Article

lock Open Access lock Peer-Reviewed

0

Views

ARTIGO ORIGINAL

Substituição isolada da valva aórtica em pacientes com função ventricular deprimida

Gilberto Venossi BarbosaI; Blau F. de SouzaII; Nei A ReyII; Orlando Carlos WenderIII; Pedro Pimentel FilhoII; Sílvia Regina Rios VieiraI; Hilário WolmeisterI; Waldomiro C ManfroiIII; Paulo P WestphalenI

DOI: 10.1590/S0102-76381989000300003

RESUMO

Para avaliar o valor prognóstico da fração de ejeção do ventrículo esquerdo, entre 210 pacientes com lesões da valva aórtica operados, consecutivamente, entre maio de 1981 e outubro de 1988 e que receberam as próteses Omniscience e Meditronic-Hall, foram selecionados 112 e divididos, de acordo com a fração de ejeção do ventrículo esquerdo, em dois grupos: o G1 = FE > 40%, ficou com 52 pacientes com médias de idade 39 ± 12 anos, FE = 58 ± 10% e classe funcional (NYHA) = 2,8; o GE = FE < 40% ficou com 60 pacientes com médias de idade 48 ± 17 anos, FE = 27 ± 13% e (NYHA) = 3,6. Nas cirurgias, foram utilizados hipotermia e hemodiluição moderadas, oxigenador de bolhas, infusão cardioplégica St. Thomas. As médias dos tempos de circulação extracorpórea e parada cardíaca foram: no G1 =8 2 ± 18 e 49 ±7 minutos, e 96 ± 11 e 55 ± 6 minutos, no Grupo 2; o tamanho das próteses foi 25,2 ± 1,8 milímetros. No Grupo 1, a mortalidade imediata foi 3,8% no G1 e 5,8 no G2, e a tardia 4% no G1, e no G2 foi 8,7%. No G1 houve significante associação entre a mortalidade e a função ventricular sistólica. Clínicamente, no G1, 65% dos pacientes estão na (NYHA) I, 28% na II, 5% na III e 2% na IV. No G2, 46% estão na (NYHA) I, 25% na II, 13% na III, e 16% na IV. A sobrevida atuarial em sete anos foi 88 ± 2% no G1 e 76 ± 4% no G2. Portanto, os pacientes com FE < 40% apresentaram mortalidade mais elevada, menor sobrevida a curto e longo prazo e resultados clínicos menos satisfatórios. Para obtermos melhores resultados, devemos operar antes que a FE em repouso e exercício se torne deprimida, ou que apareça intolerância ao exercício moderado.

ABSTRACT

To evaluate the prognostic value of resting left ventricular ejection fraction (LVEF) a series of 210 consecutive patients with aortic valve disease operated upon between May 1981 and October 1988 was studied retrospectively. All patients had their aortic valve replaced by Omniscience or Meditronic prosthesis; 112 formed the study group because they have complete follow up and cineangiocardiographic data. Based on pre-operatory left ventricular ejection fraction the patients were divided in two groups: Group 1 = 52 patients with LVEF > 40%, 39 ± 12 years, NYHA functional class 2.8, and EF 58 ± 10%. Group 2 = 60 patients with LVEF < 40, 48 ± 17 years, NYHA functional class 3.6, and LVEF of 27 ± 12%. During surgery moderate hypothermia and hemodilution were utilized, with dubble oxygenator and cardioplegia With St. Thomas cardioplegic solution. Mean extracorporeal circulation and cardiac arrest time were respectively 82 ± 18 and 49 ± 7 minutes in Group 1 and 96 ± 11 and 55 ± 6 minutes in Group 2. The size of the prosthesis were 25.2 ± 1.8 mm in Group 1. The short term mortality was 3.8% in Group 1 and 5.8 in Group 2. The long-term mortality was 4.0% in Group 1 and 8.7% in Group 2. In Group 1 there was a significant association between mortality and left ventricular systolic function. In the follow-up evaluation, among patients in Group 1, 65% were in class I, 28% were in functional class II, 5% in class III, and 2% in class IV. Among patients in group II 46% were in class I, 25% in class II, 13% in class III, and 16% in class IV. The 7 year survival rate was 88 ± 2% in Group 1 and 76 ± 4% in Group 2. Thus, patients with LVEF less than 40% had higher short and longterm mortality and worse clinical course. For better surgical results patients with aortic valve disease should be operated upon before the reduction of left ventricular systolic function.
Texto completo disponível apenas em PDF.

