RESUMO
INTRODUCTION: Percutaneous aortic valve replacement has been performed in daily practice for less than 10 years. This technique was until recently reserved for patients with very high surgical risk. There is little data in the literature documenting the impact of this percutaneous technique on the patient population continuing to benefit from a surgical replacement of the aortic valve. We studied the characteristics of these patients immediately before and after the introduction of the percutaneous technique in the CHU Brugmann. MATERIALS AND METHODS: Two separate cohorts of patients were retrospectively studied: one before the percutaneous era between 2005 and 2010 and the other after introduction of the percutaneous technique in our daily practice between 2010 and 2015. Demographic, intraoperative, mortality and postoperative morbidity indices were compared. RESULTS: The number of surgical replacements of the aortic valve was 194 before and 132 after introduction of the percutaneous technique. The demographic, operative characteristics and postoperative morbidity and mortality of the patients remained the same between the two cohorts. Only the incidence of pulmonary arterial hypertension (12.1 vs 25 %, p = 0.015) and recent myocardial infarction (0 vs 3 %, p = 0.003) were higher in the second cohort. CONCLUSION: Replacement of the aortic valve percutaneously did not significantly change the demographic characteristics and postoperative morbidity and mortality of patients candidate for surgical replacement of the aortic valve. Nevertheless, after its introduction, the number of surgical replacements dropped considerably in our center.
INTRODUCTION: Le remplacement valvulaire aortique percutané est réalisé en pratique quotidienne depuis moins de dix ans. Cette technique était jusqu'il y a peu réservée aux patients à très haut risque chirurgical. Il existe peu de données dans la littérature documentant l'impact de cette technique percutanée sur la population de patients continuant à bénéficier d'un remplacement chirurgical de la valve aortique. Nous avons étudié les caractéristiques de ces patients immédiatement avant et après l'introduction de la technique percutanée au CHU Brugmann. Matériel et méthodes : Deux cohortes distinctes de patients ont été étudiées rétrospectivement : l'une avant l'ère percutanée entre 2005 et 2010 et l'autre après introduction dans notre pratique quotidienne de la technique percutanée entre 2010 et 2015. Les données démographiques, peropératoires, la mortalité et des indices de morbidité postopératoire ont été comparés. Résultats : Le nombre de remplacements chirurgicaux de la valve aortique était de 194 avant et 132 après introduction de la technique percutanée. Les caractéristiques démographiques, opératoires et la morbi-mortalité postopératoire des patients sont restées identiques entre les deux cohortes. Seules les incidences d'hypertension artérielle pulmonaire (12,1 vs 25 %, p = 0,015) et d'infarctus myocardiques récents (0 vs 3 %, p = 0,003) étaient supérieures dans la seconde cohorte. CONCLUSION: Le remplacement de la valve aortique par voie percutanée n'a pas considérablement modifié les caractéristiques démographiques et la morbimortalité postopératoire des patients candidats à un remplacement chirurgical de la valve aortique. Le nombre total de remplacement chirurgical de la valve aortique a considérablement chuté.
Assuntos
Valva Aórtica/cirurgia , Intervenção Coronária Percutânea , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Myocardial ischemia secondary to dissection of the ascending aorta remains a relatively rare complication. A 76-year old man with no prior history developed sudden chest pain. The electrocardiogram showed a ST-segment elevation in leads II and III suggesting an inferior wall acute myocardial infarction. Upon arrival, he received anticoagulation and antiplatelet aggregation intravenously and orally respectively. Coronary angiography showed an anomalous origin of the right coronary and extrinsic stenosis by a false lumen. Computed tomography confirmed the diagnosis of type A aortic dissection with an extension to the right coronary. Emergency ascending aorta replacement with Dacron graft and a right coronary artery graft was perfomed. This case illustrates how myocardial infarction can mask an aortic dissection. The initial treatment of a myocardial infarction with anticoagulation and/or oral antiplatelet aggregation should not be modified, even if it increases postoperative bleeding when emergent cardiac surgery is necessary.
