Artéria torácica interna como fonte de circulação colateral em paciente com obstrução aorto-ilíaca e indicação de cirurgia de revascularização miocárdica ­ relato de caso / Internal thoracic artery as a source of collateral circulation in a patient with aortoiliac obstruction and indication for myocardial revascularization surgery ­ case report

RESUMO: Paciente do sexo feminino, 51 anos, com doença arterial coronariana (DAC), angina e dispnéia (classe III NYHA). Antecedentes: hipertensão arterial, dislipidemia, ex-tabagista e claudicação intermitente, estável para 200 metros. A cineangiocoronariografia realizada pela artéria radial (AR) esquerda revelou doença triarterial, com função ventricular preservada, sendo indicada a cirurgia de revascularização miocárdica (CRM). Pulsos femorais não eram palpáveis, havia pulso filiforme na AR direita e houve oclusão da AR esquerda após o procedimento. Solicitada ultrassonografia vascular (USV) das artérias dos membros inferiores que mostrou perviedade de todos os segmentos arteriais, com fluxo monofásico, de velocidade reduzida, desde as artérias femorais comuns, compatível com obstrução em território aorto-ilíaco. A USV das artérias torácicas internas (ATI) demonstrou calibre acima de 3,0 mm das mesmas (ATI direita: 3,6 mm e ATI esquerda: 3,3 mm), possivelmente relacionado à participação na colateralização para manutenção do fluxo para os membros inferiores. Realizada angiotomografia computadorizada (ATC) de aorta e ATIs, confirmando oclusão da aorta após a emergência das artérias renais e as ATIs, bilateralmente, como fonte da circulação colateral para o território distal à oclusão. Diante da impossibilidade de utilização das ATIs para a CRM, optou-se por tratamento percutâneo, realizado com sucesso, tendo a paciente, alta no dia seguinte. A artéria torácica interna (ATI) tem indicação Classe I como enxerto para a artéria descendente anterior esquerda (DA) na CRM. Em casos com oclusão aortoilíaca (síndrome de Leriche), a ATI pode ser fonte de circulação colateral para artérias abaixo do nível da oclusão. Seu uso inadvertido pode levar a graves complicações isquêmicas nos territórios dependentes. Em pacientes com indicação de CRM e doença arterial obstrutiva periférica, a USV no pré operatório pode diagnosticar as obstruções arteriais, incluindo o acometimento do território aorto-ilíaco. Nesses casos é fundamental a investigação também das ATIs e avaliar a origem da circulação colateral para os membros inferiores.

Valve-in-valve mitral por via transatrial em paciente com septo interatrial calcificado: uma via alternativa / Transatrial mitral valve-in-valve in a patient with calcified interatrial septum: an alternative approach

Caso clínico • NLR, Masculino, 68 anos Consulta inicial: Paciente com disfunção de prótese biológica mitral por rotura de folheto e diversas internações por hipervolemia e congestão sistêmica. Troca valvar mitral realizada em 2006, com fechamento de CIA com patch de pericárdio bovino no mesmo tempo cirúrgico.

Infarto agudo do miocárdio como complicação de mixoma atrial / Acute myocardial infarction as a complication of atrial myxoma

INTRODUÇÃO: Os mixomas são as neoplasias cardíacas primárias mais comuns. Geralmente se apresentam com sintomas de doença valvar mitral ou de eventos tromboembólicos. Apesar de mais frequentes em mulheres, os homens apresentam maior probabilidade de apresentar evidências de embolização. A incidência de embolização está associada a tamanhos menores (≤4,5 cm). Embora a embolização sistêmica seja frequente, o envolvimento da artéria coronária, levando a sua oclusão e consequentemente infarto agudo do miocárdio (IAM), é extremamente raro. OBJETIVO: Descrição de uma série de casos de associação de mixomas com IAM por embolização coronariana. MÉTODOS: Análise retrospectiva de prontuários de hospital terciário de Cardiologia, dos últimos 38 anos. Foram avaliados 138 pacientes portadores de mixomas. RESULTADOS A associação de mixoma atrial com evento coronariano foi evidenciado em 3 pacientes, do sexo feminino, de 28, 47 e 48 anos. A apresentação clínica inicial foram sintomas de insuficiência cardíaca em 1 paciente; as outras duas eram assintomáticas. A ressonância magnética cardíaca (RMC) definiu realce tardio de padrão coronariano com acometimento transmural e redução significativa da fração de ejeção nas três pacientes. Os mixomas tinham grandes dimensões, o menor com 4,5 cm de diâmetro. As principais características dos eventos estão descritas na tabela1. CONCLUSÃO: A ocorrência de embolização coronária na evolução dos mixomas deve ser lembrada e pesquisada, principalmente nos pacientes que têm redução de fração de ejeção. A ausência de sinais e sintomas específicos dificulta o diagnóstico e retarda o tratamento. Estes achados sugerem a recomendação do tratamento cirúrgico precoce e anticoagulação assim que o diagnóstico de mixoma for feito para prevenção das complicações embólicas.

