[Surgical management of the aortic valve in patients older than 70 years of age]. / Manuseio cirúrgico da valva aórtica em pacientes acima de 70 anos.

PURPOSE: To assess the short and long-term benefits of patients who were submitted to isolated aortic valve replacement or valve replacement (VR) concomitant myocardial revascularization (MR); to evaluate the incidence of postoperative complications, hospital mortality and late mortality. METHODS: From January 1985, through December 1989, 20 consecutive patients underwent surgical intervention, 15 male (75%) and 5 female (25%), the mean age was 74.8% (ranging from 70 to 86 years old), and the aortic valve gradient ranged between 78 and 180 mmHg (mean = 97 mmHg). They presented preoperative diagnosis to have either isolated aortic stenosis (AS) or As and coronary artery disease (CAD). No patient was in NYHA functional class I; 3 patients (15%) were in class II, 14 (70%) in class III and 3 (15%) in class IV. RESULTS: The most frequent post-operative complications found were: extended intubation in 7 patients (35%), bleeding in 4 (20%), acute renal failure in 3 (15%) and ventricular arrhythmia in 3 (15%). Hospital mortality occurred in 2 patients (10%) who had been submitted to VR and concomitant MR. Late mortality occurred in 1 patient (5%). Through December 1989, 11 patients (64%) were in functional class I (NYHA), 3 (18%) in class II, 3 (18%) in class III and none in class IV. CONCLUSION: We concluded that the surgical treatment is indicate to elderly patients with isolated AS os with AS and concomitant CAD. There was a significant post-operative improvement of the functional class (NYHA) to the surviving patients.

[Acute myocardial infarction in patients under 40 years of age]. / Infarto agudo do miocárdio em pacientes com idade inferior a 40 anos.

PURPOSE: To evaluate the short and long-term prognosis of a group of patients aged 40 and under, who developed an acute myocardial infarction. PATIENTS AND METHODS: In the last 15 years we studied a group of 73 patients aged 40 and under with a confirmed diagnosis of first acute myocardial infarction. Patients with infarctions caused by coronary embolisms or to revascularization procedures were excluded. RESULTS: Ninety percent were male and mean the age was 35. The most frequent risk factors observed were cigarette smoking in 64 (88%), hypertension in 16 (22%), hypercholesterolemia in 12 (16%) and diabetes in 3 (4%). Seven (9%) patients had no risk factors. The myocardial infarction was anterior em 50 (68%) cases and inferior in the remaining 23 (32%). Severe heart failure (Killip III and IV) was present in 3 (4%). Angiographic studies were performed in 63 (86%). Cineangiography showed critical coronary lesions (obstruction greater than 70%) in one vessel in 38 (60%) patients, multivessel disease in 18 (28%) and 7 (12%) had normal coronary vessels. In-hospital mortality was 5% (3 patients died due to severe heart failure and 1 due to cerebro-vascular accident). The 56 survivors were followed-up to 15 years, with overall survival of 74%. Fourty-nine (71%) were asymptomatic and 7 (10%) had recurrent chest pain. There were 7 (10%) late deaths and follow-up was lost in 6 (9%). Reinfarctions were observed in 5 cases (7%). Revascularization procedures were performed in 12 (17%) patients (bypass-graft surgery in 9 and coronary angioplasty in 3). CONCLUSION: Young patients with acute myocardial infarction have a low mortality rate in the early phase and a favorable outcome after the discharge of the hospital.

[Adrenergic coronary vasoconstriction during myocardial hypoperfusion]. / Vasoconstricção coronária adrenérgica nas situações de hipoperfusão miocárdica.

The intramural branches of the coronary arteries of dogs were studied using venilite casts. The intramyocardial vessels have a general pattern with straight branches that cross from the epicardium toward the endocardium. Many branches were observed throughout the extension of these vessels, mainly in the subendocardium, where there is a rich interconnecting plexus. Some branches divides immediately in the subepicardium. These anatomic findings concur with the observations that the subendocardium is more susceptible to ischemia, as it is dependent on an extensive vascularization. These anatomic findings indicate that during constant underperfusion, the alpha adrenergically mediated vasoconstriction of the subepicardial vessels have an unexpected beneficial effect because of decreased transmural steal.