerning age, sex, body surface, and mean blood pressure. Pulse pressure was significantly higher in the aortic regurgitation group compared with that in the control group (78+/-3 versus 48+/-1mmHg, P<0.01). Arterial compliance and distensibility were significantly greater in the aortic regurgitation group compared with that in the control group (11.0+/-0.8 versus 8.1+/-0.7 10(-10) N-1 m4, P=0.01 e and 39.3+/-2.6 versus 31.1+/-2.0 10(-6) N-1 m2, P=0.02, respectively). CONCLUSION: Patients with chronic aortic regurgitation have increased arterial distensibility. Greater vascular compliance, to lessen the impact of systolic volume ejected into conduit arteries, represents a compensatory mechanism in left ventricular and arterial system coupling.

[Aortic dissection associated with systemic lupus erythematosus]. / Dissecção da aorta associada a lupus eritematoso sistêmico.

A 33-year-old female patient, with a 4-year history of hypertension plus a 3-year history of systemic lupus erythematosus, who had been taking high dosages of corticosteroids, has shown repetitive respiratory infections and congestive heart failure for the past 8 months. Angiocardiography confirmed the diagnosis of aortic insufficiency with aneurysmatic dilation of Valsalva's posterior sinus, ascending aorta of normal diameter and normal coronary arteries. Aortic dissection causing aortic insufficiency due to collapse of aortic leaflets was spotted during the surgery and was corrected by a bovine pericardial tube and suspension of aortic valve. The postoperative (PO) period was complicated by left-sided seizures followed by left hemiparesis and respiratory infection. She was discharged on the 25th PO day with mild left hemiparesis and in functional class I (NYHA), using medicines. We emphasize the need to consider the diagnosis of aortic dissection in patients with systemic lupus erythematosus and aortic insufficiency, specially in those who have a history of systemic arterial hypertension and long-term corticosteroid therapy.

[Cerebral malformation of the conceptus associated with maternal bacterial endocarditis and with aortic valve replacement during pregnancy]. / Malformação cerebral do concepto associada à endocardite infecciosa materna e à substituição da valva aórtica durante a gestação.

A twenty-three years old woman, without previous heart disease developed endocarditis with negative bloods cultures on the fourth month of her third pregnancy. Fever was controlled through antibiotics, however she developed cardiac insufficiency and was submitted to surgery for replacement of aortic valve with a bioprosthesis. The post operative period showed no problems and the patient was discharged on the forty second day after admission. On the thirty ninth week of pregnancy she gave cesarean birth, without complications. The newly born, apgar 5 (1 min.) and 7 (5 min) presented signs of neurological problems, characterized on the second month as a cerebral atrophy. Among various possible factors, the most likely would be cardiopulmonary bypass circulation as the cause of the neurological malformation.

[Endocarditis in heart valve bioprosthesis caused by Cardiobacterium hominis]. / Endocardite em bioprótese valvar cardíaca por Cardiobacterium hominis.

A 36-year-old female patient developed Cardiobacterium hominis endocarditis on a mitral valve prosthesis. The etiologic agent was identified in the seventh day of incubation of the blood cultures specimens. Crystalline penicillin (18.10(6) UI daily) and amikacin (800 mg daily) were administered for 42 days. Surgical treatment for heart failure unresponsive to medical treatment was carried on in the eighteenth day of antibiotic therapy. A bovine pericardium prosthesis was inserted. The patient was discharged and is asymptomatic after seven months.

[Analysis of the mechanical properties of the left ventricle in patients with aortic valve disease]. / Análise das propriedades mecânicas do ventrículo esquerdo em portadores de valvopatia aórtica.

The morphological and functional aspects of the left ventricle (LV) were assessed by echocardiography and cardiac catheterization performed simultaneously in 41 patients. Eleven were normal (N), 14 had aortic stenosis (AS) and 16 had aortic regurgitation (AR). Of the 14 patients with AS, eight were in New York Heart Association (NYHA) functional class I and II (ASA group) and six were in NYHA functional class III and IV (ASB group). Of the 16 patients with AR, seven were in NYHA functional class I and II (ARA group) and nine in functional class III and IV (ARB group). In the ASA group normal values of the LV function were obtained because of the development of an adequate hypertrophy that in normalizing the systolic stroke was able to keep a suitable function. In the ASB group there was a reduction of the LV function due to an increase of the systolic stroke and to the reduction of the contractile muscle state. Thus, in the whole AS group we found an inversed relation between the ejection fraction and the systolic stroke. In the ARA group we found a normal cardiac function as consequence of an adequate development of the LV dilation and hypertrophy. Despite the find of reduction of the contractile state, the systolic stroke normalizing was capable to keep the cardiac function at normal values. The ARB group presented an important depression of the cardiac function due the increase of the systolic stroke and to the decrease of the contractile state of the cardiac muscle.