Análise da durabilidade e perfil hemodinâmico da bioprótese Epic. Um Follow Up de 10 anos / Analysis of durability and hemodynamic profile of the epic bioprosthesis. A 10-year Follow Up

INTRODUÇÃO: A doença valvar é responsável por acometer mais de 100 milhões de pessoas no mundo e a substituição valvar em geral é o tratamento de escolha. As próteses biológicas são propensas à degeneração valvar estrutural (DVE), seja por um processo multifatorial mediado pela calcificação do tecido conjuntivo, ou pela deterioração do colágeno, o que leva a disfunção protética (estenose e /ou desgaste) e interfere na sua durabilidade. Os autores tiveram como objetivo avaliar o desempenho hemodinâmico da bioprótese EpicTM (prótese com terapia anticalcífica) em pacientes submetidos a cirurgia de troca valvar, bem como sua durabilidade e eventuais complicações como trombose, fratura e/ou disfunção. MÉTODOS: Foram analisados um total de 104 pacientes submetidos à troca valvar no período de 2002 a 2008, cuja média das idades foi de 38,9 anos±16,8 anos, sendo observada uma idade mínima de 9 anos e máxima de 73 anos. Os pacientes foram alocados em grupo de próteses sendo somente mitral (n: 38); somente aórtico (n:43); somente tricúspide (n:7) e mitro-aórtico (n: 16) e analisados conforme as caratéristicas pré e pós operatórias, além do seguimento pós cirúrgico. RESULTADOS: Dentro da amostra de 104 pacientes foi possível avaliar o seguimento em 99 pacientes. No grupo somente mitral encontramos um porcetagem maior de paciente do sexo feminino, com ritmo de FA/flutter e febre reumática. No grupo aórtico pacientes do sexo masculino, com hipertensão e ritmo sinusal. No grupo tricúspide os pacientes eram mais jovens e com ritmo de MP. O tempo médio livre de reoperação foi de 12,99 anos (IC 12,09-13,89). A curva livre de reoperação foi 98±1,4% em 3 anos, 95±2,2% em 5 anos 85±3,6% em 10 anos. Não foi observado nenhum óbito nos grupos avaliados. Reoperação foi realizada em 21 pts (5 por EI, 2 por VPP, 1 por trombose de prótese e 13 por disfunção estrutural da prótese). O tipo da disfunção foi estenose em 7pts e fratura do folheto em quatro pacientes Entre os 13 pacientes (12,5%) reoperados por disfunção da prótese, 2 eram mitrais, 7 aórticos, 3 tricúspides e 1 mitro/aórtico. Na análise multivariada observaos que os pacientes tabagistas tinham 10,6 vezes mais risco de evoluir com disfunção e a idade foi um fator protetor. CONCLUSÕES: Apesar da amostra estudada ter 78% dos pacientes com menos de 50 anos de idade a evolução tardia (13 anos) pós implante da prótese EPIC foi muito favorável, com mortalidade zero e curva livre de reoperação de 85±3,6 % em 10 anos. Disfunção estrutural ocorreu em 12,5% A incidência de reoperação foi maior nos pacientes mais jovens.

