A randomized, double-blind, and placebo-controlled study with tranexamic acid of bleeding and fibrinolytic activity after primary coronary artery bypass grafting.

Cardiopulmonary bypass is frequently associated with excessive blood loss. Platelet dysfunction is the main cause of non-surgical bleeding after open-heart surgery. We randomized 65 patients in a double-blind fashion to receive tranexamic acid or placebo in order to determine whether antifibrinolytic therapy reduces chest tube drainage. The tranexamic acid group received an intravenous loading dose of 10 mg/kg, before the skin incision, followed by a continuous infusion of 1 mg kg(-1) h(-1) for 5 h. The placebo group received a bolus of normal saline solution and continuous infusion of normal saline for 5 h. Postoperative bleeding and fibrinolytic activity were assessed. Hematologic data, convulsive seizures, allogeneic transfusion, occurrence of myocardial infarction, mortality, allergic reactions, postoperative renal insufficiency, and reopening rate were also evaluated. The placebo group had a greater postoperative blood loss (median (25th to 75th percentile) 12 h after surgery (540 (350-750) vs 300 (250-455) mL, P = 0.001). The placebo group also had greater blood loss 24 h after surgery (800 (520-1050) vs 500 (415-725) mL, P = 0.008). There was a significant increase in plasma D-dimer levels after coronary artery bypass grafting only in patients of the placebo group, whereas no significant changes were observed in the group treated with tranexamic acid. The D-dimer levels were 1057 (1025-1100) microg/L in the placebo group and 520 (435-837) microg/L in the tranexamic acid group (P = 0.01). We conclude that tranexamic acid effectively reduces postoperative bleeding and fibrinolysis in patients undergoing first-time coronary artery bypass grafting compared to placebo.

A randomized, double-blind, and placebo-controlled study with tranexamic acid of bleeding and fibrinolytic activity after primary coronary artery bypass grafting

Cardiopulmonary bypass is frequently associated with excessive blood loss. Platelet dysfunction is the main cause of non-surgical bleeding after open-heart surgery. We randomized 65 patients in a double-blind fashion to receive tranexamic acid or placebo in order to determine whether antifibrinolytic therapy reduces chest tube drainage. The tranexamic acid group received an intravenous loading dose of 10 mg/kg, before the skin incision, followed by a continuous infusion of 1 mg kg-1 h-1 for 5 h. The placebo group received a bolus of normal saline solution and continuous infusion of normal saline for 5 h. Postoperative bleeding and fibrinolytic activity were assessed. Hematologic data, convulsive seizures, allogeneic transfusion, occurrence of myocardial infarction, mortality, allergic reactions, postoperative renal insufficiency, and reopening rate were also evaluated. The placebo group had a greater postoperative blood loss (median (25th to 75th percentile) 12 h after surgery (540 (350-750) vs 300 (250-455) mL, P = 0.001). The placebo group also had greater blood loss 24 h after surgery (800 (520-1050) vs 500 (415-725) mL, P = 0.008). There was a significant increase in plasma D-dimer levels after coronary artery bypass grafting only in patients of the placebo group, whereas no significant changes were observed in the group treated with tranexamic acid. The D-dimer levels were 1057 (1025-1100) æg/L in the placebo group and 520 (435-837) æg/L in the tranexamic acid group (P = 0.01). We conclude that tranexamic acid effectively reduces postoperative bleeding and fibrinolysis in patients undergoing first-time coronary artery bypass grafting compared to placebo.

Unsupported valvuloplasty in children with congenital mitral valve anomalies. Late clinical results.

