Anatomic correction of transposition of the great vessels.

We present a new approach for anatomic correction of transposition of the great arteries. The two coronary arteries, with a piece of the aortic wall attached, are transposed to the posterior artery. The two aortic openings are closed with a patch. The aorta and pulmonary artery are transected, contraposed, ant then anastomosed. The interventricular septal defect is closed with a patch, through a right ventriculotomy approach, because the right ventricle is no longer part of the systemic circulation. Two patients, aged 3 months and 40 days weighing 4,200 and 3,700 grams, respectively, were operated upon with deep hypothermia and total circulatory arrest. There was good recovery from the operation, with normal cardiocirculatory conditions. Renal failure developed in the first patient, and she died on the third postoperative day. During this time the cardiocirculatory conditions were good. The second patient made an uneventful recovery. Hemodynamic studies 20 days after the operation showed complete correction of the malformation. Five and one-half months after the operation, he weighs 7,500 grams, and his development is very good. We believe that this operation will be reproducible by most cardiovascular septal defect and pulmonary hypertension.

Criss-cross heart with intact ventricular septum.

We report a case of a criss-cross heart in a 6-month-old male child with echocardiographic and angiocardiographic findings of concordant atrioventricular and discordant ventriculoarterial connexions and an intact ventricular septum. This entity has been described with a ventricular septal defect as part of its own anatomic spectrum. The concept of the criss-cross heart, however, is best restricted to a form of spatial atrioventricular arrangement in which the atrioventricular connexions are criss-crossed.

Angioplasty for primary treatment of aortic coarctation: immediate results in two adult patients.

Two adult patients with severe aortic coarctation were treated by angioplasty performed percutaneously through the right femoral artery. A 20 mm balloon catheter was used, being inflated several times within the stenosis. The final angiographic result was excellent in both cases. The gradients were 38 and 46 mm Hg before and 5 and 3 mm Hg after angioplasty, respectively. The arterial pulses in the legs were normal after the procedure and no complication was observed.

Pulmonary valvoplasty--experience of 100 cases.

One-hundred patients with pulmonary valve stenosis underwent pulmonary valvoplasty, their ages ranging from 1 to 59 years. The systolic gradient across the valve ranged from 47 to 260 mm Hg (97.67 +/- 41.15) prior to the valvoplasty, and from 0 to 55 mm Hg (14.72 +/- 11.40) immediately after dilatation (P less than 0.0001). The clinical follow-up of 18.2 months of 56 patients showed a tendency for the systolic thrill to disappear, the systolic murmur became softer and there was a tendency to normalization of the electrocardiogram. A hemodynamic restudy was carried out in 54 patients and the systolic gradients across the valve ranged from 21.55 +/- 23.86. Seven patients required redilatation. In patients with hypertrophy of the infundibulum prior to valvoplasty this was observed to regress, indicating that infundibular hypertrophy is reversible.

It is valid to dilate native aortic coarctation with a balloon catheter.

We report our experience in 37 patients with aortic coarctation who underwent balloon aortoplasty. Of the 37, the lesion was native in 34 cases. Clinical re-evaluation was possible in 22 patients, with a mean follow-up period of 13 months and, of these, 21 patients were asymptomatic. Haemodynamic and angiographic studies were performed in 13 patients, with a mean period of follow-up of 12 months, showing excellent results in 11 patients. Aneurysmal formation had occurred in one and recoarctation in the other patient. Our experience has proved that balloon aortoplasty is an effective method for treating patients with aortic coarctation. Adequate selection in terms of the morphology of the coarctation and the size of the balloon catheter are crucial factors in the success of the procedure.

[Technical modification of total cavo-pulmonary connection]. / Modificação técnica da conexão cavo-pulmonar total.

A variation of total cavopulmonary connection without anastomosing the superior vena cava to the right pulmonary artery branch is presented. Both vena cava flow go through an intra atrial tunnel to the right atrial appendage, which is anastomosed to the right pulmonary artery, in anatomical eligible cases.

[Results of percutaneous balloon valvuloplasty in membranous subaortic stenosis]. / Resultados da valvoplastia percutânea por cateter balão na estenose subaórtica em membrana.

PURPOSE: To evaluate the results of percutaneous balloon valvuloplasty (PBV) for membranous subaortic stenosis (MSAS). METHODS: Seven patients with MSAS were submitted to PBV using the retrograde approach. Hemodynamic and angiographic studies were performed before and after the procedure. The balloon/annulus ratio varied between 0.9 to 1.05. RESULTS: The systolic gradient (SG) between the left ventricle (LV) and aorta was reduced from 57.8 +/- 11.6 to 22.0 +/- 8.6 mmHg (p < 0.001) and the LV systolic pressure from 154.5 +/- 30.3 to 118.7 +/- 18.4 mmHg (p < 0.001). One patient had arterial occlusion and was submitted to surgical embolectomy and another one showed severe mitral regurgitation combined with aortic insufficiency (AI) and required surgical valvuloplasty. There was no mortality. Four patients had a 11 +/- 10 month follow up: the SG measured by echocardiogram was 34 +/- 7 mmHg and no patient showed worsening of the AI. CONCLUSION: PBV is an effective procedure to reduce the subaortic SG, with an acceptable morbidity and persistence of the results in the short term follow up. PBV is a valid alternative as an initial mode of therapy in the management of patients with MSAS.