Persistent Inflammatory Activity in Blood Cells and Artery Tissue from Patients with Previous Bare Metal Stent

BACKGROUND: Studies have pointed out a higher mortality after coronary artery bypass surgery (CABG) in patients with stent. OBJECTIVE: To evaluate inflammatory markers in peripheral blood cells and in coronary artery tissue samples obtained during CABG in patients with stent compared to controls. METHODS: The case series consisted of two groups, one with previous stent implantation (n = 41) and one control (n = 26). The expression of the LIGHT, IL-6, ICAM, VCAM, CD40, NFKB, TNF, IFNG genes was analyzed in peripheral blood cells collected preoperatively. The coronary artery was evaluated for: interleukin-6, ICAM, VCAM, CD40, NFKB, TNF-alpha and IFN-gamma by immunohistochemistry. A total of 176 tissue samples were grouped for analysis in: A1- arteries with stent (n = 38); A2- native arteries from patients with stent in another artery (n = 68); and A3- arteries without stent from controls undergoing routinely CABG surgery (n = 70). A significance level of 0.05 was adopted. RESULTS: Patients with stent showed higher TNF (p = 0.03) and lower CD40 gene expression (p = 0.01) in peripheral blood cells than controls without stent. In coronary artery samples, the TNF-alpha protein staining was higher in the group A1, not only in the intima-media layer (5.16 ± 5.05 vs 1.90 ± 2.27; p = 0.02), but also in the adipose tissue (6.69 ± 3.87 vs 2.27 ± 4.00; p < 0.001). Furthermore, group A1 had a higher interleukin-6 protein staining in adipose tissue than group A3 (p = 0.04). CONCLUSION: We observed a persistently higher systemic TNF expression associated with exacerbated TNF-alpha and interleukin-6 local production in patients with stents. This finding may contribute to a worse clinical outcome.

Persistent Inflammatory Activity in Blood Cells and Artery Tissue from Patients with Previous Bare Metal Stent.

BACKGROUND: Studies have pointed out a higher mortality after coronary artery bypass surgery (CABG) in patients with stent. OBJECTIVE: To evaluate inflammatory markers in peripheral blood cells and in coronary artery tissue samples obtained during CABG in patients with stent compared to controls. METHODS: The case series consisted of two groups, one with previous stent implantation (n = 41) and one control (n = 26). The expression of the LIGHT, IL-6, ICAM, VCAM, CD40, NFKB, TNF, IFNG genes was analyzed in peripheral blood cells collected preoperatively. The coronary artery was evaluated for: interleukin-6, ICAM, VCAM, CD40, NFKB, TNF-alpha and IFN-gamma by immunohistochemistry. A total of 176 tissue samples were grouped for analysis in: A1- arteries with stent (n = 38); A2- native arteries from patients with stent in another artery (n = 68); and A3- arteries without stent from controls undergoing routinely CABG surgery (n = 70). A significance level of 0.05 was adopted. RESULTS: Patients with stent showed higher TNF (p = 0.03) and lower CD40 gene expression (p = 0.01) in peripheral blood cells than controls without stent. In coronary artery samples, the TNF-alpha protein staining was higher in the group A1, not only in the intima-media layer (5.16 ± 5.05 vs 1.90 ± 2.27; p = 0.02), but also in the adipose tissue (6.69 ± 3.87 vs 2.27 ± 4.00; p < 0.001). Furthermore, group A1 had a higher interleukin-6 protein staining in adipose tissue than group A3 (p = 0.04). CONCLUSION: We observed a persistently higher systemic TNF expression associated with exacerbated TNF-alpha and interleukin-6 local production in patients with stents. This finding may contribute to a worse clinical outcome.

Mortality Predictors in the Surgical Treatment of Active Infective Endocarditis.