OBJECTIVE: To analyze late clinical evolution after surgical treatment of children, with reparative and reconstructive techniques without annular support. METHODS: We evaluated 21 patients operated upon between 1975 and 1998. Age 4.67+/-3.44 years; 47.6% girls; mitral insufficiency 57.1% (12 cases), stenosis 28.6% (6 cases), and double lesion 14.3% (3 cases). The perfusion 43.10+/-9.50 min, and ischemia time were 29.40+/-10.50 min. The average clinical follow-up in mitral insufficiency was 41.52+/-53.61 months. In the stenosis group (4 patients) was 46.39+/-32.02 months, and in the double lesion group (3 patients), 39.41+/-37.5 months. The echocardiographic follow-up was in mitral insufficiency 37.17+/-39.51 months, stenosis 42.61+/-30.59 months, and in the double lesion 39.41+/-37.51 months. RESULTS: Operative mortality was 9.5% (2 cases). No late deaths occurred. In the group with mitral insufficiency, 10 (83.3%) patients were asymptomatic (p=0.04). The majority with mild reflux (p=0.002). In the follow-up of the stenosis group, all were in functional class I (NYHA); and the mean transvalve gradient varied between 8 and 12 mmHg, average of 10.7 mmHg. In the double lesion group, 1 patient was reoperated at 43 months. No endocarditis or thromboembolism were reported. CONCLUSION: Mitral stenosis repair has worse late results, related to the valve abnormalities and associated lesions. The correction of mitral insufficiency without annular support showed good long-term results.

Valve repair in children with congenital mitral lesions: late clinical results.

Mitral valve repair may be performed without ring support with advantages related to results and complications. The objective of this study was to analyze the long-term clinical results following surgical repair and reconstruction without the use of rings in cases of congenital mitral lesions in children less than 12 years of age. Twenty-one patients who had undergone surgery during the period from 1975 to 1998 were evaluated. The mean age was 4.6 +/- 3.4 years. Females represented 47.6% of the total. Mitral regurgitation was present in 57.1% (12 patients), stenosis in 28.6% (6 patients), and the mixed lesion group represented 14.3% (3 patients). Perfusion time was 43.1 +/- 9.5 minutes and ischemic time 29.4 +/- 10.5 minutes. Follow-up time was 41.5 +/- 53.6 months for the regurgitation group, 46.3 +/- 32.0 months for the stenosis group, and 39.41 +/- 37.51 months for the mixed lesion group. Echocardiographical follow-up time was 37.17 +/- 39.51 months for the regurgitation group, 42.61 +/- 30.59 months for the stenosis group, and 39.41 +/- 37.51 months for the mixed lesion group. Operative mortality was 9.5% (two cases). There were no late deaths. In the regurgitation group, 10 patients (83.3%) were asymptomatic (p = 0.004). In the echocardiographical follow-up, most of the patients had minimal regurgitation. In the clinical follow-up of the stenosis group all patients were in functional class I (NYHA). The mean transvalvular gradient measured by echocardiography was from 8 to 12 mmHg with a mean gradient of 10.7 mmHg. In the mixed lesion group there was one reoperation at postoperative month 43. There were no cases of endocarditis or thromboembolism. Mitral valve repair in congenital lesions is associated with good late results. The majority of cases in the regurgitation group remain asymptomatic and do not require reoperation. Rings or annular support are not necessary in such cases. Satisfactory repair is more difficult to achieve in cases of mitral stenosis due to valvular abnormalities and the seriousness of the associated lesions.

Results of the surgical treatment of chronic atrial fibrillation.

OBJECTIVE: Report clinical experience in surgical treatment of atrial fibrillation (AF) by Cox-maze procedure. METHODS: 61 patients underwent surgical treatment for AF. Two had primary AF and 59 AF secondary to heart disease (2 atrial septal defects, 57 mitral). Ages ranged from 20 to 74 years (mean = 49). There were 44 females (72%). The surgical technique employed was Cox 3 without cryoablation. The patients were follow-up in specific at patient clinics and underwent periodical ECG, exercise tests, echocardiogram and Holter monitoring. RESULTS: In-hospital mortality was 4.9% and late mortality 1.6%. A temporary pacemaker was used in 28 (46%) and a definitive in 7 patients (11.4%). On hospital discharge, AF remained in 17%; 63.9% had sinus rhythm, 6.9% atrial rhythm, 1.7% junctional rhythm, and 10.3% had pacemaker rhythm. In the last evaluation, AF was present in 19.5%; (70.5% sinus rhythm, 4% atrial rhythm, 2% atrial tachycardia, and 4% pacemaker rhythm). There was no report of thromboembolic episodes. Chronotropic response was considered adequate in 19%, intermediate in 29%, and inadequate in 42%. In Holter monitoring, the mean heart rate was 82 +/- 8 bpm, with a minimum of 57 +/- 7 bpm and maximum of 126 +/- 23 bpm, with supraventricular extrasystoles in 2.3 +/- 5.5% of the total heartbeats and ventricular extrasystoles in 0.8 +/- 0.5%. In the echocardiogram, the A wave was present in the left atrium in 87.5%. CONCLUSION: Maze procedure is effective and has acceptable surgical risk. Atrial or sinus rhythms remain stable with a small but remarkable frequency of atrial and ventricular arrhythmias. Left atrial contraction is present, although attenuated, as well as the chronotropic response to exercise.

