Atrioventricular Valve Repair in Single Ventricle Physiology: Timing Matters.

OBJECTIVES: Atrioventricular valve (AVV) regurgitation in patients with single ventricle (SV) physiology severely impacts prognosis; the appropriate timing for surgical treatment is unknown. We sought to study the results of surgical treatment of AVV regurgitation in SV patients and evaluate risk factors for mortality. METHODS: Medical records of 81 consecutive patients with moderate or severe AAV regurgitation who were submitted to AVV repair or replacement during any stage of univentricular palliation between January 2013 and May 2017 were examined. We studied demographic data and perioperative factors looking for predictors that might have influenced the results. Binary logistic regression was used to assess the impact on postoperative ventricular dysfunction and mortality. RESULTS: Median age and weight were seven months (interquartile range [IQR]: 3-24) and 5.2 kg (IQR: 3.7-11.2), respectively. Seventy (86.4%) patients underwent AVV repair, and 11 (13.6%) patients underwent AVV replacement. There was an association between AVV repair effectiveness and timing of intervention (P = .004). Atrioventricular valve intervention at the time of initial surgical palliation was associated with more ineffective repairs (P = .001), while AVV replacement was more common between Glenn and Fontan procedures (P = .004). Overall 30-day mortality was 30.5% (25 patients). In-hospital mortality was 49.4%, and it was higher when AVV repair was performed concomitant with initial (stage 1) palliation (64.1% vs 35.7%; P = .01) and when an effective repair was not achieved (75% vs 41%; P = .008). Multivariable analysis identified timing concomitant with stage 1 palliation as an independent risk factor for mortality (P = .01); meanwhile, an effective repair was a protective factor against in-hospital mortality (P = .05). CONCLUSION: Univentricular physiology with AVV regurgitation is a high-risk group of patients. Surgery for AVV regurgitation at stage 1 palliation was associated with less effective repair and higher mortality in this initial experience. On the other hand, effective repair determined better outcomes, highlighting the importance of experience and the learning curve in the management of such patients.

Atrial Fibrillation Ablation in Systolic Dysfunction: Clinical and Echocardiographic Outcomes / Ablação da Fibrilação Atrial na Disfunção Sistólica: Evolução Clínica e Ecocardiográfica

Background: Heart failure and atrial fibrillation (AF) often coexist in a deleterious cycle. Objective: To evaluate the clinical and echocardiographic outcomes of patients with ventricular systolic dysfunction and AF treated with radiofrequency (RF) ablation. Methods: Patients with ventricular systolic dysfunction [ejection fraction (EF) <50%] and AF refractory to drug therapy underwent stepwise RF ablation in the same session with pulmonary vein isolation, ablation of AF nests and of residual atrial tachycardia, named "background tachycardia". Clinical (NYHA functional class) and echocardiographic (EF, left atrial diameter) data were compared (McNemar test and t test) before and after ablation. Results: 31 patients (6 women, 25 men), aged 37 to 77 years (mean, 59.8±10.6), underwent RF ablation. The etiology was mainly idiopathic (19 p, 61%). During a mean follow-up of 20.3±17 months, 24 patients (77%) were in sinus rhythm, 11 (35%) being on amiodarone. Eight patients (26%) underwent more than one procedure (6 underwent 2 procedures, and 2 underwent 3 procedures). Significant NYHA functional class improvement was observed (pre-ablation: 2.23±0.56; postablation: 1.13±0.35; p<0.0001). The echocardiographic outcome also showed significant ventricular function improvement (EF pre: 44.68%±6.02%, post: 59%±13.2%, p=0.0005) and a significant left atrial diameter reduction (pre: 46.61±7.3 mm; post: 43.59±6.6 mm; p=0.026). No major complications occurred. Conclusion: Our findings suggest that AF ablation in patients with ventricular systolic dysfunction is a safe and highly effective procedure. Arrhythmia control has a great impact on ventricular function recovery and functional class improvement. .