Assuntos
Aneurisma Aórtico , Dissecção Aórtica , Angiografia Coronária , Eletrocardiografia , Humanos , Infarto do MiocárdioRESUMO
A 56-day old baby girl referred for recurrent respiratory tract infections and stridor, showed a rare association of a Cor Triatriatum Sinister (CTS) and a right Partial Anomalous Pulmonary Venous Return (PAPVR), in the form of a stenosed Scimitar vein, draining the right pulmonary veins to the subdiaphragmatic inferior vena cava (IVC), on echography and angiography. The baby underwent successful surgical repair of the CTS, by resection of the obstructive false membrane and reconnection of the Scimitar vein to the left atrium. At the age of 5 years, the child is doing well without any evidence of obstruction on the right or the left pulmonary venous drainage.
Assuntos
Anormalidades Múltiplas/diagnóstico , Coração Triatriado/diagnóstico , Cardiopatias Congênitas/diagnóstico , Artéria Pulmonar/anormalidades , Síndrome de Cimitarra/diagnóstico , Anormalidades Múltiplas/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Coração Triatriado/cirurgia , Feminino , Seguimentos , Cardiopatias Congênitas/cirurgia , Hemodinâmica/fisiologia , Humanos , Recém-Nascido , Medição de Risco , Síndrome de Cimitarra/cirurgia , Resultado do TratamentoRESUMO
Re-operative valvular surgery is common nowadays. Increased mortality and morbidity are generally associated. Re-operations in cardiac surgery are technically more difficult because of adhesions and a more advanced cardiac status of the patient. Results reported 20 years ago carried a high mortality risk. Experience and technological evolution have produced a substantial reduction in postoperative mortality nowadays. The present review focuses on historical results of redo valve surgery, risks factors for postoperative mortality, technical progress and surgical strategies contributing to better results.
Assuntos
Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Complicações Pós-Operatórias/etiologia , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Complicações Pós-Operatórias/mortalidade , Reoperação , Fatores de Risco , Resultado do TratamentoRESUMO
Two operations for coronary artery aneurysm with fistula are reported. This rare congenital malformation can be associated with acute and chronic complications. Surgical treatment is generally recommended. The surgical strategy remains controversial and is discussed. Retrograde cardioplegic cardiac arrest and retrograde dissection of the fistula are favoured. Conservative treatment of the dilated coronary segments was adopted. In both cases, the postoperative course was uneventful and no residual shunts were diagnosed at postoperative echocardiography.
Assuntos
Aneurisma Coronário/cirurgia , Cardiopatias/cirurgia , Fístula Vascular/cirurgia , Adulto , Procedimentos Cirúrgicos Cardíacos/métodos , Aneurisma Coronário/congênito , Aneurisma Coronário/diagnóstico por imagem , Angiografia Coronária , Feminino , Cardiopatias/congênito , Cardiopatias/diagnóstico por imagem , Humanos , Fístula Vascular/congênito , Fístula Vascular/diagnóstico por imagemRESUMO
BACKGROUND: Tracheobronchial compression of vascular origin is an uncommon but important cause of respiratory distress in infants and children. We reviewed our surgical experience with 31 children, presenting vascular tracheobronchial compression. METHODS: Thirty-one children, with a median age of seven months, were operated on for airway and/or oesophageal compression secondary to vascular anomalies. Diagnostic findings, mainly established by bronchoscopy and angiography, revealed several pathologic disorders such as right aortic arch with aortic diverticulum in 10, double aortic arch in five, innominate artery compression in six, arteria lusoria in four, and pulmonary artery sling in one patient. Five children developed tracheobronchial compression after previous repair of a complex congenital heart disease. Clinical symptoms on admission were dominantly stridor, recurrent airway infection, dyspnea, respiratory distress and upper digestive complaints such as dysphagia and gastroesophageal reflux. RESULTS: Surgical relief was successful in 30 patients. Only one child with palliated tetralogy of Fallot and pulmonary artery sling died because of intractable extensive tracheobronchial stenosis. Late follow-up over three to 90 months showed a symptom-free evolution in most patients, including one reoperation for recurrent compression and one late death. CONCLUSIONS: Tracheobronchial compression by vascular structures in childhood is uncommon and may be masked by nonspecific respiratory symptoms, resulting in an often delayed diagnosis. Once imaging studies have clearly delineated the causal pathologic vascular structures, surgical correction is often straightforward and effective, in spite of the common presence of tracheobronchial malacia.