Ventricular evoked response in patients with hypertrophic obstructive cardiomyopathy treated with DDD pacing.

OBJECTIVE: To assess the changes in ventricular evoked responses (VER) produced by the decrease in left ventricular outflow tract gradient (LVOTG) in patients with hypertrophic obstructive cardiomyopathy (HOCM) treated with dual-chamber (DDD) pacing. METHODS: A pulse generator Physios CTM (Biotronik, Germany) was implanted in 9 patients with severe drug-refractory HOCM. After implantation, the following conditions were assessed: 1) Baseline evaluation: different AV delay (ranging from 150 ms to 50 ms) were sequentially programmed during 5 to 10 minutes, and the LVOTG (as determined by Doppler echocardiography) and VER recorded; 2) standard evaluation, when the best AV delay (resulting in the lowest LVOTG) programmed at the initial evaluation was maintained so that its effect on VER and LVOTG could be assessed during each chronic pacing evaluation. RESULTS: LVOTG decreased after DDD pacing, with a mean value of 59 +/- 24 mmHg after dual chamber pacemaker, which was significantly less than the gradient before pacing (98 + 22 mmHg). An AV delay > 100 ms produced a significantly lower decrease in VER depolarization duration (VERDD) when compared to an AV delay < or = 100 ms. Linear regression analyses showed a significant correlation between the LVOTG values and the magnitude of VER (r = 0.69; p < 0.05) in the 9 studied patients. CONCLUSION: The telemetry obtained intramyocardial electrogram is a sensitive means to assess left ventricular dynamics in patients with HOCM treated with DDD pacing.

[Late evaluation with spiral computed tomography of smooth bovine pericardium grafts]. / Avaliação tardia por tomografia computadorizada espiral de enxertos de pericárdio bovino liso como substitutos aórticos.

PURPOSE: To evaluate morphologically by spiral computed tomography (SCT) bovine pericardial grafts as aortic substitutes. METHODS: Ten patients were submitted to aortic graft evaluation with SCT. There were 8 ascending and 2 descending grafts. Examination was done after 2 to 7 years post operative. Ages ranged from 49 to 67 years, with 6 male and 4 female patients. All had implanted smooth surface naked pericardial grafts. RESULTS: Surgical result was good in all. Distal dissection persisted in some cases. One had a peri-graft hematoma, 5 had no structural changes and 4 presented mild graft dilatation. There were no graft calcification or pseudoaneurysm. CONCLUSION: Glutaraldehyde preserved naked smooth surface bovine pericardial aortic grafts present satisfactory structural aspect, as seen by SCT, at medium term follow-up. Mild dilatation may be seen in some cases.

Avaliaçäo tardia por tomografia computadorizada espiral de enxertos de pericárdio bovino liso com substitutos aórticos / Late evaluation of bovine pericardium grafts as aortic substitutes by spiral computed tomography

OBJETIVO - Avaliar, morfologicamente, por tomografia computadorizada espiral, enxertos de pericárdio bovino liso empregados como substitutos aórticos. MÉTODOS - Dez pacientes foram submentidos a exame por tomografia computadorizada espiral para reconstituiçäo da imagem dos enxertos. Os critérios de seleçäo foram tempo de seguimento superior a 2 anos, enxertos de pericárdio liso näo revestido, implantados na aorta ascendente ou descendente. RESULTADOS - Os exames demonstram bom resultado cirúrgico em todos os casos, persistindo em alguns, a imagem de dissecçäo aórtica distal à anastomose. Um caso apresentava hematoma entre o enxerto e a parede aórtica, em 5 näo foram encontradas alteraçöes estruturais no pericárdio e, nos demais, foi detectada dilataçäo de grau leve, em relaçäo ao diâmetro descrito do enxerto implantado. Näo foram vistos sinais de calcificaçäo ou pseudoaneurismas. CONCLUSÄO - Os enxertos tubulares de pericárdio bovino liso, näo revestido, apresentam resultados satisfatórios quando empregados como substitutos aórticos. A médio prazo, näo foram detectados anormalidades estruturais relacionadas ao material empregado, pela tomografia computadorizada espiral, exceto dilataçäo em alguns casos.