Fundamento: Insuficiência cardíaca e fibrilação atrial (FA) frequentemente coexistem em um ciclo deletério. Objetivo: Avaliar a evolução clínica e ecocardiográfica de portadores de disfunção ventricular e FA tratados com ablação por radiofrequência (RF). Métodos: Portadores de disfunção sistólica [fração de ejeção (FE) < 50%] e FA rebelde a tratamento clínico foram submetidos à ablação por RF escalonada em três etapas na mesma sessão com isolamento das veias pulmonares, ablação dos ninhos de FA, pesquisa e ablação de taquicardias atriais e "taquicardia de background". Os dados clínicos (classe funcional da NYHA) e ecocardiográficos (FE; diâmetro do átrio esquerdo) pré- e pós-procedimento foram comparados (teste de McNemar e teste t, respectivamente). Resultados: 31 pacientes (6 mulheres, 25 homens) de 37 a 77 anos (média, 59,8 ± 11 anos) foram submetidos à ablação por RF. A cardiopatia foi predominantemente idiopática (19 p; 61%). Na evolução média de 20,3 ± 17 meses, 24 pacientes (77%) estavam em ritmo sinusal, sendo 11 (35%) com amiodarona. Oito pacientes (26%) foram submetidos a mais de um procedimento (6 submetidos a 2 procedimentos e 2 a 3 procedimentos). Observou-se melhora expressiva da classe funcional da NYHA (pré-ablação: 2,23 ± 0,56; pós: 1,13 ± 0,35; p < 0,0001). A avaliação ecocardiográfica evolutiva também mostrou melhora significativa da função ventricular (FE pré: 44,68% ± 6,02%; pós: 59% ± 13,2%; p = 0,0005) e redução significativa no diâmetro do átrio esquerdo (pré: 46,61 ± 7,3 mm; pós: 43,59 ± 6,6 mm; p = 0,026). Não ocorreram complicações maiores. Conclusão: Os resultados deste estudo sugerem que ablação de FA em portadores de disfunção ventricular seja um procedimento seguro e com eficácia elevada a médio prazo. O controle da arritmia tem grande impacto na recuperação da função ventricular e na melhora clínica avaliada pela classe funcional. .

Atrial fibrillation ablation in systolic dysfunction: clinical and echocardiographic outcomes.

BACKGROUND: Heart failure and atrial fibrillation (AF) often coexist in a deleterious cycle. OBJECTIVE: To evaluate the clinical and echocardiographic outcomes of patients with ventricular systolic dysfunction and AF treated with radiofrequency (RF) ablation. METHODS: Patients with ventricular systolic dysfunction [ejection fraction (EF) <50%] and AF refractory to drug therapy underwent stepwise RF ablation in the same session with pulmonary vein isolation, ablation of AF nests and of residual atrial tachycardia, named "background tachycardia". Clinical (NYHA functional class) and echocardiographic (EF, left atrial diameter) data were compared (McNemar test and t test) before and after ablation. RESULTS: 31 patients (6 women, 25 men), aged 37 to 77 years (mean, 59.8 ± 10.6), underwent RF ablation. The etiology was mainly idiopathic (19 p, 61%). During a mean follow-up of 20.3 ± 17 months, 24 patients (77%) were in sinus rhythm, 11 (35%) being on amiodarone. Eight patients (26%) underwent more than one procedure (6 underwent 2 procedures, and 2 underwent 3 procedures). Significant NYHA functional class improvement was observed (pre-ablation: 2.23 ± 0.56; postablation: 1.13 ± 0.35; p < 0.0001). The echocardiographic outcome also showed significant ventricular function improvement (EF pre: 44.68% ± 6.02%, post: 59% ± 13.2%, p = 0.0005) and a significant left atrial diameter reduction (pre: 46.61 ± 7.3 mm; post: 43.59 ± 6.6 mm; p = 0.026). No major complications occurred. CONCLUSION: Our findings suggest that AF ablation in patients with ventricular systolic dysfunction is a safe and highly effective procedure. Arrhythmia control has a great impact on ventricular function recovery and functional class improvement.

Ventricular assist device implantation with CentriMag VAS® for biventricular mechanical support.

Despite recent advances in acute heart failure treatment, actual results remain limited in refractory cardiogenic shock. Temporary ventricular assist devices have emerged as an alternative in this serious and challenging medical. The purpose of this communication is to present a case of refractory cardiogenic shock, underwent temporary left ventricular assistance device implantation, progressing to right ventricular failure and conversion to biventricular support.

Pediatric heart transplantation from donors with depressed ventricular function: an analysis of the United Network of Organ Sharing Database.