[Simultaneous treatment of pulmonary valve stenosis and patent ductus arterious by interventional catheterization]. / Tratamento simultâneo da estenose pulmonar valvar e da persistência do canal arterial através do cateterismo intervencionista.

The association of pulmonary valve stenosis and patent ductus arteriosus is uncommonly found in clinical practice of pediatric cardiology. The authors describe 2 patients with this association that were successfully treated in the same procedure by interventional cardiology: first case, a 14 month old boy was submitted to percutaneous pulmonary valvoplasty with reduction of systolic gradient between pulmonary artery and right ventricle from 71 to 3 mmHg. The 2.0 mm of diameter and conical shape duct was successfully occluded using a 38-5-5 coil; second case, a 20 month old girl was submitted to percutaneous pulmonary valvoplasty with reduction of systolic gradient between pulmonary artery and right ventricle from 60 to 5 mmHg. An attempt to close the 3.5 mm of diameter and concial shape duct using coil was performed, but the device embolized into the pulmonary artery. After immediate retrieval, a 12 mm Rashkind umbrella was implanted. Indication of treatment of both conditions, technical aspects and complications related to the procedures, and patients follow up are also discussed.

[Subaortic stenosis associated with atrioventricular septal defect. A rarely mentioned condition]. / Estenose subaórtica associada a defeito do septo atrioventricular. Uma condição pouco referida.

White male patient, 14 years old, who developed a severe subaortic stenosis in the late postoperative period of a total correction of atrioventricular septal defect. Clinical diagnosis was confirmed by echocardiography and cardiac catheterization. The patient underwent reoperation for treatment of the new condition, with resection of subaortic stenosis. Atrioventricular septal defects show a narrow and deformed left ventricle outflow tract, susceptible to obstruction before or after operation. It is, therefore, advisable to investigate a possible obstruction before the operation at the operation room and in the late postoperative period.

[Pulmonary hypertension: a serious complication in the postoperative period of tetralogy of Fallot]. / Hipertensão arterial pulmonar: séria complicação no pós-operatório de tetralogia de Fallot.

Among 1,142 patients who underwent total correction of tetralogy of Fallot from May of 1960 to december of 1986, five (0.43%) presented refractory cardiac failure. Pre and postoperative control was based on symptoms and clinical signals, electrocardiogram, conventional radiographies, cardiac catheterism, cineangiocardiography, and necropsy in one case. The evolution in immediate and late postoperative periods were not good. One patient deceased in the first day after surgery: the others had complications as severe pulmonary insufficiency, diffuse and severe hypocontractibility of the right ventricle, with three late decreases. Only one patient is alive, with congestive cardiac failure hardly controllable.

[The usefulness of digital angiography in performing coronary angioplasty. An analysis of 100 cases]. / Utilidade da angiografia digital na realização da angioplastia coronária. Análise de 100 casos.

PURPOSE: To analyse the actual contribution of digital angiography in the angioplasty setting and to assess its utility to optimize angioplasty results. METHODS: One hundred patients with single vessel coronary artery disease, without previous angioplasty or coronary artery bypass graft surgery, who underwent angioplasty from January to December 1990. Views were obtained in standard films and also in digitized angiograms. The latter was acquired before angioplasty in order to precisely quantify the stenosis and also to measure the reference diameter of the artery that was used and to choose the balloon catheter for each case. New acquisitions were done during and after the end of the procedure to confirm the residual stenosis and to measure the final diameter. RESULTS: The mean stenosis pre angioplasty was 78.2%, the mean reference diameter 2.8 mm and the mean diameter at the stenotic site 0.8 mm. The balloon artery relation was 0.9:1. After angioplasty the residual stenosis was 13.6% and the dilated segment had a final diameter of 2.6 mm. There were no complications in any patient. CONCLUSION: Digital angiography is a useful method for laboratories devoted to coronary interventions for it allows confirmation of the severity of the stenosis, optimizes the balloon/artery relation, monitors partial results and measures the residual stenosis as well as the final diameter.

[Coronary sinus atrial septal defect, ventricular septal defect and absence of left superior vena cava]. / Comunicação interatrial do tipo seio coronário, comunicação interventricular e ausência de veia cava superior esquerda.

