Surgical treatment of Ebstein's anomaly. Early and late results in twenty patients subjected to valve replacement.

Twenty patients with Ebstein's anomaly underwent corrective operations between 1965 and 1978. Sixteen were in Functional Class III or IV (N.Y.H.A.) and four were in Class II but were having episodes of anoxia, syncope, or a rapid increase in cardiac size. In the first 10 cases (1965 to 1972) the tricuspid valve was replaced with a Starr-Edwards prosthesis, and in the second group (1972 to 1978) a dura mater valve was used. Five patients also underwent plication of a very large atrialized right ventricular segment. The atrial septal defect was closed totally in four cases, partially in eleven cases, and left open in five cases; one patient also underwent closure of the ventricular septal defect. Four patients died in the immediate postoperative period, three of whom were in the first group. There were three late postoperative deaths in the remaining 16 patients, all of them in the first group. All 13 of the surviving patients are in Functional Class I, except for one patient who is in Class II.

Homologous dura mater cardiac valves. Structural aspects of eight implanted valves.

We studied eight homologous dura mater valves removed 1 to 35 months after implantation. Five dura mater valves were placed in the mitral position and three in the aortic position. Two of the valves were obtained after deaths not related to the valve itself and six after reoperations due to immediate or late incompetence. In 2 cases the dura mater valves were entirely normal, both macroscopically and microscopically. In 2 other cases the leaflets were caught by stitches related to the struts, a technical error that caused laceration of the leaflets. Not withstanding this fact, the dura mater was normal on histologic examination. In 3 cases, and probably in 1 other, one or two leaflets were detached partially from the suture line, probably because of a technical error in the manufacture of the valve. These studies demonstrated satisfactory evolution of the homologous dura mater valves until 35 months after implantation. No signs of rejection or degeneration of the dura mater were observed in the present series.

Congenital tricuspid stenosis treated by a palliative open operation. Report of a case.

The case is presented of a patient with congenital tricuspid stenosis who was treated successfully by a palliative open operation. The preoperative diagnosis was tricuspid atresia. At operation, however, congenital tricuspid stenosis was detected and managed by commissurotomy.. The postoperative course was very good. Later, the associated ventricular septal defect (VSD), pulmonary annular stenosis, and probably the atrial septal defect (ASD) will be corrected. We emphasize the importance of diagnosing congenital tricuspid stenosis correctly, because of the possibility of operating upon the valve itself.

Intrapulmonary balloon for temporary relief of pulmonary hypertension.

In this report, we shall describe a case of interventricular septal defect with severe cardiac and respiratory insufficiency unresponsive to clinical treatment. The critical condition of the patient prompted us to introduce an obstructive balloon into the pulmonary artery with the objective of reducing pulmonary flow and improving respiratory insufficiency. The mean pressure was reduced from 45 to 19 mm. Hg, and the infant's cardiopulmonary status improved dramatically. After 36 hours, during which the clinical picture stabilized, a banding operation was performed with success.

Homologous dura mater cardiac valves. Study of 533 surgical cases.

A group of 533 patients had cardiac valves replaced with homologous dura mater valves. The dura mater was preserved in a solution of 98 per cent glycerol and antibiotics for a period of 12 days before used. The leaflets were mounted in a stainless steel ring covered by Dacron velour. Two hundred forty-five patients had mitral valve replacement; 205 patients, aortic valve replacement; 17 patients, tricuspid valve replacement; and 2 patients, pulmonary valve replacement. Sixty-four patients were subjected to multivalvular replacements. The patients were followed for a period of 1 to 40 months after surgery with satisfactory clinical and hemodynamic results. Because 2 patients developed endocarditis produced by fungii, fungicidal drugs were added to the preservative solution. No bacterial endocarditis has been observed. No pressure gradient through the valve has been noted at rest. Anticoagulant drugs have not been used in the postoperative period.

Surgical treatment of ruptured aneurysms of the innominate artery.