Estimulaçäo cardíaca atrioventricular sincrônica através de um eletrodo flutuante único (Modo VDD) / Synchronous atrioventricular stimulation of the heart with a single floating electrode (Mode VDD)

Um marcapasso bicameral que utiliza um eletrodo flutuante único para estimulaçäo no modo VDD foi implantado em 25 pacientes com distúrbios da conduçäo intra-cardíaca do tipo bloqueio atrioventricular total (21 pacientes) ou de 2o. grau (4 pacientes). Presumiu-se funçäo sinusial normal através do eletrocardiograma convencional e da história clínica. As etiologias dos distúrbios de conduçäo foram a miocardioesclerose (22 pacientes), cirúrgica (2 pacientes) ou a doença de Chagas (1 paciente). O eletro flutuante único SL 60 (Biotronik), dotado de dois sensores atriais situados a 13 cm da extremidade que contém o eletrodo ventricular unipolar, foi introduzido por via transvenosa. As medidas eletrofisiológicas (média +/_ erro padräo) no implante foram onda P de 2,87 +/_ 0,27 mV, QRS de 10,97 +/_ 0,92 mV e linmiar de estimulaçäo ventricular de 0,51 +/_ 0,04 V. O gerador de pulsos Dromos SL (Biotronik) foi mantido na programaçäo padräo. Após implante os pacientes realizaram teste ergométrico e/ou eletrcrdiograma ambulatorial de 24 horas. As complicaçöes registradas foram a perda da sensibilidade atrial em dois pacientes (8 por cento), requerendo reposicionamento do eletro, insuficiência cronotrópica ao exercício por bradicardia sinusal em um (4 por cento) e estimulaçäo de músculo peitoral ou inibiçäo temporária do gerador por miopotenciais em um (4 por cento), solucionada por reprogramaçäo. Em até 6 meses de seguimento, 24 pacientes (96 por cento) apresentam sincronismo atrioventricular adequado graçs estimulaçäo procuzida pelo marcapasso implantado. O implante de um marcapasso atrioventricular sequencial com eletrodo flutuante único é simples e a estimulaçäo VDD é efetiva em pacientes com bloqueios cardíaco e funçäo sinusal normal. Seu uso em pacientes chagásicos deve ser avaliado, pois miopotenciais cardíacos reduzidos podem comprometer a sensibilidade atrial.

[Surgical myocardial revascularization in young patients]. / Cirurgia de revascularização miocárdica em pacientes jovens.

PURPOSE: To determine early and late results of surgical myocardial revascularization (SMR) in young patients. METHODS: We studied retrospectively 73 patients aging less than 40 years and submitted to SMR between 1975 and 1989. The method used was patient card review and thelephone contact with the patient or his physician. RESULTS: Follow-up was obtained in all cases in a period of 2 to 185 (59.9 +/- 41.0) months. Of the coronary risk factors smoking was the most frequent. One vessel coronary artery disease was observed in 16 (21.9%) patients, 2 and 3 vessel coronary artery disease in 26 (35.6%) and 32 (43.8%) patients respectively. SMR was considered complete in 68 (93.2%) patients. An associated procedure was performed on 10 cases: Left ventricular aneurysm repair in 9 (12.3%) and mitral valve replacement in one (1.4%). Perioperative myocardial infarction occurred in 7 (9.5%) patients and one of them died (operative mortality: 1.4%). During follow-up, 6 (8.3%) patients died with an actuarial survival rate of 89.1% at 15 years. An event free survival rate of 68.3% was observed at 10 years. From 66 survivors, 53 (80.3%) were asymptomatic at late follow-up and 48 (72.7%) patients returned to work. CONCLUSION: Surgical myocardial revascularization in young patients associated with medical treatment, has good early and late results with a high percentage of patients asymptomatic and reemployed at a late follow-up.