BACKGROUND: Wait-list mortality for children awaiting heart transplantation remains high. Potential donor hearts with depressed ventricular function are often declined. We aimed to test the hypothesis that pediatric heart transplant recipients of grafts with depressed ventricular function would have comparable survival with those with normal function. METHODS AND RESULTS: A retrospective study was performed for pediatric heart transplants from the United Network of Organ Sharing Database from October 26, 1999, to June 30, 2011. Patients were grouped based on accepted donor left ventricular ejection fraction (LVEF): normal function (LVEF ≥55%), mildly depressed function (LVEF 45%-54%), or moderately-to-severely depressed function (LVEF <45%). During the study period, there were 3672 pediatric heart transplants; 3306 (90%) had a LVEF reported. Ventricular function was mildly depressed in 245 (7%) and moderately-to-severely depressed in 172 (5%). Patients receiving grafts with moderately-to-severely depressed function were more likely to be younger and weigh less (P<0.001 for both) than those receiving grafts with normal function. Median graft survival from accepted donors with normal ventricular function (10.6 years) was similar to survival from accepted donors with mildly depressed ventricular function (9.7 years; P=0.24) and from accepted donors with moderately-to-severely depressed ventricular function (9.1 years; P=0.13). On propensity-matched analysis, donor ventricular function was not associated with graft survival. CONCLUSIONS: The use of donors with depressed ventricular function is uncommon in pediatric heart transplantation (<15% of all transplants), yet graft survival does not differ significantly from accepted donors with normal ventricular function. Hearts from donors with depressed ventricular function may be considered in selected patients.

Disfunción ventricular transitoria y reversible posdrenaje de derrame pericárdico en el postoperatorio de cardiopatía congénita / Transient and reversible ventricular dysfunction after drainage of pericardial effusion in postoperative congenital heart disease

Analizamos la evolución poscorrección quirúrgica de una comunicación interauricular, en una paciente de 7 años de edad que presenta dos complicaciones. Una inicial, dada por el acúmulo de líquido en la cavidad pericárdica, que se manifiesta por sintomatología inespecífica (fiebre, decaimiento, inapetencia), que requiere sospecha y diagnóstico temprano evacuando el derrame y administrando antiinflamatorios no esteroideos y corticoides, para evitar la reproducción del derrame. Y una segunda posdrenaje del derrame, dada por falla ventricular significativa que requiere tratamiento enérgico mediante inotrópicos, diuréticos y asistencia ventilatoria mecánica, logrando su reversibilidad sin secuelas. Se describe la evolución clínica, electrocardiográfica y ecocardiográfica. Se recalca la necesidad de sospechar clínicamente en forma temprana esta entidad, en todo postoperatorio de cirugía cardíaca por cardiopatía congénita, que presente este tipo de síntomas y signos, de manera de indicar la pericardiocentesis en forma oportuna y evitar la progresión al taponamiento cardíaco.

Disfunción ventricular transitoria y reversible posdrenaje de derrame pericárdico en el postoperatorio de cardiopatía congénita / Transient and reversible ventricular dysfunction after drainage of pericardial effusion in postoperative congenital heart disease

Analizamos la evolución poscorrección quirúrgica de una comunicación interauricular, en una paciente de 7 años de edad que presenta dos complicaciones. Una inicial, dada por el acúmulo de líquido en la cavidad pericárdica, que se manifiesta por sintomatología inespecífica (fiebre, decaimiento, inapetencia), que requiere sospecha y diagnóstico temprano evacuando el derrame y administrando antiinflamatorios no esteroideos y corticoides, para evitar la reproducción del derrame. Y una segunda posdrenaje del derrame, dada por falla ventricular significativa que requiere tratamiento enérgico mediante inotrópicos, diuréticos y asistencia ventilatoria mecánica, logrando su reversibilidad sin secuelas. Se describe la evolución clínica, electrocardiográfica y ecocardiográfica. Se recalca la necesidad de sospechar clínicamente en forma temprana esta entidad, en todo postoperatorio de cirugía cardíaca por cardiopatía congénita, que presente este tipo de síntomas y signos, de manera de indicar la pericardiocentesis en forma oportuna y evitar la progresión al taponamiento cardíaco

Cell transplantation: differential effects of myoblasts and mesenchymal stem cells.

