RBCCV Brazilian Journal of Cardiovascular Surgery Revista Brasileira de Cirurgia Cardiovascular

Objective: To compare the effects of deep breathing exercises (DBE) and the flow-oriented incentive spirometry (IS) in patients undergone coronary artery bypass grafting (CABG) through the following variables: forced vital capacity - FVC, forced expiratory volume in 1 second - FEV1, maximal respiratory pressures and oxygen saturation. Methods: Thirty six patients in CABG postoperative period underwent thirty minutes of non-invasive ventilation during the first 24 hours after extubation and were randomly shared into two groups as following: DBE (n=18) and IS (n=18). The spirometric variables were assessed on the preoperative period and seventh postoperative day (POD). The respiratory muscle strength and oxygen saturation were assessed on the preoperative period, first, second and seventh POD. Results: The groups were considered homogeneous in relation to the demographic and surgical variables. It has been noted fall in the values of FVC and FEV1 between the preoperative period and the seventh POD, but without significant differences between groups. The maximal respiratory pressures showed drop in the first POD but with gradual and partial recovery until the seventh POD, also without significant differences between groups. The oxygen saturation was the only variable that was completely recovered on the seventh POD, also without significant differences between groups. Conclusion: There were not observed significant differences in maximal respiratory pressures, spirometric variables and oxygen saturation in patients undergone deep breathing exercises and flow-oriented incentive spirometry after coronary artery bypass grafting.

Keywords: Breathing exercises. Postoperative care. Physical therapy modalities. Postoperative complications. Coronary artery bypass.

Introduction: Acute and severe pain is frequent in patients who undergo cardiothoracic surgery. Patient controlled analgesia (PCA) can be used to manage postoperative pain. Objective: To compare analgesia of morphine PCA alone (without continous infusion) with morphine PCA plus a continuous infusion on postoperative period after cardiac surgery and to evaluate pain scores, morphine consumption, number of demand, patient satisfaction and side effects. Methods: Randomized trial was conducted to assess patients who underwent cardiac surgery receiving either morphine PCA alone or morphine PCA plus continous infusion. In the post operative period, PCA was started at extubation in both regiments according to randomization. Pain intensity, morphine consumption, number of demand, satisfaction and side effects were assessed at zero, six, twelve, eighteen, twenty four and thirty hours after patients' extubation. Results: The study enrolled 100 patients. 50 patients received morphine PCA alone, (Group A) and 50 patients received morphine PCA plus a background infusion, (Group B). Group B patients had less demand, consumed more morphine and were more satisfied regarding analgesia. No statistical differences were shown between groups related to pain intensity, and side effects. Conclusions: Pain control was effective and similar in both groups. Morphine PCA alone seems to be better for postoperative pain manage in cardiac surgery, due to its less morphine expense with the same effectiveness.

Keywords: Analgesia, Patient-Controlled. Cardiovascular surgical procedures. Postoperative care.

It is well known that anesthesia and certain surgeries predispose patients to changes in respiratory function, pulmonary volumes, and gas exchange. Cardiac surgery, which is considered a major surgery, may trigger respiratory complications in the postoperative period. These complications have various causes, such as heart and lung functions in the pre-operative, the use of cardiopulmonary bypass (CPB), and the level of sedation. In these extensive thoracic procedures, respiratory dysfunction may be significant, persisting in the postoperative period. Physiotherapy is offered to patients in the ICU as part of a multidisciplinary treatment plan. It is a time-consuming treatment, and is possible at various times during the patient's stay in the ICU. However, it is particularly valuable in postoperative recovery in order to avoid respiratory and motor complications. Thus, a literature review was performed, aiming to arrange current and relevant information on available resources for respiratory monitoring, as well as its importance in evaluating and treating lung function impairment, as this complication is a frequent cause of death in surgical patients.

Keywords: Thoracic surgery. Cardiac surgical procedures. Physical therapy. Postoperative care.

Lung complications during postoperative period of cardiac surgery are frequently, highlighting atelectasis and hypoxemia. Alveolar recruitment maneuvers have an important role in the prevention and treatment of these complications. Thus, this study reviewed and updated the alveolar recruitment maneuvers performance in the immediate postoperative period of cardiac surgery. We noted the efficacy of alveolar recruitment through different specific techniques and the need for development of new studies.