INTRODUCTION: Active infective endocarditis is associated with high morbidity and mortality. Surgery is indicated in high-risk conditions, and the main determinants of mortality in surgical treatment should be evaluated. OBJECTIVE: To identify mortality predictors in the surgical treatment of active infective endocarditis in a long-term follow-up. METHODS: This prospective observational study involved 88 consecutive patients diagnosed with active infective endocarditis, who underwent surgery between January 2005 and December 2015. Fifty-eight (65.9%) patients were male, the mean age was 50.87±16.15 years. A total of 31 (35.2%) patients had a history of rheumatic fever; 48 (54.5%) had had heart surgery with prosthetic valve implantation; 45 (93.8%) had biological prosthetic valve endocarditis and 3 (6.3%) mechanical prosthetic valve; 40 (45.5%) patients had the disease in their native valve. The mean EuroSCORE II was 8.9±6.5%, and the main surgical indication was refractory heart failure in 38 (43.2%) patients. A total of 68 bioprosthesis (36 aortic, 32 mitral) and 29 mechanical prostheses (12 aortic, 17 mitral) were implanted and three mitral valve plasties performed. A total of 25 (28.4%) patients underwent double or triple valve procedures. Aortic annulus reconstruction by abscess was performed in 18 (20.5%) and six (6.81%) patients had combined procedure. The mean surgery time was 359±97.6 minutes. RESULTS: The overall survival in up to a 10-year follow-up period was 79.5%. In the univariate analysis, the main mortality predictors were positive blood cultures (P=0.003), presence of typical microorganisms (P=0.008), most frequently Streptococcus viridans (12 cases; 25%); C-reactive protein (hazard ratio [HR] 1.034, 95% confidence interval [CI] 1.000 to 1.070, P=0.04); creatinine clearance (HR 0.977, 95% CI 0.962 to 0.993, P=0.005); length of surgery: every five minutes multiplies the chance of death 1.005-fold (HR 1.005, 95% CI 1.001 to 1.009, P=0.0307); age (HR 1.060, 95% CI 1.026 to 1.096, P=0.001); and EuroSCORE II (HR 1.089, 95% CI 1.030 to 1.151, P=0.003). CONCLUSION: A positive blood culture with typical microorganism, C-reactive protein, age, EuroSCORE II, total surgical time and the presence of postoperative complications were the major predictors of mortality and significantly impacted survival in up to a 10-year follow-up period.

Mortality predictors in the surgical treatment of active infective endocarditis

Abstract Introduction: Active infective endocarditis is associated with high morbidity and mortality. Surgery is indicated in high-risk conditions, and the main determinants of mortality in surgical treatment should be evaluated. Objective: To identify mortality predictors in the surgical treatment of active infective endocarditis in a long-term follow-up. Methods: This prospective observational study involved 88 consecutive patients diagnosed with active infective endocarditis, who underwent surgery between January 2005 and December 2015. Fifty-eight (65.9%) patients were male, the mean age was 50.87±16.15 years. A total of 31 (35.2%) patients had a history of rheumatic fever; 48 (54.5%) had had heart surgery with prosthetic valve implantation; 45 (93.8%) had biological prosthetic valve endocarditis and 3 (6.3%) mechanical prosthetic valve; 40 (45.5%) patients had the disease in their native valve. The mean EuroSCORE II was 8.9±6.5%, and the main surgical indication was refractory heart failure in 38 (43.2%) patients. A total of 68 bioprosthesis (36 aortic, 32 mitral) and 29 mechanical prostheses (12 aortic, 17 mitral) were implanted and three mitral valve plasties performed. A total of 25 (28.4%) patients underwent double or triple valve procedures. Aortic annulus reconstruction by abscess was performed in 18 (20.5%) and six (6.81%) patients had combined procedure. The mean surgery time was 359±97.6 minutes. Results: The overall survival in up to a 10-year follow-up period was 79.5%. In the univariate analysis, the main mortality predictors were positive blood cultures (P=0.003), presence of typical microorganisms (P=0.008), most frequently Streptococcus viridans (12 cases; 25%); C-reactive protein (hazard ratio [HR] 1.034, 95% confidence interval [CI] 1.000 to 1.070, P=0.04); creatinine clearance (HR 0.977, 95% CI 0.962 to 0.993, P=0.005); length of surgery: every five minutes multiplies the chance of death 1.005-fold (HR 1.005, 95% CI 1.001 to 1.009, P=0.0307); age (HR 1.060, 95% CI 1.026 to 1.096, P=0.001); and EuroSCORE II (HR 1.089, 95% CI 1.030 to 1.151, P=0.003). Conclusion: A positive blood culture with typical microorganism, C-reactive protein, age, EuroSCORE II, total surgical time and the presence of postoperative complications were the major predictors of mortality and significantly impacted survival in up to a 10-year follow-up period.