BACKGROUND: Cellular transplantation has emerged as a novel therapeutic option for treatment of ventricular dysfunction. Both skeletal myoblasts (SM) and mesenchymal stem cells (MSC) have been proposed as ideal cell for this aim. The aim of this study is to compare the efficacy of these cells in improving ventricular function and to evaluate the different histological findings in a rat model of severe post-infarct ventricular dysfunction. METHODS: Myocardial infarction was induced in Wistar rats by left coronary occlusion. Animals with resulting ejection fraction (EF) lower than 40% were included. Heterologous SM were obtained by lower limb muscle biopsy and MSC by bone marrow aspiration. Nine days after infarction, rats received intramyocardial injection of SM (n=8), MSC (n=8) or culture medium, as control (n=11). Echocardiographic evaluation was performed at baseline and after 1 month. Histological evaluation was performed after HE and Gomori's trichrome staining and immunostainig against desmin, fast myosin and factor VIII. RESULTS: There was no difference in baseline EF and left ventricular end diastolic (LVEDV) and systolic volume (LVESV) between all groups. After 1 month a decrease was observed in the EF in the control group (27.0+/-7.10% to 21.46+/-5.96%, p=0.005) while the EF markedly improved in SM group (22.66+/-7.29% to 29.40+/-7.01%, p=0.04) and remained unchanged in the MSC group (23.88+/-8.44% to 23.63+/-10.28%, p=0.94). Histopathology identified new muscular fibers in the group that received SM and new vessels and endothelial cells in the MSC. CONCLUSION: Skeletal myoblasts transplantation resulted in myogenesis and improvement of ventricular function. In contrast, treatment with mesenchymal stem cells resulted in neoangiogenesis and no functional effect.

Implante cardíaco de mioblastos. Informe adicional a tres años / Myoblasts cardiac implant. Additiional inform up to three years

El cardioimplante de mioblastos autólogos (CMA) en escaras necróticas es un tratamiento en vías de estudio clínico para evaluar la mejoría de la disfunción ventricular postinfarto. El objetivo fue comprobar la factibilidad y seguridad del CMA en pacientes con secuelas necróticas y evaluar los cambios clínicos y en la motilidad segmentria durante el seguimiento

Implante cardíaco de mioblastos. Informe adicional a tres años / Myoblasts cardiac implant. Additiional inform up to three years

El cardioimplante de mioblastos autólogos (CMA) en escaras necróticas es un tratamiento en vías de estudio clínico para evaluar la mejoría de la disfunción ventricular postinfarto. El objetivo fue comprobar la factibilidad y seguridad del CMA en pacientes con secuelas necróticas y evaluar los cambios clínicos y en la motilidad segmentria durante el seguimiento (AU)

O transplante em conjunto de células mioblásticas esqueléticas e mesenquimais (cocultivadas) na disfunção ventricular pós-infarto do miocárdio / Combined transplantation of skeletal myoblasts and mesenchymal cells (cocultivation) in ventricular dysfunction after myocardial infarction

OBJETIVO: A terapia celular no miocárdio tem sido realizada fundamentalmente com dois tipos celulares: as células mioblásticas esqueléticas (miogênicas) e as mesenquimais (angiogênicas) com resultados satisfatórios. Foi analisado o resultado do transplante em conjunto destas células (CEM) em ratos infartados. MÉTODOS: Foram induzidos ao infarto do miocárdio, por meio de ligadura da coronária esquerda 26 ratos Wistar. Após uma semana, os animais foram submetidos à ecocardiografia para avaliação da fração de ejeção (FE, por cento) e dos volumes diastólico e sistólico finais do ventrículo esquerdo (VDF, VSF,ml). Após dois dias os animais foram reoperados e divididos em dois grupos: 1) controle (n=10) que recebeu 0,15 ml de meio de cultura e 2) CEM (n=16) que recebeu 7.5x106 células mioblásticas esqueléticas e mesenquimais, heterólogas, na região do infarto. As células foram obtidas a partir da punção da crista ilíaca e da biópsia do músculo esquelético, ambas submetidas à cultura celular in vitro. Após um mês, os animais foram submetidos a nova ecocardiografia. RESULTADOS: Não houve diferença significativa entre os dois grupos quanto a FE, VDF e VSF nos valores ecocardiográficos de base. Um mês após o transplante, foram observados diminuição da FE no grupo controle (29.31 ± 5.6 por cento para 23.54 ± 6.51 por cento p=0.048) e acréscimo da FE no grupo CEM (24.03 ± 8.68 por cento para 31.77 ± 9.06 por cento, p=0.011). Identificou-se a presença de neovasos e fibras musculares, nas regiões de fibrose miocárdica no grupo CEM. CONCLUSAO: O cocultivo das células mioblásticas esqueléticas e das células mesenquimais é funcionalmente efetivo.