Keywords: Cardiac Surgical Procedures. Pulmonary Atelectasis. Positive-Pressure Respiration. Physical Therapy (Specialty). Postoperative Care.

The cardiovascular diseases are among the main death causes in the developed world. They have been increasing epidemically in the developing countries. In spite of several alternatives for the treatment of the coronary artery disease; the surgery of the myocardial revascularization is an option with proper indications of medium and long-term with good results. It provides the remission of the angina symptoms contributing to the increase of the expectation and improvement of the life quality. Most of patients undergoing myocardial revascularization surgery develop postoperative lung dysfunction with important reduction of the lung volumes, damages in the respiratory mechanism, decrease in the lung indulgence and increase of the respiratory work. The reduction of volumes and lung capacities can contribute to alterations in the gas exchanges, resulting in hypoxemia and decrease in the diffusion capacity. Taking this into account, the Physiotherapy has been requested more and more to perform in the pre as well as in the postoperative period of this surgery. This study aimed at updating the knowledge regarding the respiratory physiotherapy performance in the pre and postoperative period of the myocardial revascularization surgery enhancing the prevention of lung complications. The Physiotherapy uses several techniques in the preoperative period; such as: the incentive spirometry, exercises of deep breathing, cough, inspiratory muscle training, earlier ambulation and physiotherapeutic orientations. While in the postoperative period, the objective is the treatment after lung complications took place, performed by means of physiotherapeutic maneuvers and noninvasive respiratory devices, aiming at improving the respiratory mechanism, the lung reexpansion and the bronchial hygiene. Respiratory physiotherapy is an integral part in the care management of the patient with cardiopathy, either in the pre or in the postoperative period, since it contributes significantly to a better prognosis of these patients with the use of specific techniques.

Keywords: Physical Therapy (Specialty). Myocardial Revascularization. Preoperative Care. Postoperative Care.

INTRODUCTION: The application of two levels of ventilation by positive pressure (BiPAP^®) associated with conventional respiratory therapy (CRT) in postoperative periord of cardiac surgery may contribute to reduction of pulmonary complications.
OBJECTIVES: To evaluate the safety and compliance of preventive application of BiPAP^® CRT associated with immediate postoperative myocardial revascularization.
METHODS: 26 patients undergoing coronary artery bypass grafting were randomly allocated in one of the groups. Patients of the Control Group (CG) were treated only with conventional respiratory therapy, compared to BiPAP group (BG) (in addition to conventional respiratory therapy the patients were subjected to 30 minutes of ventilation by two levels twice a day). The conventional respiratory therapy was held in both groups, twice a day. All patients were evaluated for vital capacity, airway permeability, maximal respiratory pressures, oxygen saturation, heart rate, respiratory frequency, Volume Minute, tidal volume, systolic and diastolic blood pressure. Evaluations were performed during hospitalization preoperatively, immediately after extubation, 24h and 48h after extubation.
RESULTS: In CG 61.5% of patients had some degree of atelectasias, in comparison to 54% of BG (P=0.691). The vital capacity was higher in the GB postoperatively (P<0.015). All the other ventilometric, gasometric, hemodynamic and manometric parameters were similar between groups.
CONCLUSION: Coronary artery bypass grafting leads to deterioration of respiratory function postoperatively, and the application of positive pressure ventilation (BiPAP^®) may be beneficial to restore lung function more quickly, especially vital capacity, safely, and well accepted by patients due to greater comfort with the sensation of pain during the execution of respiratory therapy.

Keywords: Cardiovascular surgical procedures. Physical therapy modalities. Postoperative care. Pulmonary ventilation.

The authors discuss the different moments of the National Policy of High-complexity Cardiovascular Care, focusing on the attention to Cardiovascular Pediatrics. This process begun with the attempt to meet the local needs, but, very soon, became a national matter due to the verification of a significant shortage in the attention given to patients with congenital cardiovascular diseases. In 2002 the shortage of procedures in these cases was around 65%. The participation of different agents from the civil society and the Government will be demonstrated regarding the formulation of the politics directed to the attention to cardiovascular pediatrics. Some authors are cited during the discussion to base each moment of the process. The National Policy of High-complexity Cardiovascular Care was regulated on June 15th, 2004, through the Ministerial Directive No 1169/GM as well as the Pediatric Cardiovascular Surgery, on the same date, through the Ministerial Directive No 210 SAS/MS. The importance of the civil society participation in the elaboration of the public social politics is emphasized. The intervention of agents who experience the day-to-day difficulties is of the utmost importance to the better knowledge of questions involving the social area

Keywords: Child. Adolescent. Public policies. Cardiac surgical procedures/history. Heart defects, congenital.