[The relationship between left ventricular function and the precipitation of symptoms in severe chronic aortic insufficiency]. / Relação entre função ventricular esquerda e desencadeamento de sintomas na insuficiência aórtica crônica severa.

PURPOSE: To study the relationship between symptoms and left ventricular function in 68 patients with severe chronic aortic regurgitation using echocardiogram and radionuclide left ventriculography at rest. METHODS: Three stages of natural history are assumed: the 1st, at the beginning of the study, when all patients were asymptomatic (clinical stage 0); the 2nd, at the end of 36 month persistence of asymptomatic (clinical stage 1), consisting of 45 patients (group AA); the 3rd, on occasion of manifestation of the symptoms during this period of time (clinical stage 2), consisting of 21 patients (group AS-PRE), with two fatalities not related to valvopathy. RESULTS: The comparison between the groups resulted in similarities in the mean ages, mean time of knowledge of the disease, predominance of males and rheumatic etiology. The profile analysis showed that the significant initial differences between the average of all echocardiographic variables (diastolic diameter, systolic diameter, shortening fraction, final systolic stress, volume-mass ratio, contractility index) and of the ejection fraction of the left ventricle obtained by the radionuclide ventriculography at rest, remained during the study. CONCLUSION: Development of symptoms grouped patients with more advanced excentric hypertrophy, did not coincide with any immediate change in the laboratory markers studied at rest and it was used as a referential for surgical therapy.

[Mitral valve aneurysm associated with mitral insufficiency in absence of aortic insufficiency]. / Aneurisma de valva mitral associado a insuficiência mitral, em ausência de insuficiência aórtica.

Two 31 year old patients were interned with cardiac insufficiency (functional class III). Case number one infective endocarditis with mitral valve 8 months before. Case number two had previous rheumatic disease. Both had severe mitral insufficiency and were submitted to replacement of mitral valve. Surgical findings included the presence of aneurysm mitral leaflet (posterior in case one and both in case two). The pathologic study showed mitral valve prolapse and signs of previous endocarditis in case one and rheumatic lesion in the other case.

[Comparison between percutaneous balloon valvuloplasty and open commissurotomy for mitral stenosis]. / Avaliação comparative entre valvoplastia percutânea e comissurotomia a céu aberto na estenose mitral.

PURPOSE: To compare immediate and late (12 months) follow-up of clinical and Doppler echocardiographic results between percutaneous mitral balloon valvuloplasty and open commissurotomy in a prospective and randomized trial. METHODS: Eighty eight symptomatic patients with severe mitral stenosis and favorable anatomy were randomized in a prospective trial comparing the two procedures. All patients were submitted to clinical and Doppler echocardiographic evaluation before the procedures and immediate and twelve months thereafter. RESULTS: Mean mitral gradient (mmHg) decreased from 12.2 +/- 5.8 to 5.80 +/- 2.7 (p < 0.001) in commissurotomy group (CG) and from 11.7 +/- 6.1 to 5.0 +/- 2.4 (p < 0.001) in the balloon valvuloplasty group (VG). Mitral valve are (cm2) increased from 0.98 +/- 0.21 to 2.52 +/- 0.46 in CG and from 1.05 +/- 0.25 to 2.18 +/- 0.40 in VG (p < 0.001). In both groups there was a slight decrease in mitral valve area at 12 month follow-up. There was no death in either group. One patient in the VG had moderate mitral regurgitation and underwent surgery. At the 12 month follow-up, all patients in CG and 97.7% of patients in VG were in New York Heart Association functional class I or II. CONCLUSION: Both procedures were safe and showed similar immediate improvement in mitral gradient and functional class. Mitral valve area had a greater increase immediately after commissurotomy, however, there was a significantly greater reduction in the CG after 12 months of follow-up, when compared to balloon valvuloplasty. In both groups, mitral gradient remained reduced and most patients did not change functional class during the follow-up.