The cases of 3 patients with an aneurysm of the innominate artery treated surgically are reported. The clinical manifestations were different, and the surgical procedures employed also varied. In 1 patient, the neck of the aneurysm was isolated and clamped near the aortic arch. It was closed, and a graft was interposed between the ascending aorta and the right carotid and subclavian arteries. In the second, the aneurysm was resected under cardiopulmonary bypass, deep hypothermia, and total circulatory arrest. The neck was closed with a large Teflon patch, and a tube graft was interposed between the ascending aorta and the right carotid artery. In the third, a graft was interposed between both carotid arteries; conventional cardiopulmonary bypass was instituted, and the aorta was clamped between the innominate and the left carotid arteries. The neck of the aneurysm was closed, and a graft was interposed between the ascending aorta and the right carotid and subclavian arteries. All patients had an excellent postoperative course. Our comments regarding the clinical and surgical aspects of this condition are based on the present experience and reports in the literature.

Transposition of the great arteries associated with total anomalous pulmonary venous connection: a surgical approach.

The association of transposition of the great arteries with total anomalous pulmonary venous connection is very rare. In this report we describe 1 patient with this combination of anomalies who underwent successful repair. The patient has made an uneventful recovery.

Four years experience with dura mater cardiac valves.

The clinical use of homologous dura mater cardiac valves was begun in January 1971. Between January 1971 and May 1975, 751 patients received 849 dura mater valves: 428 mitral, 365 aortic, 52 tricuspid and 4 pulmonary. The hospital mortality observed in this series was 13.6% and late mortality was 2.5%. The main causes of death were low-output syndrome in the immediate post-operative period or cardiac failure in the late post-operative period, due to myocardial impairment. Paravalvular leaks and errors in the manufacture of the valve were the main causes of regurgitation both in the immediate and late post-operative period. The incidence of thromboembolism, bacterial and fungal endocarditis was: 0.79%, 0.39%, 0.53% respectively. The results obtained with dura mater valve in a period of four years are satisfactory from the clinical and hemodynamic points of view.

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.

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.

The De Vega annuloplasty as surgical treatment for tricuspid incompetence.

Seventy-six patients with tricuspid insufficiency associated with other valvular lesions underwent De Vega annuloplasty. There were mitral lesions in 74 patients, aortic valve lesions in eight and atrial septal defects (ASD) in four. The radiographic and electrocardiographic findings and hemodynamic data are reported for 66 patients. Replacement of one or two valves was performed in 56 patients, one or two valves commissurotomy in 21 and closure of the ASD in four. The immediate postoperative mortality was 19.7%. Forty-four patients were followed from six to 59 months. There were three late deaths and clinical conditions were improved in all the survivors except one who presented mitral restenosis. Discrete residual tricuspid incompetence occurred in 11 patients (25%). We conclude that the De Vega annuloplasty is the treatment of choice for functional tricuspid incompetence.

[Right ventricular dysplasia associated with Ebstein type malformation of the tricuspid valve. A case report]. / Displasia ventricular direita associada à malformação "tipo Ebstein" da valva tricúspide. Relato de caso.

Right ventricular dysplasia, also named right ventricular cardiomyopathy, cardiac lipidosis and partial absence of the right ventricular myocardium, is an uncommon disease in which the myocardium is partially replaced by fat and fibrous tissue. The clinical picture is usually characterized by complex arrhythmias, causing sudden death in adolescents and young adults, and cardiac failure. In this report, an association between this disease and "Ebstein-type" tricuspid valve malformation has been diagnosed in a 22 year old female patient with cianosis and dyspnea on exertion.

[Hemorrhagic infarction due to myocardial reperfusion. Report of 4 cases]. / Infarto hemorrágico conseqüente à reperfusão miocárdica. Relato de quatro casos.

Four different clinical cases in which the myocardial reperfusion occurred after acute myocardial infarction, and was followed by significant hemorrhagic ventricular damage. We discuss some possible etiologic mechanism of the problem and present some methods of myocardial protection which are meant to lessen those negative effects of the reperfusion. We conclude setting the difficulty to determine the critical moment after which the myocardial reperfusion turns inefficient or even harmful.

[Surgical treatment of tetralogy of Fallot associated with an anomalous coronary vessel]. / Tratamento cirúrgico da tétrade de Fallot associada a coronária anômala.