A 22 year-old male patient was admitted with supracardiac, nonobstructive, total anomalous pulmonary venous connection and large atrial septal defect. Cardiac catheterization revealed severe pulmonary hypertension due to pulmonary overflow (Qp/Qs 6, pulmonary vascular resistance = 1.6 Woods/m2). Complete repair was performed through median sternotomy and cardiopulmonary bypass. The patient was discharged from hospital on the sixth postoperative day with no complications, using converting enzyme inhibitor and aspirin. At six-month follow-up he is currently asymptomatic, with preserved biventricular function and no echocardiographic signs of pulmonary hypertension.

Keywords: Heart defects, congenital. Hypertension, pulmonary. Pulmonary veins/abnormalities.

OBJECTIVE: The aim of this study is to describe our experience in aortic coarctation surgery in adult patients by assessing the immediate and mid-term outcomes. METHODS: From January 1987 to March 2000, 50 consecutive adult patients underwent surgery for correction of aortic coarctation, through left lateral thoracotomy. Of these, forty two (84%) patients presented high blood pressure, with mean systolic arterial pressure of 170.56 mmHg (125-220 mmHg). The mean of pressure gradient in the coarctation area was 51.4 mmHg (18-123 mmHg). Other associated surgical cardiovascular diseases were not treated in the same operative act, except in two cases of patent ductus arteriosus (PDA). Three different techniques were used: aortic coarctation resection with end-to-end anastomosis was performed in 20 (40%) patients, coarctation enlargement with bovine pericardial patch was performed in 22 (44%) patients and synthetic tube interposition was performed in eight (16%) patients. RESULTS: Operative morbidity was low; there was one case of bleeding who required reoperation. The most common immediate postoperative event was high blood pressure (98%), but it was easily controlled by intravenous drugs. There was no hospital death. Mean residual pressure gradient was 18.7 (8-33 mmHg). Patients were discharged in 9.5 days (5-30). Postoperative follow-up mean was 46.8 months (1-145 months) in 45 (91.8%) patients. Forty one (91.1%) of these followed-up patients had normal blood pressure, whereas 75.6% of them without drugs intake. 93.3% of these followed-up patients were asymptomatic. Four of them required further surgical operation, one needed a pacemaker implant, other two patients needed a cardiac valve replacement and one had endocarditis. There was one related death due to sepsis secondary to endocarditis. CONCLUSION: Surgical treatment of aortic coarctation, even in adult patients, is an efficient therapeutic choice, regardless of the applied surgical technique, with low morbidity and mortality. It reduces efficiently the arterial pressure levels in both immediate and mid-term follow-up

Keywords: Aortic coarctation/surgery. Aorta/surgery. Heart defects, congenital. Adult.

OBJECTIVE: Mitral valve insufficiency must be treated by repair whenever as possible as it provides better results - especially within the pediatric population in order to avoid valve replacement inconvenients. The aim of this study is to describe mitral valve repair technique based on an anatomical and functional approach. METHODS: During a 13 months period, eight children (age ranged from 2 and 12 years old 6.37 ± 3.66) with mitral valve insufficiency underwent intermittent anterior and posterior annuloplasty associated with Alfieri's repair - performed by placing a stitch between the anterior and posterior leaflets in the point of maximal regurgitation thus creating a double orificial mitral valve. RESULTS: There were no surgical deaths. All patients underwent postoperative echocardiography. Three patients showed mild mitral valve insufficiency and five patients showed no insufficiency. The time in intensive care unit ranged from 2 to 4 days (2.5 ± 0.75), and the time of stay in hospital ranged from 5 to 8 days (6.37 ± 1.06). CONCLUSION: In spite of the little sample size, the proposed technique proved itself to be simple and effective in the treatment of single mitral valve insufficiency within the pediatric population. In addition, it also yielded satisfactory immediate results. Long-term follow-up is nevertheless necessary in order to evaluate long-term results

Keywords: Heart defects,congenital. Child. Mitral valve.