Long-term Mortality Predictors in Patients with Small Aortic Annulus Undergoing Aortic Valve Replacement with a 19- or 21-mm Bioprosthesis.

Introduction: Replacement of the aortic valve in patients with a small aortic annulus is associated with increased morbidity and mortality. A prosthesis-patient mismatch is one of the main problems associated with failed valves in this patient population. Objective: To evaluate the long-term mortality predictors in patients with a small aortic annulus undergoing aortic valve replacement with a bioprosthesis. Methods: In this retrospective observational study, a total of 101 patients undergoing aortic valve replacement from January 2000 to December 2010 were studied. There were 81 (80.19%) women with a mean age of 52.81±18.4 years. Severe aortic stenosis was the main indication for surgery in 54 (53.4%) patients. Posterior annulus enlargement was performed in 16 (15.8%) patients. Overall, 54 (53.41%) patients underwent concomitant surgery: 28 (27.5%) underwent mitral valve replacement, and 13 (12.7%) underwent coronary artery bypass graft surgery. Results: Mean valve index was 0.82±0.08 cm(2)/m(2). Overall, 17 (16.83%) patients had a valve index lower than 0.75 cm(2)/m(2), without statistical significance for mortality (P=0.12). The overall 10-year survival rate was 83.17%. The rate for patients who underwent isolated aortic valve replacement was 91.3% and 73.1% (P=0.02) for patients who underwent concomitant surgery. In the univariate analysis, the main predictors of mortality were preoperative ejection fraction (P=0.02; HR 0.01) and EuroSCORE II results (P=0.00000042; HR 1.13). In the multivariate analysis, the main predictors of mortality were age (P=0.01, HR 1.04) and concomitant surgery (P=0.01, HR 5.04). Those relationships were statistically significant. Conclusion: A valve index of < 0.75 cm(2)/m(2) did not affect 10-year survival. However, concomitant surgery and age significantly affected mortality.

Long-term mortality predictors in patients with small aortic annulus undergoing aortic valve replacement with a 19- or 21-mm bioprosthesis

Abstract Introduction: Replacement of the aortic valve in patients with a small aortic annulus is associated with increased morbidity and mortality. A prosthesis-patient mismatch is one of the main problems associated with failed valves in this patient population. Objective: To evaluate the long-term mortality predictors in patients with a small aortic annulus undergoing aortic valve replacement with a bioprosthesis. Methods: In this retrospective observational study, a total of 101 patients undergoing aortic valve replacement from January 2000 to December 2010 were studied. There were 81 (80.19%) women with a mean age of 52.81±18.4 years. Severe aortic stenosis was the main indication for surgery in 54 (53.4%) patients. Posterior annulus enlargement was performed in 16 (15.8%) patients. Overall, 54 (53.41%) patients underwent concomitant surgery: 28 (27.5%) underwent mitral valve replacement, and 13 (12.7%) underwent coronary artery bypass graft surgery. Results: Mean valve index was 0.82±0.08 cm2/m2. Overall, 17 (16.83%) patients had a valve index lower than 0.75 cm2/m2, without statistical significance for mortality (P=0.12). The overall 10-year survival rate was 83.17%. The rate for patients who underwent isolated aortic valve replacement was 91.3% and 73.1% (P=0.02) for patients who underwent concomitant surgery. In the univariate analysis, the main predictors of mortality were preoperative ejection fraction (P=0.02; HR 0.01) and EuroSCORE II results (P=0.00000042; HR 1.13). In the multivariate analysis, the main predictors of mortality were age (P=0.01, HR 1.04) and concomitant surgery (P=0.01, HR 5.04). Those relationships were statistically significant. Conclusion: A valve index of < 0.75 cm2/m2 did not affect 10-year survival. However, concomitant surgery and age significantly affected mortality.

A new classification of post-sternotomy dehiscence.

