[Partial median sternotomy in H. A new approach for cardiac surgery]. / Esternotomia parcial mediana em H. um novo acesso para a cirurgia cardíaca.

PURPOSE: To present our results with the minimally invasive thoracotomy (MIT) in patients with valve disease and to describe a new type of thoracotomy. METHODS: Twenty-five patients with valve disease as the major cardiac problem were operated during a five month period. Two types of incisions were used: one in an inverted-T fashion and another in a H fashion. Fourteen patients were submitted to an inverted-T incision and eleven to a H incision. In 24% of the patients reoperation was being performed. RESULTS: The incisions ranged from 7.5 to 11 cm (mean 9.1 cm), mean ICU stay was 31 h and hospital stay 4.8 days. In all but one patient the operation could be adequately in performed through the MIT, in only one patient total sternotomy had to be performed. CONCLUSION: The MIT may have some advantages such as, better aesthetic results, less pain and more sternal stability. These factors may improve early extubation and decrease hospital stay. The H type incision allows an adequate exposition of the most central part of the chest and all heart valves with adequate exposure. This technique led to no complications during reoperations and we believe it to be as safe as the total sternotomy.

Bilateral carotid endarterectomy combined with myocardial revascularization during the same surgical act.

The best surgical approach for the treatment of patients with severe cerebral artery disease and simultaneous serious coronary artery disease still remains controversial. In this report we present a case of a 72-year-old female patient admitted to the hospital with unstable angina. Triple coronary artery obstructive disease and severe bilateral carotid artery stenosis were diagnosed. A combined, simultaneous surgical procedure was performed. After total circulatory by-pass with a membrane oxygenator, the patient's body temperature was lowered to 32 degrees C. During the cool-down period, three proximal anastomoses of segments of autologous saphenous veins were performed in the ascending aorta. Immediately afterwards, bilateral carotid endarterectomy was performed, followed by three distal anastomoses to coronary arteries. The patient showed a satisfactory post-operative outcome. It was concluded that the combination of moderate hypothermia, hemodilution with appropriate hemodynamic control, as used in this patient, was an effective method of cerebral protection. The simultaneous approach of carotid endarterectomy and coronary artery by-pass surgery should be seen as a safe option for the treatment of this type of patient.

[Inadvertent anastomosis to a coronary vein]. / Anastomose inadvertida para veia coronária.

The inadvertent revascularization of the anterior interventricular vein in patients with obstructive lesions of the anterior interventricular artery was the cause of recurrent angina in two patients. In one of the patients the bypass was performed with autogenous saphenous vein graft, in the other one the bypass was performed with the left internal thoracic artery. The reoperation was performed in one patient after one year and in the other one after five years from the first operation. In both cases the arteriovenous fistulas were interrupted and bypasses were performed using the left internal thoracic artery to the anterior interventricular arteries. The postoperative course was uneventful in both patients. In both patients the anterior interventricular arteries had intramyocardial course, what probably had lead into error during the first operation.

Total inversion of the left lung circulation: morphologic and functional analyses.

BACKGROUND: An experimental model for total inversion of left lung circulation was developed. With this model, the authors demonstrate that it is possible to reverse the pulmonary circulation and preserve the normal function and morphology of the lung. METHODS: Eight dogs had their left pulmonary circulation reversed. The blood from the pulmonary artery trunk was diverted to the pulmonary veins, and returned from the pulmonary artery into the left atrium. In order to monitor the flow through the reversed system, color Doppler echocardiography was performed on the ninth postoperative day. The dogs were reoperated after 15 days for re-evaluation. Blood gas analyses from the aorta and the pulmonary artery were used to study the functional status of the lung in both operations. The morphology was studied by comparing biopsies of the lung performed before and after reversal of flow. RESULTS: Blood gas analysis showed no significant difference between the samples of from the aorta and pulmonary artery. Color Doppler echocardiography was a reliable method for the study of the inverted circulation. The histological study showed no differences in the morphology of the lung after the reversed circulation. CONCLUSIONS: Left pulmonary circulation was fully reversed. Pulmonary function and morphology remained normal.

Esternotomia parcial mediana em H. Um novo acesso para a cirurgia cardíaca / Partial sternotomy in H. A new approach for cardiac surgery

OBJETIVO - Apresentar a nossa experiência com a toracotomia minimamente invasiva (TMI) em pacientes com doença valvar e descrever um novo tipo de toracotomia. MÉTODOS - Vinte e cinco pacientes com doença, como maior problema cardíaco, foram submetidos a operaçäo em um período de 5 meses. A incisäo utilizada foi uma TMI em duas formas, uma em T invertido e outra em H. Nesta série, as reoperaçöes constituíram 24 por cento. RESULTADOS - O tamanho da incisäo de pele variou de 7,5 a 11,0cm (média=9,1cm). O tempo de permanência médio na UTI foi de 31h e hospitalar de 4,8 dias. Em todos os pacientes a cirurgia pôde ser realizada apropriadamente através desse acesso, sendo que em apenas um, foi necessária esternotomia total. CONCLUSÄO - A TMI apresenta algumas vantagens, como melhor resultado estético, menos dor e maior estabilidade torácica. Estes fatores possibilitam uma extubaçäo precoce, diminuindo o tempo de internaçäo hospitalar. A esternotomia em H apresenta como grande benefício a exposiçäo da parte mais central do tórax, permitindo um melhor acesso a todas as valvas cardíacas. Esta técnica apresentou complicaçöes nas reoperaçöes, o que nos faz acreditar que seria täo segura quanto a esternotomia total.