Cirurgia de revascularização miocárdica em pacientes jovens / Surgical myocardial revascularization in young patients

Objetivo - avaliar os resultados imediatos e tardios da cirurgia de revascularizaçäo em pacientes jovens. Métodos - foram estudados retrospectivaemnte 73 pacientes com idades inferiores a 40 anos e submetidos a cirurgia de revascularizaçäo miocárdica no período de 1975 a 1989, utilizando-se a revisäo dos prontuários e o contato telefônico com os pacientes e/ou médicos-assitentes. Resultados - todos os pacientes foram acompanhados por um período de 2 a 185 (média 59, 9 +/- 41,0) meses. Dentre os fates de risco, o tabagismo foi o mais frequente (89,0 por cento). Dezesseis (21,9 por cento) pacientes apresentavam lesäo coronariana uniarterial, 26 (35,6 por cento) tinham doença biarterial e 32 (43,8 por cento) apresentavam doença triarterial. A revascularizaçäo foi considerada completa em 93, 2 por cento dos casos, sendo que 12,3 por cento foram também submetidos à aneurismectomia do ventrículo esquerdo. Desenvolveram infarto agudo do miocárdio perioperatório 7 (9,5 por cento) doentes, tendo ocorrido móbito hospitalar (1,3 por cento). Tardiamente, 6 (8,3 por cento) pacientes faleceram perfazendo probabilidade de sobrevida de 89, 1 por cento em 15 anos e probabilidade de sobrevida livre de eventos de 68,3 por cento em 10 anos. Encontram-se assintomáticos 80,3 dos pacientes, sendo que 72,7 por cento retornaram ao trabalho. Conclusäo a cirurgia de revascularizaçäo miocárdica em pacientes jovens, associada ao tratamento clínico, mostrou bons resultados a curto e longo prazo, com lata percentagem de pacints sobreviventes, assintomáticos e reassumindo suas atividades trabalhísticas.

Purpose - To determine early and late results of surgical myocardial revascularization (SMR) in young patients. Methods - We studied retrospectively 73 patients aging less than 40 years and submitted to SMR between 1975 and 1989. The method used was patient card review and thelephone contact with the patient or his physician. Results - Follow-up was obtained in all cases in a period of 2 to 185 (59.9±41.0) months. Of the coronary risk factors smoking was the most frequent. One vessel coronary artery disease was observed in 16 (21.9%) patients, 2 and 3 vessel coronary artery disease in 26 (35.ó%) and 32 (43.8%) patients respectively. SMR was considered complete in 68(93.2%) patients. An associated procedure was performed on 10 cases: Left ventricular aneurysm repair in 9 (12.3%) and mitral valve replacement in one (1.4%). Perioperative myocardial infarction occured in 7 (9.5%) patients and one of them died (operative mortality: 1.4%). During follow-up, 6 (8.3%) patients died with an actuarial survival rate of 89.1 % at 15years. An eventfree survival rate of 68.3% was observed at 10 years. From 66 survivors,53 (80.3%) were asymptomatic at late follow-up and 48 (72.7%) patients returned to work Conclusion - Surgical myocardial revascularization in young patients associated with medical treatment, has good early and late results with a high percentage of patients asymptomatic and reemployed at a late follow-up

Side-to-side carotid-subclavian anastomosis for interrupted aortic arch.

A simple technique is proposed for restoring aortic flow in an interrupted aortic arch simulating a type B interruption that does not require aortic cross-clamping, circulatory arrest, or the ligation of major aortic branches. Side-to-side anastomosis between the left carotid and subclavian arteries together with division of the ductus arteriosus and pulmonary artery banding proved effective for relieving aortic arch stricture in that location.

Aprotinin in children undergoing correction of congenital heart defects. A double-blind pilot study.