The dehiscence after median transesternal sternotomy used as surgical access for cardiac surgery is one of its complications and it increases the patient's morbidity and mortality. A variety of surgical techniques were recently described resulting to the need of a classification bringing a measure of objectivity to the management of these complex and dangerous wounds. The different related classifications are based in the primary causal infection, but recently the anatomical description of the wound including the deepness and the vertical extension showed to be more useful. We propose a new classification based only on the anatomical changes following sternotomy dehiscence and chronic wound formation separating it in four types according to the deepness and in two sub-groups according to the vertical extension based on the inferior insertion of the pectoralis major muscle.

A new classification of post-sternotomy dehiscence / Uma nova classificação das deiscências após esternotomias

The dehiscence after median transesternal sternotomy used as surgical access for cardiac surgery is one of its complications and it increases the patient's morbidity and mortality. A variety of surgical techniques were recently described resulting to the need of a classification bringing a measure of objectivity to the management of these complex and dangerous wounds. The different related classifications are based in the primary causal infection, but recently the anatomical description of the wound including the deepness and the vertical extension showed to be more useful. We propose a new classification based only on the anatomical changes following sternotomy dehiscence and chronic wound formation separating it in four types according to the deepness and in two sub-groups according to the vertical extension based on the inferior insertion of the pectoralis major muscle.

A deiscência após a esternotomia transesternal mediana utilizada em cirurgia cardíaca é uma de suas complicações e provoca o aumento da morbidade e mortalidade dos pacientes. Várias técnicas cirúrgicas têm sido descritas para o seu tratamento, o que contribuiu para aumentar a importância da classificação destas deiscências. Os métodos de classificação inicialmente descritos se baseavam na infecção do sítio cirúrgico, entretanto, é cada vez mais clara a relevância da descrição exata da localização e a extensão da área cruenta resultante como parâmetros para definição da técnica cirúrgica a ser escolhida. Neste relato é sugerida uma nova classificação baseada somente nas alterações anatômicas das feridas que as classifica em quatro tipos, de acordo com a profundidade, e em dois subgrupos, de acordo com a sua extensão vertical, tendo como referência a inserção da margem inferior do músculo peitoral maior.

Assessment of sternal closure using titanium plate.

INTRODUCTION: The use of plates and screws for more rigid fixation of the sternum, without maintaining contact between the upper portion of the sternum and mediastinum. The present study seeks new choice of plate with a significant difference, the same does not need to be removed in order to proceed to open when necessary sternal emerging opening of the bone. OBJECTIVE: The current study aims to evaluate the efficacy and safety of this procedure. METHODS: To this end, we selected ten patients with coronary artery disease have shown no significant risk factors for mediastinitis. The surgery was thus performed in the usual way that all patients with coronary artery disease surgeries are done at the institution. Only at the time of sternal closure is that there was a change, with the combination of steel wires and plates. RESULTS: All cases had sternal closure properly with good outcome in the medium term. CONCLUSION: The use of plates ENGIMPLAN proved safe and effective for sternal closure.

Assessment of sternal closure using titanium plate / Avaliação do fechamento esternal com placa de titânio

INTRODUCTION: The use of plates and screws for more rigid fixation of the sternum, without maintaining contact between the upper portion of the sternum and mediastinum. The present study seeks new choice of plate with a significant difference, the same does not need to be removed in order to proceed to open when necessary sternal emerging opening of the bone. OBJECTIVE: The current study aims to evaluate the efficacy and safety of this procedure. METHODS: To this end, we selected ten patients with coronary artery disease have shown no significant risk factors for mediastinitis. The surgery was thus performed in the usual way that all patients with coronary artery disease surgeries are done at the institution. Only at the time of sternal closure is that there was a change, with the combination of steel wires and plates. RESULTS: All cases had sternal closure properly with good outcome in the medium term. CONCLUSION: The use of plates ENGIMPLAN proved safe and effective for sternal closure.