Pulmonary artery coarctation often happens in patients with pulmonary atresia. The correction has been usually performed using cardiopulmonary bypass and during the neonatal period, influencing pulmonary artery development and prognosis. Three patients with pulmonary atresia with PDA underwent correction using median sternotomy without cardiopulmonary bypass. The PDA maintained the arterial saturation during Blalock Taussig anastomoses upon the contralateral pulmonary artery. Arterioplasty was performed using an autologous pericardium with 7-0 PDS running suture and saturation was maintained by Blalock shunt. All patients presented good follow-up and where discharged with good enlargment of coarctation area.

Keywords: Pulmonary artery. Pulmonary atresia. Heart defects, congenital. Extracorporeal circulation. Pulmonary circulation.

The single suture technique was developed to obtain stabilization and exposure of all all coronary branches during off-pump coronary artery bypass, while maintaining hemodynamic stabilily during the procedure. We describe the use of this technique during an off-pump correction of a coronary artery fistula associated with right coronary dilatation. The suggested technique is quicker and less complex than on-pump surgery. Furthermore, it can be a useful tool for congenital fistula correction in select cases, stimulating the practice of less invasive heart surgery in these patients.

Keywords: Cardiopulmonary Bypass. Arteriovenous Fistula. Coronary Artery Disease. Congenital Abnormalities. Heart Defects, Congenital.

BACKGROUND: Hospital mortality for surgical reconstruction of the outflow of the right ventricle with pulmonary homograft is variable. OBJECTIVES: To identify risk factors associated with hospital mortality and clinical profile of patients. METHODS: Children underwent reconstruction of the outflow tract of right ventricle with pulmonary homograft. Analyzed as risk factors for the clinical, surgical and morphological aspects of the prosthesis. RESULTS: Ninety-two patients operated on between 1998 and 2005 presented mainly pulmonary atresia with ventricular septal defect and tetralogy of Fallot. Forty patients were treated in the first month of life. He needed 38 surgeries to Blalock Taussig due to clinical severity. The median age at surgery for total correction was 22 months, ranging from 1 to 157 months. Size pulmonary homograft ranging from 12 to 26 mm and length of bypass was 132 ± 37 minutes. After surgery there were seventeen deaths (18% cases) on average 10.5 ± 7.5 days. The predominant cause was multiple organ failure. In the univariate analysis between the types of heart disease, they found in favor of age at surgery, size of homograft, pulmonary valve Z value, CPB time, maintaining the integrity of the homograft and pulmonary tree change. There was no statistical differencein hospital mortality between the variables and the type of heart disease. CONCLUSION: The congenital obstructive right requires surgical care in the first days of life. The total correction surgery has a risk rate of 18% but there was no association with any variable studied

Keywords: Heart defects, congenital. Cardiovascular surgical procedures. Transplantation, homologous. Mortality.

INTRODUCTION: Early extubation is related to short lenth of hospitalization and less complications. OBJECTIVE: Data analisys from children extubated atsurgical room after cardiac surgery with ECC. METHODS: Retrospective data analisys. Results: From March 2006 to January 2008, 15 children submitted to heart surgery were extubated at surgery room. Age in months was 4 to 216 (76.1 months). ECC time: 30 to 95 min (51.4 min), anoxia: 14 to 67 min (35.2 min). One patient had respiratory acidosis. CONCLUSION: Early extubation in seleted patients is possible.

Keywords: Extracorporeal circulation/methods. Anesthesia. Heart defects, congenital.

INTRODUCTION: The present report describes the technique for "inverted L" upper ministernotomy with central canulation for the treatment of simple congenital cardiopathies and presents the initial results. METHODS: Ten patients (mean age: 7 ± 4.2 years; mean weight 29.1 ± 13.5 kg) were operated on between January 2006 and July 2007. RESULTS: All defects were corrected. No death was observed and no complication that required reintervention occurred. CONCLUSION: The described technique showed to be feasible and safe for the correction of certain congenital cardiopathies, with less surgical trauma, besides the aesthetic benefit and an expectation of diminished thoracic deformity in the future.

Keywords: Cardiovascular surgical procedures/methods. Hemostatic techniques. Heart defects, congenital.