Assuntos
Obstrução das Vias Respiratórias/congênito , Malformações Arteriovenosas/complicações , Malformações Arteriovenosas/cirurgia , Broncopatias/congênito , Estenose Traqueal/congênito , Obstrução das Vias Respiratórias/cirurgia , Malformações Arteriovenosas/diagnóstico , Broncopatias/cirurgia , Criança , Pré-Escolar , Feminino , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/cirurgia , Humanos , Lactente , Recém-Nascido , Masculino , Estenose Traqueal/cirurgia , Resultado do TratamentoRESUMO
We report a case of heterotaxia with single-ventricle physiology undergoing successively pulmonary artery banding (PAB) at 8 months of age, repair of pulmonary vein (PV) stenoses at 15 months of age, and a fenestrated total cavopulmonary connection (TCPC) combined with repair of a regurgitant common atrioventricular (AV) valve and a Damus-Stansel operation for a restrictive subaortic ventricle at 5 years of age, followed by percutaneous closure of the fenestration. The child is now 10 years old and is, to the best of our knowledge, the only reported long-term survivor of a Fontan type procedure done after repair of PV stenoses.
Assuntos
Derivação Cardíaca Direita , Cardiopatias Congênitas/cirurgia , Pneumopatia Veno-Oclusiva/cirurgia , Criança , Pré-Escolar , Consanguinidade , Feminino , Seguimentos , Cardiopatias Congênitas/genética , Humanos , Lactente , Veias Pulmonares/anormalidades , Veias Pulmonares/cirurgia , Pneumopatia Veno-Oclusiva/genética , ReoperaçãoRESUMO
A traumatic pseudoaneurysm of the abdominal aorta is a rare entity, occurring as the result of a missed aortic lesion at the time of the initial injury. Therefore, clinical suspicion and careful abdominal exploration at first laparotomy is mandatory to prevent aortic pseudoaneurysm formation and its risk of delayed rupture. We present a case of successful surgical treatment of a suprarenal aortic false aneurysm, presenting 4 weeks after a life-threatening gunshot wound in a 13-year-old child.
Assuntos
Falso Aneurisma/etiologia , Aorta Abdominal/lesões , Aneurisma da Aorta Abdominal/etiologia , Ferimentos por Arma de Fogo/complicações , Traumatismos Abdominais/complicações , Adolescente , Seguimentos , Humanos , Masculino , Traumatismo MúltiploRESUMO
Persistence of the left superior vena cava with drainage to the coronary sinus is a common congenital anomaly. We report an infant with such a malformation associated with marked enlargement of the coronary sinus, which produced partial supramitral obstruction and consequently impairment to the left-ventricular inflow. The patient pre-sented with cardiac failure in infancy and features mimicking cor triatriatum. Surgical relief of the supramitral obstruction resulted in immediate reversal of the pulmonary hypertension, with clinical improvement. This rare entity, only once previously reported, is an unusual cause of pulmonary hypertension in infancy.