INTRODUÇÃO: A utilização de placas e parafuso para a mais rígida fixação do esterno, sem manter contato entre a porção superior do esterno e o mediastino. O estudo atual busca nova opção de placa, com um diferencial importante; a mesma não precisa ser retirada para que se proceda à abertura esternal em caso de necessidade emergente de abertura do osso. OBJETIVO: O presente estudo tem por objetivo avaliar a eficácia e a segurança de tal procedimento. MÉTODOS: Para tal, foram selecionados dez pacientes portadores de doença arterial coronária que não apresentassem importantes fatores de risco para mediastinite. As cirurgias foram, portanto, realizadas da maneira habitual, a todas os procedimentos em portadores de coronariopatias são feitas na Instituição. Somente no momento do fechamento esternal é que houve uma modificação, com a associação de fios de aço e placas. RESULTADOS: Todos os casos apresentaram fechamento esternal de forma adequada com boa evolução a médio prazo. CONCLUSÃO: O emprego das placas ENGIMPLAN se mostrou seguro e eficaz no fechamento esternal.

Use of the pectoralis major fasciocutaneous flap in the treatment of post sternotomy dehiscence: a new approach / Utilização do retalho fasciocutâneo do músculo peitoral maior na deiscência de esternotomia: uma nova abordagem

OBJECTIVE: To describe a new surgical technique for the treatment dehiscence after median thoracotomy transsternal using fasciocutaneous flap composed of the pectoralis major fascia. METHODS: Between January 2009 and December 2010, from 1,573 patients submitted to coronary artery bypass graft, 21 developed wound dehiscence after sternotomy and were treated with bilateral pectoralis major muscle fasciocutaneous flap, including partial portion of the rectus abdominis fascia. Patients were followed for a minimum of 90 days postoperatively. RESULTS: All patients had favorable outcome following 90 days, not having any partial or total dehiscence. There were no cases of postoperative infection. CONCLUSION: The procedure was rapid and effective. Compared with techniques using muscle, myocutaneous or greater omentum flaps, this surgery was less aggressive and maintained the integrity of tissue region. The authors considered that this technique should be used as the first option, leaving the flaps to more complex cases of relapse.

OBJETIVO: Descrever uma nova técnica cirúrgica para a reparação das deiscências pós-toracotomia mediana transesternal com o uso de retalho composto fasciocutâneo da fáscia do músculo peitoral maior. MÉTODOS: Entre janeiro de 2009 e dezembro de 2010, de um total de 1.573 cirurgias de revascularização do miocárdio, 21 pacientes que apresentaram deiscência da esternotomia foram submetidos à correção com retalho fasciocutâneo bilateral do músculo peitoral maior, incluindo parcialmente a fáscia do músculo reto abdominal. Os pacientes foram acompanhados por um mínimo de 90 dias de período pós-operatório. RESULTADOS: Todos os pacientes apresentaram evolução favorável no seguimento de 90 dias, não ocorrendo nenhuma parcial ou total da deiscência. Não houve nenhum caso de infecção pós-operatória. CONCLUSÃO: Este procedimento mostrou ser rápido e efetivo. Comparando com o uso de retalhos musculares, musculocutâneos ou de omento, foi uma cirurgia menos agressiva e que manteve a integridade dos tecidos da região. Considerou-se que essa técnica deveria ser utilizada como primeira opção, deixando os retalhos mais complexos para os casos de recidivas.

Use of the pectoralis major fasciocutaneous flap in the treatment of post sternotomy dehiscence: a new approach.

OBJECTIVE: To describe a new surgical technique for the treatment dehiscence after median thoracotomy transsternal using fasciocutaneous flap composed of the pectoralis major fascia. METHODS: Between January 2009 and December 2010, from 1,573 patients submitted to coronary artery bypass graft, 21 developed wound dehiscence after sternotomy and were treated with bilateral pectoralis major muscle fasciocutaneous flap, including partial portion of the rectus abdominis fascia. Patients were followed for a minimum of 90 days postoperatively. RESULTS: All patients had favorable outcome following 90 days, not having any partial or total dehiscence. There were no cases of postoperative infection. CONCLUSION: The procedure was rapid and effective. Compared with techniques using muscle, myocutaneous or greater omentum flaps, this surgery was less aggressive and maintained the integrity of tissue region. The authors considered that this technique should be used as the first option, leaving the flaps to more complex cases of relapse.