[Comparative study between inoue single balloon and double balloon in percutaneous mitral valvuloplasty. Immediate results and after 1 year follow-up]. / Estudo comparativo entre balão único de inoue e duplo balão na valvoplastia mitral percutânea. Resultados imediatos e após seguimento de um ano.

PURPOSE: To compare early and 12 months results of mitral stenosis (MS) correction by percutaneous balloon valvuloplasty (PMBV) using Inoue's single-balloon or double balloon techniques. METHODS: We submitted 139 consecutive patients to PMBV using Inoue single-balloon (n = 56, GI) or the double balloon technique (n = 83, GII). The two groups were similar, in: age, sex, functional class (FC), echocardiographic (ECHO) score, mitral valve area (MVA), and gradient (G) or presence of regurgitation. Clinical and ECHO data were compared before (PRE), immediately after (POI) and one year following the procedure (PO12M). RESULTS: PMBV was successfully performed in 53 (95%) patients of GI and in 79 (96%) of GII. Statistical analyses showed that the groups were similar at POI but different at PO12M (p < 0.002). ECHO immediately after PMBV showed that: MVA increased from 0.99 +/- 0.23 to 2.01 +/- 0.44cm2 (p < 0.001) in GI and from 0.94 +/- 0.23 to 2.09 +/- 0.35cm2 (p < 0.001) in GII and G decreased from 11.58 +/- 5.02 to 5.16 +/- 2.23mmHg (p < 0.001) in GI and from 12.48 +/- 4.89 to 5.96 +/- 3.21mmHg (p < 0.001) in GII. After one year 36 (64%) patients in GI and 62 (74%) in GII underwent an ECHO study. A comparison between immediate and one year follow-up results showed that MVA decreased from 2.01 +/- 0.4 to 2.00 +/- 0.3cm2 (NS) in GI and from 2.09 +/- 0.3 to 1.74 +/- 0.4cm2 (p < 0.001) in GII and G decreased from 5.16 +/- 2.2 to 5.50 +/- 2.9mmHg (NS) in GI and from 5.96 +/- 3.2 to 8.61 +/- 4.8mmHg (p < 0.001) in GII. There was therefore a sustained improvement of MVA and G after one year in GI and a significant decrease in MVA and G in GII. The FC after one year was similar and satisfactory in both groups. CONCLUSION: Both techniques are equally effective in relieving MS immediately after PMBV, but after one year, despite similar FC, Inoue-balloon technique seems to be superior to maintain MVA and G.

[Neurological events in infective endocarditis]. / Eventos neurológicos na endocardite infecciosa.

PURPOSE: The study of frequency, modalities and course of neurological complications of infective endocarditis (IE), as well as the current indication and value of supplementary examinations. METHODS: Sixty-three patients with IE, 39 with native valve and 24 with valvar prosthesis, were prospectively studied; the mean age was 42 years and 45 (71.4%) were males. Two groups were formed: A) 41 patients without neurological events and B) 22 patients who presented 28 neurological events before or during hospitalization: ischemic cerebrovascular accident 20, hemorrhagic cerebrovascular accident 2, meningeal hemorrhage 2, meningitis 2, brain abscess 1 and seizure 1. All patients were submitted to neurological clinical examination; 57 computerized tomographies of the cranium, 28 arteriographies and 32 cerebrospinal fluid analysis were performed. RESULTS: The incidence of neurological events corresponded to 34.92% of IE patients, with a clear predominance (85.71%) of vascular as compared to infectious manifestations. Mortality was 2.32 times higher in group B patients (22.73% x 9.76%), albeit p = 0.256, and was not related to staphylococcal etiology. The neurological events were not related to sex, age and presence of valvar prosthesis. The presence of neurological complications was greater (p = 0.047) in patients with simultaneous infections in two valves (mitral and aortic) and also (p = 0.00884) in those with IE in prosthesis implanted for less than three months. All supplementary neurological examinations in group A were normal. CONCLUSION: 1) Occurrence of neurological events is a factor which influences the prognosis of IE; 2) supplementary neurological examinations did not reveal subclinical neurological complications; 3) neurological complications were significantly more frequent in patients with simultaneous mitral and aortic valve IE; 4) IE in prosthesis implanted for less than 3 months has a greater probability to develop a neurological picture as compared to IE in prosthesis implanted for more than 3 months.