Stimulated by the challenge of updating and organizing all the information acquired in the health field, computer medicine has developed on a wide global scale. The recent success of the Internet for distribution of information has created a need for the production and distribution of medical programs for use via this network. The creation of a decision-making program through the World Wide Web for congenital heart diseases could provide updated information for cardiac surgeons, pediatricians and cardiologists involved in patient management. The objectives of this project were the following: - to create a of decision-making model in pediatric cardiac surgery using Tricuspid Atresia, a complex congenital heart disease, as an example; - to evaluate the complexity of the creation of this model and the benefits of using the computer and the Web Interface; - to test its validity in 16 cases treated at the "Universidade Federal de São Paulo" (UNIFESP) between 1980 and March 1997. Using suitable hardware and HTML program language, this program was developed using a group of the texts; 7 pictures and 37 images. During creation of this program, the possibility of its easy development and rapid updating was demonstrated. The validation analysis showed a significant agreement (91.7%) with the surgical indication performed by specialists at the UNIFESP.

Keywords: Heart defects, congenital. Tricuspid atresia. Decision making, computer assisted. Internet.

Objective: To compare patients submitted to the conventional ultrafiltration (CUF) with and without a technical modification that allows use of residual blood from the circuit tubes and oxygenator. Method: From March 2002 to January 2005, 301 patients undergoing to congenital heart defects surgery with cardiopulmonary bypass (CPB) were retrospectively analyzed and divided in two groups: Group A - 130 submitted to CUF and Group B, 171 patients submitted to CUF with a technical modification that uses residual blood. Demographic data, diagnosis, surgical treatment, intra-operative and postoperative data, the need and amount of blood transfusions, laboratorial results and length of hospital stay were compared between the groups. Results: There was no differences in the initial hematocrit before CPB (p = 0.06), but in the Group B, the values after ultrafiltration were higher (p <0.0001). Group B patients received more transfusions in the first 48 hours of the postoperative period (p <0.0001). There was no signicant difference in the time of mechanical ventilation (p = 0.34), but the inotropic support (p <0.0001), antibiotic therapy (p = 0.0006), length of stay in the intensive care unit (p <0.0001) and length of hospital stay (p <0.0001) were greater for Group B. Conclusions: CUF with the technical modification was not better than conventional CUF, because in spite of elevating the hematocrit after the CBP, it caused greater postoperative bleeding with a greater need of blood transfusions and longer hospitalar stays.

Keywords: Ultrafiltration. Extracorporeal circulation. Heart defects, congenital.

Objective: Patients with functional single ventricle show bad survey, most of which result in cardiac failure even in the case that they are operated. The right heart bypass operations except for right atrium and right ventricle connections lack pulsatile pulmonary ventricle system besides the volume lack coming to the common ventricle. To solve the problem, we tried to create a pulmonary ventricle which produces pulsatile pressure experimentally. Methods: We tried to form a right ventricle system which produces pulsatile pressure. The experimental model was carried on six sheep. The pressures of the created pulmonary ventricle, pulmonary artery and the left ventricle were measured after leaving the cardiopulmonary bypass. Results: The mean of the systolic and diastolic pulmonary artery pressures were 15,6 ± 2.0 mmHg and 4.5 ± 1.5 mmHg. The mean of the left ventricular systolic pressure was mean 76.6 ± 4.4 mmHg. Conclusion: A ventricle producing pulsatile pressure is necessary for regulating the pulmonary artery flow with high central venous pressure and low non-pulsatile pulmonary pressure in the anomalies with functional single ventricles.

Keywords: Heart ventricles, abnormalities. Heart defects, congenital. Heart bypass, right.

This study aims to gather and present scientific evidence on the role of a physiotherapist in the pre, peri and postoperative of pediatric cardiac surgery. This professional is able to prevent, minimize or reverse possible respiratory dysfunction and motor sequelae resulting from these interventions. Studies discuss the involvement of respiratory system, specifically the clearance of bronchial secretions and ventilatory adequacy, as a result of surgical procedure. Scientific evidences suggest the effectiveness of physiotherapy in reducing indices of: pneumonia, atelectasis, hospitalization, sequelae deleterious and length of bed restriction, beyond clinical improvement. These data confirm positive contribution of physiotherapeutic intervention in these surgeries.