Estenose aórtica: disfunção sistólica e disfunção diastólica - conduta / Aortic stenosis: left ventricular systolic and diastolic dysfunction - management

A estenose aórtica constitui importante entidade clínica por ser uma das doenças cardíacas mais freqüentes. Ao impor uma sobrecarga de pressão ao ventrículo esquerdo, a pressão sistólica intraventricular e o estresse sistólico na parede do ventrículo elevam-se com conseqüente hipertrofia, a qual pode evoluir para disfunção sistólica e disfunção diastólica. Enquanto a hipertrofia for adequada às condições impostas pela elevação da pós-carga, o estresse sistólico é mantido e a função ventricular, conservada. A partir do momento em que há desproporção entre a hipertrofia e a pós-carga, o estresse sistólico eleva-se e a função ventricular declina. Quando o gradiente de pressão transvalvar permanece elevado, apesar da queda da fração de ejeção, a troca valvar é o tratamento mais indicado, com resultados cirúrgicos favoráveis. No entanto, quando o gradiente é inferior a 40 mmHg, é necessário que se determine se a obstrução valvar é a causa primária da disfunção ventricular ou se há associação entre miocardiopatia de outra etiologia e estenose aórtica leve. Além da história clínica e do exame físico, o cálculo da área valvar ou da resistência valvar e a realização da ecocardiografia com infusão de dobutamina têm sido de grande valia na diferenciação entre as duas condições clínicas. Havendo evidências de que a queda da fração de ejeção é secundária à obstrução aórtica, os resultados obtidos com a troca valvar, embora com elevado risco cirúrgico, são superiores àqueles obtidos com tratamento clínico e deve ser realizada com brevidade. Caso contrário, os vasodilatadores, especialmente os inibidores da enzima de conversão, estão indicados.

Operación de Fontan: resultados inmediatos y a mediano plazo con anastomosis cavopulmonar total / Fontan procedure: early and mid-term results wiht total cavopulmonary anastomosis

Background: During the last five years, 65 patients with univentricular heart have been treated surgically in our institution, according to a protocol of staged operations that have been previously reported. Aim: To evaluate the early and mid-term outcome of those patients that have completed their staging protocol by means of a Fontan procedure. Patients and Methods: Between April 1996 and June 2001, 23 patients (age 16 to 223 months) underwent a Fontan procedure, 15 with an intracardiac lateral tunnel technique and 8 with an extracardiac conduit. A retrospective review of their clinical, surgical, echocardiographic, angiographic and hemodynamic data was performed, trying to identify risk factors for both mortality and functional capacity (FC). Follow up was complete in all survivors. Results: Three patients died early after surgery (13.04 percent). Excessive pulmonary blood flow was a risk factor for early death (p= 0.03). One patient died at 14 months. Follow up was 29.9 months (1-63). For those who survived the operation, five years survival was 93.3 percent. The majority of patients are in FC I or II, with no related risk factors. Conclusions: Our current results are comparable with those of larger series. Patients reach good FC and mid-term survival, irrespective of type of single ventricle or the surgical strategy

[Fontan procedure: early and mid-term results with total cavopulmonary anastomosis]. / Operación de Fontan: resultados inmediatos y a mediano plazo con anastomosis cavopulmonar total.

BACKGROUND: During the last five years, 65 patients with univentricular heart have been treated surgically in our institution, according to a protocol of staged operations that have been previously reported. AIM: To evaluate the early and mid-term outcome of those patients that have completed their staging protocol by means of a Fontan procedure. PATIENTS AND METHODS: Between April 1996 and June 2001, 23 patients (age 16 to 223 months) underwent a Fontan procedure, 15 with an intracardiac lateral tunnel technique and 8 with an extracardiac conduit. A retrospective review of their clinical, surgical, echocardiographic, angiographic and hemodynamic data was performed, trying to identify risk factors for both mortality and functional capacity (FC). Follow up was complete in all survivors. RESULTS: Three patients died early after surgery (13.04%). Excessive pulmonary blood flow was a risk factor for early death (p = 0.03). One patient died at 14 months. Follow up was 29.9 months (1-63). For those who survived the operation, five years survival was 93.3%. The majority of patients are in FC I or II, with no related risk factors. CONCLUSIONS: Our current results are comparable with those of larger series. Patients reach good FC and mid-term survival, irrespective of type of single ventricle or the surgical strategy.

Neurodevelopmental outcome of patients after the fontan operation: A comparison between children with hypoplastic left heart syndrome and other functional single ventricle lesions.