[Mitral catheter-balloon valvuloplasty in surgical high risk patients]. / Valvoplastia mitral por cateter-balão em pacientes de alto risco operatório.

PURPOSE: To evaluate percutaneous mitral balloon valvuloplasty (PMBV) in surgical high risk patients. METHODS: Twenty (12%) patients out of 172 submitted to a PMBV were considered high surgical risk cases; 17 (85%) were women and mean age was 43 (18-69). Thirteen (65%) were in acute pulmonary edema (3 were pregnant, 2 had previous cerebrovascular event, 1 had pulmonary thromboembolism and other had chronic renal failure), and 7 (35%) were in functional class (CF) III (2 had coronary artery disease, 2 severe obesity, 1 pulmonary neoplasia, 1 cardiac cachexia and one with previous cerebrovascular event). All patients underwent PMBV through transseptal technique. Double balloon was used in 10 (50%) patients; Inoue balloon in 5 (25%), mono-foil in 3 (15%) and bi-foil in 2 (10%). RESULTS: Seventeen (85%) obtained success and 2 (10%) had clinical improvement. The hemodynamic results pre versus post-PMBV showed: left atrium pressure (LAP) mmHg 28.2 +/- 10.0 x 15.2 +/- 9.2 (n = 20) (p < 0.001), mitral medium gradient (G) mmHg 21.2 +/- 10.7 x 10.7 +/- 6.7 (n = 18) (p < 0.001), mitral valve area (MVA) cm2 0.73 +/- 0.3 x 1.73 +/- 0.6 (n = 11) (p < 0.001), pulmonary artery pressure mmHg 52.0 +/- 18.2 x 40.1 +/- 14.7 (n = 18) (p < 0.001) and cardiac index L/min/m2 2.1 +/- 0.4 x 2.5 +/- 0.6 (n = 14) (p < 0.001). Comparative echocardiography results pre, post and 6 months after PMBV showed: MVA 1.06 +/- 0.39 x 1.92 +/- 0.51 x 1.65 +/- 0.5 and G 13.8 +/- 4.7 x 7.3 +/- 3.6 x 7.3 +/- 4.4. There were two immediate deaths (pulmonary thromboembolism and multiple organs failure) and other after hospital discharge. The complications were: 2 (10%) patients with neurological complications, 1 (5%) atrial septal defect and other right atrium perforation (5%). CONCLUSION: PMBV offers an alternative to surgical treatment in high risk surgical patients and the results are maintained in the 6 month follow-up.

[Aneurysms of the left and non coronary sinus of Valsalva associated to mitral and aortic rheumatic valves and obstructive coronary disease]. / Aneurismas dos seios de Valsalva esquerdo e não-coronário associados à valvopatia reumática mitro-aórtica e à coronariopatia obstrutiva.

A 30 years old, male, patient with rare multiple aneurysms of sinus of Valsalva associated to mitral and aortic regurgitation and total occlusion of circumflex artery had the clinical diagnosis made accidentally. The multiple aneurysms were detected by transesophageal echodopplercardiography and hemodynamic study. The diagnosis were confirmed at surgery and the patient underwent correction of the aneurysms through the use of pericardial patches and mitral and aortic valve replacement.

[Postoperative course of left ventricular function in aortic insufficiency]. / Evolução pós-operatória da função ventricular esquerda na insuficiência aórtica.