Keywords: Physical therapy modalities. Cardiac surgical procedures. Heart defects, congenital.

Objetive: To evaluate the Lecompte procedure used for the correction of the transposition of the great arteries (TGA) associated with ventricular septal defect (VSD) and the left ventricle outflow tract obstruction (LVOTO) and to present the intermediate and long-term results of the surgery. Methods: Between February 1994 and July 2005, seven patients with ages between 2 and 8 years (median: 3.0) suffering from TGA, VSD and LVOTO underwent corrective surgery. In six cases, the Lecompte procedure was performed. This technique consists in right ventriculotomy, extensive resection of conal septum and construction of a ventricular tunnel connecting the left ventricle to the aorta (LV-Ao). The remaining case presented with obstruction of a valvular prosthesis implanted between the right ventricle and the pulmonary artery (RV-PA) and RV failure. This case was converted to the Lecompte procedure. Results: The cardiopulmonary bypass time varied from 105 to 194 minutes (Median: 130) and the aortic clamping time varied from 65 to 90 minutes (Median: 78). There was one death in the immediate post-operative period due to coagulopathy followed by RV failure. Six patients were released from hospital between the 5th to 30th postoperative day (Median: 11) and the follow up period was from 12 to 144 months (Median: 73.6). Conclusions: The Lecompte procedure presents the following advantages: 1. Surgical indicationfor infants; 2. Low morbility and mortality rates; 3.Free from reoperation over the long term. 4. Possibility of conversion of the Rastelli procedure into the Lecompte procedure.

Keywords: Heart defects, congenital, surgery. Cardiac surgical procedures. Transposition of great vessels, surgery. Heart valve prosthesis.

Objective: Hypoplastic left heart syndrome remains a challenge for worldwide surgeons. Initial palliation employing bilateral pulmonary artery banding along with ductal stent implantation and atrial septostomy has been proposed as an alternative approach. However, the surgically placed bands are fixed and may become inadequate after sternum closure or with somatic growth of the patient. We describe the first case in which a neonate with hypoplastic left heart syndrome was initially managed using a mini banding system that allows for fine percutaneous adjustments of pulmonary blood flow. Method: Through a mid sternotomy, a 5 day-old neonate underwent bilateral pulmonary artery banding using this new system combined with placement of a main pulmonary artery to innominate artery shunt. Results: The patient had an uneventful postoperative course. Three percutaneous adjustments of the banding system were necessary to keep the arterial oxygen saturation in the 75%-85% range. On the 48th day of life, she was submitted to stent placement (6 mm) within the atrial septum to treat a restrictive atrial septal defect. The Norwood operation and the bidirectional Glenn shunt were carried out on the 106th day of life. The bands were removed with no distortion of the pulmonary arteries. Conclusions: The clinical use of this innovative pulmonary artery banding system was feasible, safe and effective. It allowed for customization of the pulmonary blood flow according to the underlying clinical needs, resulting in a more precise balance between the pulmonary and systemic circulations.

Keywords: Heart defects, congenital. Stents. Palliative care. Hypoplastic left heart syndrome. Pulmonary artery, surgery. Balloon dilatation.

Objectives: To report a surgical strategy for the Norwood procedure in the hypoplastic left heart syndrome (HLHS) that enables short hypothermic circulatory arrest time and aortic arch reconstruction with autologous pericardium patch. To compare the results of the modified Blalock-Taussig (mBT) shunt and the right ventricle-to-pulmonary artery (RV-PA) conduit procedures as the source of pulmonary blood flow. Method: Retrospective study of 78 newborns consecutively operated between March, 1999 and June 2006. One technique for reconstruction of the neoaorta and two different techniques for reestablishment of the pulmonary blood flow: the mBT shunt in the first 37 newborns and RV-PA conduit in the last 41. Cannulation of the ductus arteriosus for systemic perfusion was the main part of the surgical strategy to reduce the hypothermic circulatory arrest time. Results: In-hospital survival for the entire cohort was 74,35%, or 67.57% for the mBT shunt and 80,49% for RV-PA conduit groups (p=0,21). Hypothermic circulatory arrest times were 45.79±1.99 min and 36,8±1,52 min (p=0,0012), respectively. Mortality rates between first and second stages were 40% for the mBT shunt and 6,9% for RV-PA conduit groups (p=0,007). Late coarctation of the aorta occurred in five patients Actuarial survival curves(Kaplan-Meier) comparison showed better results with VD-AP conduit (p=0,003). Conclusions: This surgical strategy resulted in short circulatory arrest time, low mortality and low incidence of aortic coarctation. Although the higher rate of survival to first palliation stage with the RV-PA conduit was not significant, the lower interstage mortality and superior medium-term survival in RV-AP group were statistically advantageous.