Anomalous coronary arteries crossing the outflow tract of the right ventricle in tetralogy of Fallot have a prominent surgical importance in total correction. The unintentional section of these arteries is followed by a high mortality. In the period between 1977 and 1987, 475 patients with tetralogy of Fallot were operated on. Fourteen of these patients had anomalous coronaries crossing the right ventricle. Three of the patients were less than one year of age. Eleven patients were male. Diagnosis was performed in the operating room in 13 patients. Twelve patients had the anterior descending artery originating from the right coronary, and two presented single left coronary arteries. During the surgical procedure two patients had the anomalous coronary artery divided; in one a saphenous vein bypass graft was used and in the second and end-to-end anastomosis was performed. In the remaining 12 cases, a transverse ventriculotomy (one case), extensive dissection of the anomalous coronary artery (two cases), a palliative procedure (one case), a valved conduit between the right ventricle and the pulmonary artery (one case) and total correction through the atriopulmonary approach (seven cases) were performed. No immediate mortality was observed and there was one late death. The authors suggest that, whenever anatomical conditions permit, the atriopulmonary approach should be preferred in the repair of tetralogy of Fallot associated to anomalous coronary arteries.

[Ischemic mitral valve insufficiency. Incidence, diagnosis and surgical treatment]. / Insuficiência valvar mitral isquêmica. Incidência, diagnóstico e tratamento cirúrgico.

PURPOSE: To study the incidence of ischemic mitral regurgitation (MR) and the mortality. METHODS: One-hundred-five cases of acute myocardial infarction (AMI) with MR were reviewed. Patients were divided in two groups: group A-59 (56.2%) necropsied patients without previous surgical procedures to correlate clinical pictures with the aim to determine the cause of death; group B-46 (43.8%) patients were submitted to surgical treatment. This group was subdivided in mild, moderate and severe forms of MR, and studied comparatively the type of surgical treatment and its evolution. RESULTS: Group A-23 (39%) patients with mild forms and predominant ischemic heart disease, responsible for death; 18 (30.5%) patients without previous diagnosis, masked by myocardial failure and 18 (30.5%) with severe MR and coronary heart disease; group B-14 (30.4%) patients died at the immediate post-operatory period. Higher mortality associated to ejection fraction (EF) below 35% (47.6%; p = 0.022), severe MR (41.7%; p = 0.044) and cardiogenic shock (52.9%; p = 0.14). In 41 (89.1%), the mitral valve repair was combined to coronary artery bypass grafting operation (CABG), in 4 (8.7%) this last procedure was made without mitral repair and in the remaining patients the surgery was limited to the valve. Mitral valvuloplasty was performed in 23 (50%) patients with 3 (13%) deaths, and in 19 (42.3%) the mitral valve was replaced with 9 (47.4%) deaths. CONCLUSION: The prognosis is related to the grade of EF and to the severity of MR. In mild to moderate forms, the surgical indication is due to the associated coronary heart disease and the valvuloplasty is preferred, in this instance. In severe forms, surgical intervention must be performed as soon as possible, before cardiogenic shock appears.

Mitral valve repair. Quadrangular resection of the posterior leaflet in patients with myxomatous degeneration.

OBJECTIVE: To analyze the immediate and late results of mitral valve repair with quadrangular resection of the posterior leaflet without the use of a prosthetic ring annuloplasty. METHODS: Using this technique, 118 patients with mitral valve prolapse who underwent mitral repair from January '84 through December '96 were studied. Age ranged from 30 to 86 (mean = 59.1 +/- 11.8) years and 62.7% were males. An associated surgery was performed in 22% of the patients, and coronary artery bypass graft was the most frequently performed surgery (15 patients--12.7%). In 20 (16.9%) patients other associated techniques of mitral valve repair were used and shortening of elongated chordae tendineae was the most frequent one (6 patients). RESULTS: Immediate mortality was 0.9% (one patient). Long-term rates for thromboembolism, endocarditis, reoperation and death in the late postoperative period were 0.4%, 0.4%, 1.7% and 2.2% patients/year, respectively. The actuarial curve of survival was 83.8 +/- 8.6% over 12 years; survival free from re-operation was 91.8 +/- 4.3%, free from endocarditis was 99.2 +/- 0.8% and free from thromboembolism was 99.2 +/- 0.8%. In the late postoperative period, 93.8% of the patients were in functional class 1 (NYHA), with a complete follow-up in 89.7% of the patients. CONCLUSION: Patients with mitral valve prolapse who undergo mitral valve repair using this technique have a satisfactory prognosis over 12 years.