Assuntos
Coração Triatriado/diagnóstico , Anomalias dos Vasos Coronários/complicações , Obstrução do Fluxo Ventricular Externo/etiologia , Cateterismo Cardíaco , Procedimentos Cirúrgicos Cardíacos , Coração Triatriado/complicações , Angiografia Coronária , Anomalias dos Vasos Coronários/diagnóstico , Anomalias dos Vasos Coronários/cirurgia , Diagnóstico Diferencial , Dilatação Patológica , Ecocardiografia Doppler , Humanos , Lactente , Masculino , Veia Cava Superior/anormalidades , Obstrução do Fluxo Ventricular Externo/diagnóstico , Obstrução do Fluxo Ventricular Externo/cirurgiaRESUMO
OBJECTIVE AND METHODS: From September 1990 to February 1997, 23 consecutive critically ill infants (12 males, 11 females) weighing 2500 g or less underwent cardiac surgery necessitating extracorporeal circulation (ECC). A retrospective study was carried out to evaluate short- and intermediate-term outcome. Mean weight at operation was 2265 g (range 1750-2500 g). Mean age at operation was 24 days. The indications for surgery were transposition of the great arteries (TGA; 7), ventricular septal defect (VSD; 4), aortic stenosis (AS; 3), univentricular heart (UVH; 2), tetralogy of Fallot (TOF; 2), interrupted aortic arch (IAA; 2), atrial septal defect (ASD; 1), atrioventicular septal defect (AVSD; 1) and total abnormal pulmonary venous return (TAPVR; 1). All patients were in NYHA class IV; 17 patients (74%) were intubated pre-operatively. RESULTS: The mean aortic cross-clamping time was 40 min. Twelve patients required deep hypothermia (<20 degrees C) with total circulatory arrest (mean duration 19 min). All patients were successfully weaned from extracorporeal circulation (ECC). Five patients left the operating room with an open sternum (mean duration before closure: 3.5 days). Mean duration of artificial ventilation was 10.6 days; of inotropic support 6.7 days and of intensive care stay 17.8 days. Severe complications were observed in 19 patients (83%): cardiac failure requiring high inotropic support (13), sepsis (7), and acute renal insufficiency (5). One patient needed a ventricular assist device. Five patients (22%) died in the intensive care unit (ICU): 2 AS with fibroelastosis, 2 IAA with VSD. and 1 UVH with pulmonary atresia. At discharge from the ICU, 7 patients were receiving no treatment. Mean duration of follow-up was 32 months (range 2-80 months). We had 2 reoperations: 1 for right ventricular outflow tract obstruction 1 year after a switch operation and 1 for mitral valve replacement 1 year after total abnormal pulmonary venous return repair (death 30 days post mitral valve replacement). Survival at I year was 73%. At the last clinical examination 16 patients were in NYHA class I. CONCLUSION: Despite the severity of pre-operative cardiac disease, early surgical repair with ECC in infants weighing 2500 g or less is feasible with tolerable mortality yet with significant early morbidity.
Assuntos
Circulação Extracorpórea , Cardiopatias Congênitas/cirurgia , Recém-Nascido de Baixo Peso , Peso Corporal , Procedimentos Cirúrgicos Cardíacos/mortalidade , Feminino , Seguimentos , Cardiopatias Congênitas/mortalidade , Humanos , Recém-Nascido , Masculino , Morbidade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Surgical correction of unroofed coronary sinus, left superior vena cava, dextrocardia, and situs solitus in a 4-month-old infant consisted of reroofing the coronary sinus by means of a left atrial flap while redirecting the left superior vena cava to the right atrium. Excellent access to the left side of the left atrium was afforded by the associated dextrocardia.