OBJECTIVE: To compare neurodevelopmental outcome (NDO) in patients with hypoplastic left heart syndrome (HLHS), other functional single ventricle lesions, and the standard population and to investigate predictors of NDO in the population of children with functional single ventricle (FSV). STUDY DESIGN: A time- and age-defined cohort of patients with the Fontan circulation was recruited to participate in neurodevelopmental testing, behavioral evaluation, and imaging of the central nervous system. The Wechsler Intelligence test was the primary measure of NDO. Analysis included comparison of patients with HLHS with other patients with functional single ventricles. Other potential clinical predictors of NDO were investigated. RESULTS: The mean Full Scale Wechsler Intelligence score was 101.4+/-5.4. For the HLHS subgroup the mean Full Scale Wechsler score was 93.8+/-7.3, and for the non-HLHS subgroup it was 107.0+/-7.0. Although the HLHS group had significantly lower scores than the non-HLHS subgroup, neither subgroup scored significantly different from the standard population on the Wechsler Scales. Socioeconomic status, circulatory arrest, and perioperative seizures also were predictive of neurodevelopmental outcome. CONCLUSION: Neurodevelopmental and behavioral outcome in patients who have undergone the Fontan procedure including patients with HLHS is good in the preschool and early school years, with Wechsler Intelligence scores generally in the normal range.

Insuficiência mitral e disfunçäo ventricular: quando operar? / Mitral insufficiency and ventricular dysfunction: when to operate?

A insuficiência cardíaca em fase avançada apresenta alta mortalidade a curto prazo, a despeito dos progressos verificados na terapêutica farmacológica. O aparecimento da insuficiência mitral secundária piora ainda mais a qualidade e a expectativa de vida nessa fase de evoluçäo da afecçäo. A terapêutica cirúrgica de eleiçäo é o transplante cardíaco concretizado infelizmente para uma minoria de pacientes, estando os procedimentos cirúrgicos alternativos ao transplante sob julgamento. Apresentamos uma técnica de correçäo da insuficiência mitral e remodelaçäo da cavidade ventricular esquerda por meio do aparelho valvar mitral, com implante de prótese valvar no anel atrioventricular esquerdo. Säo analisados 33 pacientes com insuficiência cardíaca terminal rejeitados para transplante cardíaco sob terapêutica clínica máxima nos quais se utilizou a técnica proposta. O período de observaçäo variou de 1 a 48 meses (média=20), tendo-se observado regressäo de uma ou duas classes funcionais em 83 'por cento' dos casos. A mortalidade hospitalar imediata foi de 9 'potr cento' (3/33) e a tardia de 10 'por cento' (3/30). A fraçäo de ejeçäo ecocardiográfica melhorou pouco, comparando os valores pré-operatórios com a última evoluçäo (28 'por cento'x 32 'por cento') mas o volume efetivo melhorou consideravelmente às custas da eliminaçäo de fraçäo regurgitante. Os resultados obtidos permitem sugerir o procedimento para pacientes com insuficiência cardíaca refratária portadores de insuficiência mitral secundária.

Disfuncíon valvular: aporte de la tercer ventrículo cisternostomía endoscópica / Ventricular dysfunction: contribution of the third ventricle cisternostomy encodoscopic

A partir de los últimos 30 años el tratamiento de la hidrocefalia ha sido el uso de un sistema válvular. la utilización de un sistema derivativo se asocia significativamente a la presencia de numerosas complicaciones, entre las cuales destacan la infección y las constantes y reiteradas disfunciones. Progresivamente y debido a la mejoría de los equipos ópticos, de iluminación y diámetro del instrumental se ha implementado la tercer ventrículo cisternostomía (TVC) endoscópia. Esta técnica descrita en los comienzos de la neurocirugía moderna, actualmente es una alternativa de primera elección y válida en solucionar definitivamente el problema en el 20 porciento de los pacientes portadores de hidrocefalia. Las complicaciones de este procedimiento superan discretamente los riesgos de los procedimientos derivativos. Nosotros presentamos una serie de 20 pacientes sometidos a TVC, en el curso de un cuadro de disfunción valvular. Se logró eliminar completamente la dependencia de la válvula al 80 porciento de los enfermos. Nuestro tiempo de seguimiento es superior a un año. No se presentaron complicaciones importantes y no hubo mortalidad asociada al procedimiento en la serie. Nosotros sugerimos realizar una TVC en todos los pacientes portadores de estenosis del acueducto, tratados con derivaciones ventriculares, durante el curso de una disfunción válvular. Creemos que nuestros resultados descartan el concepto de "dependencia válvular", al permitir eliminar definitivamente el sistema derivativo a pacientes portadores de válvulas por más de 2 años