REFERÊNCIAS

1. ADAMS, P. X.; CUNNINGHAM, J. N.; ITRELANIN, K.; BRAZIER, J. R.; REED, G. E.; SPENCER, F. C. - Clinical experience using potassium induced cardioplegia with hipothermia in aortic valve replacement. J. Thorac. Cardiovasc. Surg., 75: 564-568, 1978. [MedLine]

2. ANDERSON, R. & CRUMBLEY, A. J. - Ventricular function in surgical patients. Ann. Thorac. Surg., 35: 1-2, 1983. [MedLine]

3. BONOW, R. O.; DODD, J. T.; MARON, B. J.; O'GARA, P. T.; WHITE, G. G.; McINTOSH, C. L.; CLARK, R. E.; EPSTEIN, S. E. - Long-term serial changes in left ventricular function and reversal of ventricular dilatation after valve replacement for chronic aortic regurgitation. Circulation, 78: 1108-1120, 1988. [MedLine]

4. BONOW, R. O.; ROSING, D. R.; MARON, B. J.; McINTOSH, C. L.; JOWES, M.; BACHARACH, S. L.; GREEN. M. V.; CLARK, R. E.; EPSTEIN, S. E. - Reversal of left ventriculr dysfunction after aortic valve replacement for chronic aortic regurgitation: influence of duration of preoperative left ventricular dysfunction. Circulation, 70: 570-579. 1984. [MedLine]

5. BORER, J. S.; ROSING, D. R.; KENT, K. M.; BACHARACH, S. L.; GREEN. M. V.; McINTOSH, C. J.; MORROW, A. G. ; EPSTEIN, S. E. - Left ventricular function at rest and during exercise after aortic valve replacement in patients with aortic regurgitation. Am. J. Cardiol., 44: 1297-1305, 1979. [MedLine]

6. CARABELLO, B. A.; WILLIAMS, H.; GASH, A.; KENT. R.; BELBER, D.; MAURER, A.; SIEGEL, J.; BLASIUS, K.; SPANN, J. F. - Hemodynamic predictors of outcome in patients undergoing valve replacement. Circulation, 74: 1309-1316, 1986. [MedLine]

7. CHRISTAKIS. G.; WEISEL, R. D.; DAVID, T. E.; SALERNO, T. A.; IVANOV, J. - Predictors of operative survival after valve replacement. Circulation, 78 (Supl. 1): 25-34, 1988. [MedLine]

8. CHRISTAKIS. G.; WEISEL, R. D.; FREMES, S. E.; TEOH, K. H.; SKALENDA, J. P.; TONG, C. P.; AZUMA, J. Y.; SCHWARTZ. L.; MICKLEBOROUEH, L. L.; SCULLY, H.; GOLDMAN, B. S.; BAIRD. R. J. - Can the results of contemporary aortic valve replacement be improved? J. Thorac. Cardiovasc. Surg., 92: 37-46, 1986. [MedLine]

9. CLARK, D. G.; MACANULTY, J. H.; RAHIMTOOLA, S. H. - Valve replacement in aortic insufficiency with left ventricular dysfunction. Circulation, 61: 411-419, 1980.

10. CRAVER. J. M.; WEINTRAUB, W. S.; JONES. E. L.; GUYTON, R. A.; HALCHER, C. R. - Predictors of mortality, complications, and lenght of story in aortic valve replacement for aortic stenosis. Circulation, 78 (Supl. 1): 85-90, 1988.

11. DeWALL, R. A.; SCHUSTER. B.; HICKS Jr., G. PELLETIER, C.; BONAN, R.; MARTINEU, J. P.; PANEBLANCO, A.; YIP, L. - Seventy-six month-experience with the Omniscience cardiac valve. - J. Cardiovasc. Surg., 28: 328-332, 1987.

12. DILWORTH, L. R.; AISEN, A. M.; MANCINI, G. B. J.; LANDE, I.; BUDA, A.; MICH, A. A. - Determination of left ventricular volumes and ejection fraction by nuclear magnetic resonance imaging. Am. Heart J.,, 112: 24-32, 1987.

13. DODGE, H. T.; SANDLER, H.; BALLEW, D. W.; LORD Jr., J. D. - The use of byplane angiocardiography for the measurement of left ventricular volume in man. Am. Heart J., 60: 762-778, 1960.

14. DUBROFF, J. M.; CLARK, M. B.; WONG, C. Y. H.; SPOTNITZ, A. J.; COLLINS, R. H.; SPOTNITZ, H. M. - Left ventricular ejection fraction during cardiac surgery: a two-dimensional echocardiographic study. Circulation, 68: 95-103, 1983. [MedLine]

15. FISCHL, S. J.; GORLIN, R.; HERMAN, M. V. - Cardiac shape and function in aortic valve disease: physiologic and clinical implications. Am. J. Cardiol., 39: 170-176, 1977. [MedLine]

16. FORMAN, R.; FIRTH, B. G.; BARNARD, M. S. - Prognostic significance of preoperative left ventricular ejection fraction and valve lesion in patients with aortic valve replacement. Am. J. Cardiol., 45: 1120-1125, 1980. [MedLine]

17. GAASCHIW, W. H.; ANDRIAS, C. W.; LEVINE, H. J. - Chronic aortic regurgitation: the effect of aortic valve replacement on left ventricular volume, mass and function. Circulation, 58: 825-836, 1978. [MedLine]

18. GAULT, J. H.; COVELL, J. W.; BRAUNWALD, E.; ROSS Jr., J. - Left ventricular performance following correction of free aortic regurgitation. Circulation, 42: 773-784, 1970.