PURPOSE: To analyze the follow-up of left ventricular function (LVF) after surgical correction of severe chronic aortic insufficiency (AI). METHODS: Twenty-one out of 68 patients with AI, initially asymptomatic and that developed symptoms during the follow-up period of 24-36 months, were studied. Relationship between symptoms and LVF by echocardiogram and radioisotopic ventriculography at rest and in isotonic exercise were studied. Three clinical moments (CM) were assumed: CM-0- at the beginning of the study, when all patients were asymptomatic; CM-1- manifestation of the symptoms during 24-36 months; CM-2- corresponding to the late post-operative period of 8 months of 20 out of 21 patients (one refused the surgery). The analysis did not show any significant differences between the mean values of all echocardiographic variables (diastolic and systolic diameters, shortening fraction, final systolic stress, volume-mass ratio, contractility index) and the ejection fraction of the left ventricle (EF) obtained by the radioisotope ventriculography at rest and, including exercise, between clinical moments 0 and 1. RESULTS: In the CM-2, involution was verified for functional class I/II in all cases and absence of expressive complications or immediate or late postoperative mortality. Comparison between CM-2 and 0 showed expressive regression of the diameters at rest in the postoperative period and with significant improvement in the means mainly the percentual variation of the EF and total time of effort. CONCLUSION: Symptoms assembled patients with more advanced eccentric hypertrophy and did not coincide with any immediate change in findings studied at rest and at exercise. It represented a point of reference for surgical indication compatible with late postoperative involution of chronic adaptation of AI.

[Mitral stenosis correction by double catheter-balloon valvuloplasty technique]. / Correção de estenose mitral através de valvoplastia por técnica de duplo cateter-balão.

PURPOSE: To evaluate long-term efficacy of double balloon percutaneous mitral valvuloplasty technique (PMV2B). METHODS: Sixty-eight patients (76% female), mean-age 32 (15-69) years who had been submitted to PMV2B, that completed clinical and echodopplercardiographic one year follow-up (PO12M). Admission criteria were: exertional dyspnoea, no thromboembolism antecedent up to three months before the procedure, absence of other cardiac disease requiring correction, an admissible echodopplercardiographic score, absence of intracavitary thrombus and mitral regurgitation absent or minor. RESULTS: The patients were divided in two groups: group A of 7 (11%) patients that have a cardiac event in this period, and group B of 61 patients that completed the follow-up without a cardiac event. In group A three patients have had a severe mitral regurgitation, one case was unsuccessful and other one had a re-stenosis. There were two deaths, not related to the intervention. In group B, haemodynamic results before and immediately after PMV2B (POI) showed a significant improvement, except in relation to cardiac index. There was an increase in the grade of mitral regurgitation in 17 (28%) patients and in two cases this regurgitation became moderate. The mitral valvar area (MVA) variation between PRE x POI x PO12M presented, comparing MVA between POI and PO12M, a significant reduction. Two (3%) patients with a reduction greater than 50% of the initial increase, 33 (54%) between 10 and 50% and 26 (42%) less that 10% remained in functional class I/II. CONCLUSION: PMV2B is an attractive treatment to select symptomatic mitral stenosis patients, with a low incidence of complications, symptomatic effective improvement that was maintained in one year follow-up, although there was a reduction in MVA.

[Preoperative erythrocytopheresis in a patient with SC hemoglobinopathy and mitral stenosis]. / Eritrocitoferese pré-operatória em portador de hemoglobinopatia sc e estenose mitral.

Hemoglobinopathies are associated with thrombotic complications, when exposed to cardiopulmonary bypass. A 54-year old, black woman with hemoglobinopathy SC and severe mitral stenosis was submitted to eritrocytopheresis 48 hours before mitral commissurotomy surgery. The therapeutic determined appearance of the percentual hemoglobin A of 68% with reduction the hemoglobin S of 48% to 15% and the hemoglobin C of 51% to 17%. No complications occurred during postoperative period. To best of our knowledge, that is the first report about application the eritrocytopheresis in the pre operative extra corporeal circulation care in surgical treatment of patients with chronic rheumatic heart disease and hemoglobinopathy SC.

[Valvular surgical treatment concurrent with myocardial revascularization]. / Tratamento cirúrgico valvar concomitante à revascularização do miocárdio.