Assuntos
Anomalias dos Vasos Coronários/cirurgia , Cardiopatias Congênitas/cirurgia , Átrios do Coração/cirurgia , Humanos , Lactente , Masculino , Retalhos Cirúrgicos/métodos , Veia Cava Superior/anormalidades , Veia Cava Superior/cirurgiaRESUMO
BACKGROUND: In contrast to the wide and successful use of valved aortic and pulmonary homografts, the non-valved prolongation of the thoracic aorta for the repair of some complex congenital heart diseases has rarely been described. We present here our experience with the use of descending aorta and aortic arch homografts as non-valved conduits for the surgical repair of complex cardiac malformations in 8 patients. METHODS: One atriopulmonary conduit replacement four extraatrial cavopulmonary connections, and one intraatrial cavopulmonary repair were achieved by means of a homograft of the descending aorta with a diameter of 15 to 17 mm. Three pulmonary unifocalization procedures were carried out in 2 more patients using a curved homograft of the aortic arch with a diameter of 18 mm. Except for 1 patient, whose incompetent common atrioventricular valve was replaced with a mechanical prosthesis, all other patients were managed without anticoagulation. RESULTS: No conduit-related complications were seen during a follow-up of 18 to 42 months. One patient died perioperatively during an emergency central repair of the right ventricular outflow tract after bilateral unifocalization with arch homografts. Another patient died suddenly 4 months after cavopulmonary connection. The remaining 6 patients are currently doing well. CONCLUSIONS: Regardless of the complexity of the underlying malformations, we are encouraged to use nonvalved thoracic aortic homografts in the repair of congenital cardiac diseases because of the reduction in thrombotic, hemorrhagic, and infectious complications associated with their use; convenience in handling; and their versatility in size and shape.
Assuntos
Aorta Torácica/transplante , Cardiopatias Congênitas/cirurgia , Adolescente , Calcinose/etiologia , Cardiomiopatias/etiologia , Causas de Morte , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Masculino , Fatores de Risco , Tromboembolia/etiologia , Transplante Homólogo , Resultado do TratamentoRESUMO
We present the case of the successful reconstruction in a child of a congenital cardiac malformation (tetralogy of Fallot) complicated by acquired aortic regurgitation and aneurysm formation of the left pulmonary artery due to previous endocarditis, by using an aortic homograft for reconstruction of the left ventricular outflow tract and a pulmonary homograft for reconstruction of the right ventricular outflow tract. Regarding the excellent results recently obtained with cryopreserved homografts, the many advantages of these valves compared to mechanical prostheses, we feel that aortic and or pulmonary homografts might constitute ideal biological valves for reconstruction of left and or right ventricular outflow tract in children when the presence of a congenital anomaly of the pulmonary valve renders an autograft impossible.
Assuntos
Aneurisma/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Artéria Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Aneurisma/complicações , Insuficiência da Valva Aórtica/complicações , Procedimentos Cirúrgicos Cardíacos/métodos , Criança , Humanos , Masculino , Tetralogia de Fallot/complicações , Transplante HomólogoRESUMO
Innominate artery compression of the trachea in children is a rare cause of respiratory distress. Surgical intervention is mandatory in a selected group of individuals. In this report we describe an original technique of suspension of the innominate artery using a pericardium "Hammock". Our experience about one patient is reported. The advantage of this technique compare to other procedures is discussed.
Assuntos
Tronco Braquiocefálico/anormalidades , Estenose Traqueal/etiologia , Constrição Patológica , Endoscopia , Feminino , Humanos , Lactente , Pericárdio/cirurgia , Estenose Traqueal/cirurgiaRESUMO
We have reviewed hospital mortality and morbidity with cardiac surgery under cardiopulmonary bypass in patients over 75 years, operated during a 5 years period. It is at the expense of a sometimes difficult selection process in favour of patients with a potentially curable cardiac disease as their only problem, and despite substantially increased mortality and morbidity, that the operated elderly can have excellent probability to normalise both life expectancy and quality of life.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Fatores Etários , Idoso , Procedimentos Cirúrgicos Cardíacos/mortalidade , Feminino , Cardiopatias/fisiopatologia , Cardiopatias/cirurgia , Próteses Valvulares Cardíacas , Humanos , Masculino , Revascularização Miocárdica , Função Ventricular EsquerdaRESUMO
The surgical experience in 13 infants with total anomalous pulmonary venous connection (TAPVC) between 1987 and 1991 is reviewed. The age vary from 2 days to 35 months with a weight at intervention from 2.130 kg to 5.400 kg. The types of TAPVC were supracardiac in 4 patients, cardiac in 4, and infracardiac in 5. Seven patients (54%) were operated on in emergency. Cardiopulmonary bypass consisted of profound hypothermia and total circulatory arrest in 8 patients (60%) and continuous hypothermic bypass with low flow for the remaining 5 patients (40%). There was no operative death. The follow-up ranges from 21 to 58 months, mean 40 months. There was one reoperation. All the patients were asymptomatic and the height growth percentile is less than 5% in 20%, and the weight growth percentile is less than 5% in 30%. The early repair of infants born with TAPVC can be done with low morbidity with a good prospect on medium term follow-up.