19. GREENE, D. G.; CARLISLE, R.; GRANT, C.; BUNNELL, I. L. - Estimation of left ventricular volume by oneplane cineangiography. Circulation, 35: 61 -74, 1967.

20. GRUNKMEIER, G. L. & STARR, A. - Actuarial analysis of surgical results: rationale and method. Ann. Thorac Surg., 24: 404-413, 1977.

21. HILDNER, F. J.; JAVIER, R. P.; COHEN, L. S.; SAMET, P.; NATHAN, M. J.; YAHR, W. Z.; GREENBERG, J. J. - Myocardial dysfunction associated with valvular heart disease. Am. J. Cardiol., 30: 319-328, 1972.

22. ISKANDRIAN, A. S.; HEO, J.; PA, P. - Radionuclide angiopgrahic evaluation of left ventricular performance at rest and during exercise in patients with aortic regurgitation. Am. Heart J., 111: 1143-1147, 1986.

23. KENNEDY, J. W.; TRENHOLME, S. E.; KASSER, I. S. - Experience and laboratory reports: left ventricular volume and mass from single-plane cineangiocardiogram: a comparison of anteroposterior and right anterior oblique methods. Am. Heart J., 80: 343-357, 1970.

24. LYTLE, B. W.; COSGROVE, D. M.; GILL, C. C.; TAYLOR, P. C.; STEWART, R. W.; GOLDING, L. A.; GOORMASTIC, M.; LOOP, F. D. - Aortic valve replacement combined with myocardial revascularization. J. Thorac. Cardiovasc. Surg., 95: 402-414, 1988. [MedLine]

25. MEHMEL, H. C.; OLSHAUSEM, K.; SCHULER, G.; SCHWARZ, F.; KUBLER, W. - Estimation of left ventricular myocardial function by the ejection fraction in isolated, chronic, pure aortic regurgitation. Am. J. Cardiol., 54: 610-616, 1984. [MedLine]

26. MONRAD, E. S.; HESS, O. M.; MURAKAMI, T.; MONOGI, M. D.; CORIN, W. J.; KRAYENBUEHL, H. P. - Abnormal exercise hemodynamics in patients with normal systolic function late after aortic valve replacement. Circulation, 77: 613-624, 1988. [MedLine]

27. PEIXOTO, E. S. C.; BARROS FILHO, C. M.; PONTES, A. C. P. S.; LEITE, A. A.; BRITO, A. H. X.; DOHMANN, H. J. F.; ABRÃO, C.; OLIVEIRA, P. S.; AMIND, J. G. C.; STUDART, P. C. C. - Correlação entre a clínica do paciente avaliada pela classe funcional e a função ventricular esquerda na insuficiência aórtica crônica: II. Estresses. Arq. Bras. Cardiol., 51: 231-237, 1988. [MedLine]

28. SALOMON, N. W.; STINSON, E. B.; OYER, P.; COPELAND, J. G.; SHUMWAY, N. E. - Operative treatment of congenital aortic stenosis. Ann. Thorac. Surg., 26: 452-460, 1978. [MedLine]

29. SANTINGA, J. T.; KIRSH, M. M.; BRADY, T. J.; THRALL, J.; PITT, B. - Left ventricular function in patients with ventricular arrhythmias and aortic valve disease. Ann. Thorac. Surg., 35: 152-154, 1983.

30. SCOTT, W.; MILLER, C.; HAVERICH, A.; DAWKINS, L.; MITCHELL, R. S.; JAMESON, S. W.; OYER, P. E.; STINSON, E. B.; BALDWIN, J. C.; SHUMWAY, N. - Determinations of operative mortality for patients undergoing aortic valve replacement. J. Thorac. Cardiovasc. Surg., 89: 400-413, 1985. [MedLine]

31. SCHWARZ, F.; FLAMENG, W.; SCHAPER, J.; LANGEBARTELS, F.; SESTO, M.; HEHRLEIN, F.; SCHLEPPER, M. - Myocardial structure and function in patients with aortic valve disease and their relation to postoperative results. Am. J. Cardiol., 41: 661-669, 1978. [MedLine]

32. STAREK, P. J. K.; BEAUDET, R.; HALL, K. - The Medtronic-Hall valve: development and clinical experience. Card. Surg., 1: 223-236, 1987.

33. TURINA, J.; TURINA, M.; ROTHLIN, M.; KRAYENBUEHL, H. P. - Improved late survival in patient with chronic aortic regurgitation by earlier operation. Circulation, 70 (Supl. 1): 147, 1984. [MedLine]

34. WISENBAUGH, T.; BOOTH, D.; DEMARIA, A.; MISSEN, S.; WATERS, J. - Relationship of contractile state to ejection performance in patients with chronic aortic valve disease. Circulation, 73: 47-53, 1986. [MedLine]

CCBY All scientific articles published at www.bjcvs.org are licensed under a Creative Commons license

Indexes

All rights reserved 2017 / © 2024 Brazilian Society of Cardiovascular Surgery DEVELOPMENT BY