Thirty children undergoing surgical repair for congenital heart defects were randomly selected for a double-blind study on the anti-hemorrhagic and blood-saving properties of aprotinin. The treatment group comprised 14 patients who received aprotinin 7 mg/kg of body weight until the end of perfusion. The placebo group (n = 16) received an infusion of the corresponding volumes of saline. Patients treated with aprotinin bled less during the operation (12.6 ml/kg versus 18.1 ml/kg, p = 0.25) and in the first 24 postoperative hours (chest drainage 12.1 ml/kg versus 17.7 ml/kg, p = 0.07). Hemoglobin loss into chest drainage was reduced in the treated group by half (0.66 versus 1.21 gm in 24 hours, p = 0.07). Fewer blood donors were needed during hospitalization by patients receiving aprotinin (1.07 versus 2.75 donors per patient, p = 0.04). Postoperative transfusion was unnecessary in 64.2% of patients receiving aprotinin compared with only 25% of the placebo group (p = 0.03). Aprotinin increased diuresis significantly during perfusion (4.3 ml/kg versus 1.0 ml/kg, p = 0.005). Other parameters are evaluated, and considerations are made regarding adequacy of the dosage regimen. The drug seems to be safe and easy to handle in children.

Late outcome of unsupported annuloplasty for rheumatic mitral regurgitation.

OBJECTIVES: The aim of this study was to evaluate medium- and long-term (range 4 months to 17 years) clinical results in a series of patients treated surgically by unsupported mitral annuloplasty. BACKGROUND: Mitral valve regurgitation has usually been treated by valve replacement or ring annuloplasty. A few series have reported plastic repair procedures without annular support or remodeling. Furthermore, in rheumatic lesions the results have been inferior to those in degenerative mitral insufficiency, and the majority of previous reports have provided information on short- or medium-term follow-up. METHODS: One hundred fifty-four patients were operated on (55 male [36%] and 99 female [64%]). The mean age +/- SD was 36 +/- 16 years (range 5 to 73). Associated lesions comprised 47 aortic and 21 tricuspid valve lesions and 2 atrial septal defects. Patients with concomitant mitral stenosis were not included. Preoperative functional class was I or II in 19% and III or IV in 81%. The cardiothoracic ratio was 0.61 +/- 0.10. All patients underwent an unsupported mitral annuloplasty procedure in which the mural portion of the annulus was reduced by applying two buttressed mattress sutures at the commissures without compromising the width of the septal leaflet. When necessary, additional chordal procedures were performed. No patients received ring or posterior annular support. RESULTS: The early mortality rate was 1.9% (three patients; one of the three died of myocardial failure and two of pulmonary thromboembolism). The late mortality rate was 5.8% (nine patients; three of the nine died of myocardial failure, one each of septicemia, pulmonary thromboembolism and sudden arrhythmic death and three of unknown causes). Twenty-eight patients (18.2%) were reoperated on because of mitral valve dysfunction and 2 (1.3%) because of prosthetic aortic valve dysfunction. A residual late systolic murmur was present in 48% of patients. Late complications were systemic thromboembolism in 5.8% (one third with an aortic valve prosthesis), infective endocarditis in 1.3% and pulmonary thromboembolism in 0.6%. Postoperative functional class was I or II in 84% and III or IV in 16%. Cardiothoracic ratio was 0.58 +/- 0.10. Actuarial probability of late survival was 79.5 +/- 5.3% at 10 years and 71.0 +/- 7.4% at 14 years. Event-free survival was 67.9 +/- 8.9% at 10 years and 56.1 +/- 11.7% at 14 years. CONCLUSIONS: Rheumatic mitral regurgitation can be effectively treated by annuloplasty without prosthetic annular support, with late results comparable to those obtained with more complicated procedures. This observation is particularly important for treatment of children and young adult patients.

Surgical repair of ventricular aneurysms. Early results with Cooley's technique.

Using bovine pericardium instead of Dacron for grafting, we performed ventricular endoaneurysmorrhaphy (Cooley's technique) in 13 patients with postmyocardial infarction left ventricular aneurysm. Twelve patients were men and 1 was a woman; their ages ranged from 38 to 67 years (mean, 51.2 +/- 11.4 years). Eight patients had large anterolateral aneurysms, 4 had apical aneurysms, and 1 had a false inferior aneurysm. Postoperatively, the mean cardiac index increased from 2.07 +/- 0.50 to 3.09 +/- 0.99 L/min/m2 (p < 0.05), with a mean percentage increase of 50.17% +/- 37.03%. No patient required postoperative mechanical circulatory assistance, and pharmacologic support could be withdrawn soon after surgery. All patients had uncomplicated recoveries and were asymptomatic upon discharge, at a mean time of 9.0 +/- 2.3 days after surgery. We conclude that ventricular endoaneurysmorrhaphy provides excellent initial results, and we believe, through subjective analysis of ventriculograms, that the use of bovine pericardium for grafting produces better functional results than does the use of Dacron.