We report a rare case of a 21 month old child with a coronary sinus atrial septal defect associated with perimembranous ventricular septal defect and no left superior vena cava. The diagnosis was made by transthoracic echocardiogram and confirmed by angiography. The patient was operated on uneventfully, both defects were closed with bovine pericardial patches and the flow from the coronary veins was directed towards the left atrium. An echocardiogram revealed complete closure of both defects.

Percutaneous closure of atrial septal defects. The role of transesophageal echocardiography.

PURPOSE: Evaluation of the role of transesophageal echocardiography in percutaneous closure of atrial septal defects (ASD) with the Amplatzer septal occluder. METHODS: Patients were selected for percutaneous closure of ASD by transesophageal echocardiography (TEE), which was also used to monitor the procedure, helping to select the appropriate size of the Amplatzer device, to verify its position, and to access the immediate results of the procedure. During the follow-up, TEE was used to evaluate the presence and magnitude of residual shunt (RS), device position, and right cardiac chamber diameters. RESULTS: Twenty-two (40%) of a total of 55 studied patients were selected. Thirteen underwent Amplatzer device implantation, eight are still waiting for it, and one preferred the conventional surgical treatment. All procedures were successful, which was mainly due to proper patient selection. Six (23%) patients acutely developed RS, which spontaneously disappeared at the three-month follow-up examination in three patients. There was a significant reduction in the right ventricle diastolic diameter, from 27 mm (average) to 24 mm and 20 mm, one and three months after the procedure, respectively (p < 0.0076). CONCLUSION: With the aid of TEE, percutaneous closure of ASD can be successfully, safely, and effectively performed.

Percutaneous mitral valvotomy in patients eighteen years old and younger. Immediate and late results.

OBJECTIVE - To analyze immediate and late results of percutaneous mitral valvotomy (PMV) in patients < or = 18 year. METHODS - Between August '87 and July '97, 48 procedures were performed on 40 patients. The mean age was 15.6 years; 68.7% were females four of whom were pregnant. RESULTS - Success was obtained in 91.7% of the procedures. Immediate complications were severe mitral regurgitation (6.3%) and cardiac tamponade (2.0%). Late follow-up was obtained in 88.8% of the patients (mean value=43.2+/-33.9 months). NYHA functional class (FC) I or II was observed in 96.2% of the patients and restenosis developed in five patients, at a mean follow-up of 29.7+/-11.9 months. Three patients presented with severe mitral insufficiency and underwent surgery. Two patients died. CONCLUSION - PMV represents a valid therapeutic option in young patients. In these patients, maybe because of subclinical rheumatic activity, restenosis may have a higher incidence and occur at an earlier stage than in others persons.

[Angioplasty of the anterior descending artery with abnormal origin: use of a new low-profile catheter balloon. A case report]. / Angioplastia da artéria descendente anterior de origem anômala: aplicação de novo cateter-balão de baixo perfil. Relato de caso.

It is possible to perform transluminal coronary angioplasty (TCA) in thin vessels presenting severe obstructions. One of the achievements that made such procedure possible is the development of a new generation of balloon catheters. In this case report the TCA was performed in a very thin left anterior descending artery with an anomalous origin, a quite rare situation that represents a major problem to the traditional dilator system. The catheter used was a Probe (USCI), which differs of the traditional balloons in a number of characteristics. The authors consider the procedure in detail pointing out the advantages of using of the new generations and discuss the impact that newer technological developments will have in enlarging the indications for TCA and improving the results.

[Pulmonary atresia with intact ventricular septum. Valvar perforation by radiofrequency]. / Atresia pulmonar com septo ventricular íntegro. Perfuração valvar por radiofreqüência.

Six days old neonate with pulmonary atresia and intact ventricular septum is reported in which a communication was established between the right ventricle and the pulmonary artery. The membraneous atresia was perforated with a special radiofrequency catheter 2F connected to a Hat 200S radiofrequency generator (Osypka). The energy necessary to perforation was 15W. After perforation of the atresia, balloon dilation was performed (balloon diameter: 2, 3, 4mm of coronary angioplasty and 5, 8mm Penta Medi-tech). The valve was completely opened giving the continuity between right ventricle and pulmonary artery.

Percutaneous closure of ductus arteriosus with the amplatzer prosthesis. The Brazilian experience.