Assuntos
Cardiopatias Congênitas/cirurgia , Veias Pulmonares/anormalidades , Veias Pulmonares/cirurgia , Cateterismo Cardíaco , Ponte Cardiopulmonar , Ecocardiografia , Seguimentos , Parada Cardíaca Induzida , Cardiopatias Congênitas/diagnóstico , Humanos , Lactente , Recém-NascidoRESUMO
Circulating concentrations of leucocyte elastase were measured in 16 adult patients undergoing cardiopulmonary bypass (CPB) with a flat-sheet membrane oxygenator. Eight patients (Group I) received the calcium channel blocker nifedipine (9 micrograms.kg-1 x h-1) during CPB. Eight patients (Group II) did not receive any calcium channel blocker during surgery and served as the control group. Elastase concentrations were measured at 7 time points: 2 before, 2 during, and 3 after CPB. The bypass procedure was associated with elevation in elastase concentrations (P < 0.001). Comparing to baseline values elastase concentrations were significantly elevated (P < 0.05) 60 min after the start of CPB and on all measurements done after CPB. Elastase concentrations correlated with the duration of CPB (rs = 0.76, P < 0.001), and were not influenced by nifedipine infusion as revealed by comparing the two groups. This study demonstrates moderate elastase release during CPB with a flat-sheet membrane oxygenator and fails to confirm inhibition of elastase release by nifedipine infusion during CPB.
Assuntos
Ponte Cardiopulmonar , Leucócitos/enzimologia , Nifedipino/farmacologia , Elastase Pancreática/sangue , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Direct surgical repair of left main coronary artery (LMCA) stenosis by either the right (posterior) or left (anterior) approach can be difficult in case of complex, extensive atheromatous lesions. Complete transsection of both great vessels allows rotation of the heart, with its base facing the surgeon. Patch repair then becomes safe, precise and expedicious. The LMCA arteriotomy can easily be prolonged beyond its bifurcation as needed. Three consecutive patients were successfully operated. We suggest this approach to the surgeon concerned by restoration of a physiologic antegrade flow for his patient with complex atheromatous LMCA lesions.
Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Doença das Coronárias/cirurgia , Vasos Coronários/cirurgia , Adulto , Angiografia Coronária , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Serum elastase-1, amylase, lipase, and trypsin-like immunoreactivity were measured in a group of 17 consecutive patients with acute pancreatitis. When assayed within 24 h of the onset of symptoms, all enzymes were found to be elevated, thus showing similar sensitivity. Elastase-1 did not improve the diagnostic score of the other enzymes studied. Owing to their much quicker and less expensive determinations, amylase and lipase should be considered the best initial markers of pancreatic injury. However, during the course of pancreatitis, amylase and in a lesser degree lipase returned to normal in more cases than elastase or trypsin; both were still elevated in 90% of the patients 10 days after the onset of the symptoms. Thus, trypsin and/or elastase-1 should be reserved for cases of doubtful or delayed diagnosis. The specificity and the positive predictive value of these enzymes need to be evaluated.