[The use of a rate-responsive pacemaker after heart transplantation]. / Uso de marcapasso com resposta de freqüência após transplante cardíaco.

PURPOSE: The indications and the results of pacemaker implant following orthotopic cardiac transplantation. METHODS: Four patients implanted a cardiac pacemaker (PM) in the early post-operative period (PO) of orthotopic cardiac transplantation (from 10th to 16th PO day). The patients were 33 to 55 year-old and the indications to PM were supraventricular arrhythmia (atrial fibrillation or flutter) associated with atrioventricular block in three, and complete atrioventricular block in one patient. Previous to PM implant, patients were submitted to endomyocardial biopsy, which was normal in two patients, evidenced mild rejection in one and moderate rejection in the remaining. A ventricular rate responsive pacemaker was implanted in all patients, with sensors responsive to muscular activity in one patient, and to minute ventilation in three. RESULTS: One patient died in the 20th PO due to acute allograft rejection not controlled by immunosuppressive drugs. Three other patients had satisfactory evolution and the pacemakers were programmed during exercise testing, previous to hospital discharge. Recent evaluation revealed that these patients are in good clinical condition at the 6th, 14th and 24th PO months. Adequate pacemaker function was insured by exercise testing and ambulatory electrocardiographic recording. CONCLUSION: A ventricular rate responsive pacemaker represented a satisfactory mode of pacing, in patients with severe bradycardia, following heart transplantation.

New needle for catheter introduction in left atrium.

We describe a new needle for left atrial catheter introduction. It allows catheter introduction through the right superior pulmonary vein or through the interatrial septum. Used in 32 patients (adults and children), the device proved to be highly efficient, simple, and safe.

[Hospital risk factors in subclavian-pulmonary anastomosis with polytetrafluoroethylene graft]. / Fatores de risco hospitalar na anastomose subclávia-pulmonar com enxerto de politetrafluoretileno.

PURPOSE: Identification of risk factors for mortality in subclavian-pulmonary anastomosis using polytetrafluorethylene (PTFE). PATIENT AND METHODS: Immediate surgical results (30 days) were analyzed in 180 cyanotic patients consecutively operated on from september 1979 to march 1989. RESULTS: The hospital mortality was 12.7% (23 patients) and age at surgery, low weight (less than 3 kg) and preoperative diagnosis were considered risk factors for mortality. Pulmonary artery diameter at echocardiography, date of surgery and diameter of the conduits were associated with increased risk, but this association lacked statistical significance. Sex and previous palliative surgery have not increased hospital mortality. CONCLUSION: We believe that identification of risk factors to PTFE conduit implant plays an important role in the preoperative management of those patients in order to obtain better results in this life saving procedure.

[Modified Cooley technique for surgical repair of left ventricular aneurysms]. / Técnica de Cooley modificada para a correção cirúrgica de aneurismas do ventrículo esquerdo.

PURPOSE: To evaluate early postoperative results of modified Cooley's technique of ventricular endoaneurysmorrhaphy. PATIENTS AND METHODS: Eight patients, seven males, with ages ranging 38.0 to 67.0 years (m = 51.2 +/- 11.4 years) and with postinfarction left ventricular aneurysms were submitted to surgical repair by a modified Cooley's technique of ventricular endoaneurysmorrhaphy. RESULTS: No postoperative complication occurred and all patients were discharged from the hospital asymptomatic on a mean time of 9.0 +/- 2.3 days after surgery. The mean cardiac index increased from 2.1 +/- 0.5 to 3.3 +/- 1.1 l/min (p less than 0.05) with a mean percentual increase of 53.0%. No patient required mechanical circulatory assistance after surgery and the pharmacological support could be interrupted soon. CONCLUSION: Ventricular endoaneurysmorrhaphy searchs to restore shape, contour and volume to the left ventricle and has shown excellent initial results.