OBJECTIVE - To report the results of percutaneous occlusion of persistent ductus arteriosus with the Amplatzer prosthesis in 2 Brazilian cardiological centers. METHODS - From May 1998 to July 2000, 33 patients with clinical and laboratory diagnosis of persistent ductus arteriosus underwent attempts at percutaneous implantation of the Amplatzer prosthesis. The median age was 36 months (from 6 months to 38 years), and the median weight was 14kg (from 6 to 92kg). Sixteen patients (48.5%) were under 2 years of age at the time of the procedure. All patients were followed up with periodical clinical and echocardiographic evaluations to assess the presence and degree of residual shunt and possible complications, such as pseudocoarctation of the aorta and left pulmonary artery stenosis. RESULTS - The minimum diameter of the arterial ducts ranged from 2.5 to 7.0mm (mean of 4.0+/-1.0, median of 3.9). The rate of success for implantation of the prosthesis was 100%. Femoral pulse was lost in 1 patient. The echocardiogram revealed total closure prior to hospital discharge in 30 patients, and in the follow-up visit 3 months later in the 3 remaining patients. The mean follow-up duration was 6.4+/-3.4 months. All patients were clinically well, asymptomatic, and did not need medication. No patient had narrowing of the left pulmonary artery or of the aorta. No early or late embolic events occurred, nor did infectious endarteritis. A new hospital admission was not required for any patient. CONCLUSION - The Amplatzer prosthesis for persistent ductus arteriosus is safe and highly effective for occlusion of ductus arteriosus of varied diameters, including large ones in small symptomatic infants.

[Nonsurgical treatment of coronary pulmonary arteriovenous fistula]. / Tratamento não-cirúrgico de fístula artério-venosa coronária pulmonar.

Fifty eight year old man, with dyspnea, fatigue and progressive angina underwent cinecoronarography, which showed an arterio-venous coronary-pulmonary fistula originating from the circumflex artery to the pulmonary circulation. We decided to occlude it percutaneously, using a detachable balloon technic. The occlusion was accomplished successfully. Clinical evolution was excellent and the follow-up cinecoronarography 6 months later showed the maintainance of the initial results.

[Mitral double catheter-balloon valvuloplasty, hemodynamics evaluation of 52 cases one year after the procedure]. / Valvoplastia mitral com duplo cateter-balão, avaliação hemodinâmica de 52 casos um ano depois do procedimento.

PURPOSE: To evaluate the late hemodynamic and angiographic results of 52 patients who underwent mitral valvoplasty by the double balloon technique in the treatment of the rheumatic mitral stenosis. METHODS: The mean follow-up was of 18 months and the patients had a Doppler-echocardiogram and cardiac catheterization one year after dilatation. Of the 52 patients 84.6% were female and the mean age was 21.9% years. Eighty one percent were in NYHA class I whereas 5.7% had atrial fibrillation at the end of 18 months. RESULTS: Immediately after valvoplasty 46 patients (88.5%) had a valvar area larger, and 6 (11.5%) smaller than 1.5 cm2. The first group had a good clinical outcome with maintenance of the clinical, echocardiographic and angiographic results in the late follow-up, including the diastolic gradient and the valvar area. Of the 6 cases with mitral area smaller than 1.5 cm2, 2 had a good clinical evolution, 2 were re-dilated, 1 was scheduled for surgery and the last one is under clinical management but with poor hemodynamic results. Three (5.7%) cases developed an atrial septal defect after the procedure, with hemodynamic repercussion in 1. Mitral regurgitation developed in 16 cases (+ in 8, +/++ in 8) without changes during the follow-up period. CONCLUSION: Double balloon mitral valvoplasty is a safe effective method in the treatment of the rheumatic mitral stenosis, and offers a better evolution in patients with a valvar area larger than 1.5 cm2 after the dilatation.

[The use of primary coronary angioplasty in acute myocardial infarction in patients over 70 years of age]. / Emprego da angioplastia coronária primária no infarto agudo do miocárdio em pacientes acima de 70 anos.

PURPOSE: To evaluate the use of primary coronary angioplasty (PTCA) in patients older than 70 years, evolving with acute myocardial infarction, without the previous administration of thrombolytic agents. METHODS: Forty-two patients with acute myocardial infarction (AMI) and more than 70 years of age (m = 76.4y). There were 54.7% men and 43% of them had anterior MI. PTCA was carried out during the first 12 hours of evolution and in the first 3 hours of duration in 47% of them. PTCA was done only to the AMI related artery, which was the left descending artery in 43%, the right coronary artery in 47% and the left circumflex in the remaining patients. Nineteen percent of these patients were in Killip class III e IV. RESULTS: Primary success was achieved in 86%. The in hospital mortality was 14.2%, and it was superior in female gender (26.3%), in Killip class III and IV (37.5%), in those with multivessel coronary disease (16.6%) and in those where primary PTCA failed (33%). There were 9.3% of reinfarction, but no major hemorrhages happened. Late angiography was done in 50% of patients, showing 72% of patency in the AMI related artery, and a significant improval of global ejection fraction and of the wall motion, particularly, in those who maintained arterial patency. CONCLUSION: Primary PTCA, without former use of thrombolytic agents, when applied early in elderly patients evolving with AMI, has a high success rate and low mortality rate in this subset of high risk patients. It also shows no major hemorrhagic complications.