PURPOSE: To study the morbidity and mortality due to valvar surgical treatment performed concomitantly to myocardial revascularization. METHODS: From 1650 patients submitted to mitral or aortic valve surgical treatment, 103 (6.24%) had it associated to myocardial revascularization. Coronary insufficiency was associated to aortic valvar lesion in 66 (64.0%) patients, group I, with mean age of 62.3 +/- 8 years; and in 37 (35.9%) patients with mitral valve lesion, group II, with mean age of 57.8 +/- 5.8 years. Diagnosis was based upon the anamnesis, physical examination and confirmed by cine-coronarographic findings. RESULTS: I-Complications at the immediate postoperative; a) mortality 11 (10.6%) patients, 6 (9.09%) from group I: by low cardiac output 3, uncontrolled arrhythmia 1, mediastinitis 1; acute infarction with cardiogenic shock 1, and 5 (134.5%) of group II: uncontrolled hemorrhage 2, sudden death 1, saphenous vein graft occlusion, respiratory insufficiency and sepsis 2; b) controlled intercurrences that increased the time of hospitalization: mental disorder 5 patients; CVA 7, diabetes decompensation 2, worsening of chronic renal insufficiency 1, upper level digestive hemorrhage 1 and respiratory insufficiency 3 patients. II-late postoperative complications of 77 (83.6%) patients which could be followed up during a period of 60 months: 1) mortality: 3 (3.89%) patients; 2 due to cardiomyopathy and 1 by acute myocardial infarction; 2) late evolution-functional capacity III (NYHA) by cardiomyopathy 6; I/II 68 patients; mild angina 6 patients, 2 underwent revascularization at the end of final 36-42 months. CONCLUSION: The clinical improvement and mortality indexes statistically similar to the isolate surgical acts stimulate us to keep up with such associate procedures.

[Bilateral diaphragmatic paralysis in the immediate postoperative period after cardiac surgery]. / Paralisia bilaterial do diafragma no pós-operatório imediato de cirurgia cardíaca.

A 56 years old man was submitted to an aortic replacement with mechanical prosthesis and to saphenous vein graft to the right coronary artery. He developed respiratory insufficiency after surgery which was finally related to bilateral diaphragmatic paralysis whose diagnosis was confirmed through thorax ultrasonography. The patient remained under ventilatory assistance with positive pressure for 75 days. The introduction of thorax ventilatory negative pressure (VNP), jacket type, allowed the tracheostomy closure. The patient gradually recovered his spontaneous breathing and was discharged after 90 days with instructions to use VNP at night. He returned to his normal professional activities, without auxiliary respiratory support, 40 days after his discharge.

[Surgical intervention in patients undergoing a procedure for mitral valvoplasty by balloon catheterization]. / Intervenção cirúrgica em pacientes submetidos a procedimento para valvoplastia mitral por cateter-balão.

PURPOSE: To study the characteristics of patients undergoing catheter-balloon mitral valvoplasty (CBVM) procedure who needed surgical intervention after CBMV. PATIENTS AND METHODS: One hundred and five patients submitted a CBMV were divided in to Group I (GI) of eighteen surgical patients and Group II (GII) of eighty-seven non-surgical patients. The following parameters were analyzed. 1) age; 2) sex; 3) mitral valve area (MVA) and mean transvalvular gradient (G) by echodopplercardiography (2D); 4) Character of CBMV; 6) Relation of time between CBMV and Surgery with surgical indication; 7) Surgical findings; 8) Surgical procedure and 9) Post-operative evolution. RESULTS: Mean age of 34 (17-56) years old in GI and 33 (15-69) years old in GII; 2) Similar distribution of men and women in GI and GII; 3) Similar MVA and G in GI and GII; 4) 100% of elective character in GI and 94% in GII; 5) Transseptal via in 17 (94%) of GI and 87 (83%) of GII, retrograde arterial via in 1 (5.5%) of GI and in another (1%) of GII; 6) immediate: cardiac tamponade (28%); until 30 days: unsuccessful CBMV (39%); mitral insufficiency (MI) post-CBMV (11%), cardiac tamponade (5.5%), between 30 and 60 days: MI post-CBMV (22%), Mitral restenosis post-CBVM (5.5%); 7) Mitral stenosis (72%), MI post-CBVM (22%), hemopericardium (6%); 8) Mitral Commissurotomy (7), Mitral bioprosthesis implant (5), Commissurotomy plus Atrioseptoplasty (1), Mitral plasty (1), Pericardium drainage (1); 9) One (5.5%) death in immediate post-operative of the MI correction, 17 (94%) in functional class I/II (NYHA) 14.3 (8-27) months after surgery. CONCLUSION: Age, Sex, VMA G and Urgency character were not discriminative factors in the formation of GI and GII. The procedures for CBVM didn't interfere with post-operative prognosis.