Keywords: Hypoplastic left heart syndrome. Circulatory arrest, deep hypothermia induced. Heart defects, congenital. Aortic valve stenosis.

Ectopia cordis is a rare congenital malformation, which is commonly associated with other intracardiac defects. A two-day-old full-term baby girl was admitted to Santa Casa de Montes Claros Hospital, with thoracic ectopia cordis. A transthoracic echocardiographic study did not identify any associated congenital heart diseases. The infant underwent surgical treatment using a rib graft to create a neo-sternum. She was discharged after a good evolution on the 20th postoperative day.

Keywords: Heart defects, congenital. Ectopia cordis. Thoracic wall, abnormalities. Infant, newborn.

Objective: To make a 30-year review of the immediate results of coarctation of the aorta (CoAo) operation, between 1974 and 2004. All the patients underwent CoAo whether in isolation or associated with other congenital defects. Methods: The following data was investigated: age at the time of surgery, gender, associated lesions, type of surgical technique, and immediate surgical outcome, particularly focusing the presence of systemic arterial hypertension. Results: One hundred and four patients underwent CoAo. Of the 104 enrolled patients, 75 (72%) were pediatric patients and 29 (28%) adults patients. In the pediatric group, 23 (22%) were considered neonates, 17 (16%) infants, and 35 (34%) children. The associated defects were present in 66 (63.5%) patients, 54 (51.9%) in the pediatric group and 12 (11.3%) in the adult group. Seven (6.7%) deaths were observed in the immediate postoperative period. Among the various surgical techniques employed, aortoplasty was used in 80 patients (76.9%); end-to-end anastomosis in 15 (14.4%); Teles technique in seven (6.7%), Waldhausen technique in one (1%), and it was not possible to identify the technique in one patient (1%). Conclusions: Despite the limitations of the present study, it may be noted that the results were good with the corrective surgery being performed safely and with a low mortality rate. Medium- and long-term follow-up was impaired by the well-known structural deficiencies in Brazil.

Keywords: Aortic coarctation, surgery. Cardiac surgical procedures. Heart defects, congenital. Retrospective studies.

The author describes the simultaneous treatment of pectus excavatum and congenital intracardiac defect (atrial septal defect) represented by the interatrial foramen secundum. An 8-year-old boy, with clinical and echocardiography diagnosis of atrial septal defect associated with pectus excavatum was referred to a simultaneous surgical treatment of both abnormalities. The simultaneous surgical treatment of both pectus excavatum and congenital intracardiac defects make it difficult to access the heart. In this case, the simultaneous surgical treatment of atrial septal defect and pectus excavatum was a valuable alternative to surgical repair of both abnormalities, mainly due to its cosmetic outcome.

Keywords: Thorax, abnormalities. Funnel chest, surgery. Heart defects, congenital. Heart septal defects, atrial.

The authors describe the operative technique approach and its post-operative course used in an adult patient with coarctation of aorta, in which it was not possible to perform the traditional correction with an end-to-end anastomosis with graft interposition. During the surgery it was necessary to make an extra-anatomic bypass: ascending-descending aorta with an enlarged left posterior-lateral thoracotomy approach. The authors also make a short review of several possible approaches used for extra-anatomic bypass as well as its advantages and drawbacks.

Keywords: Heart defects, congenital. Aortic coarctation, surgery. Aorta, surgery.

Objective: To describe the technique of implantation and to show the echocardiographic follow-up of the decellularized cusps allografts used in patients with Tetralogy of Fallot. Methods: Fifteen patients underwent this implantation between March 2005 and August 2007 and they were clinically followed-up. An echocardiogram was performed to evaluate the morphofunctional result of the allografts. Results: The mean follow-up was 12.7 months (1-25 months). The echocardiography results showed that pulmonary insufficiency was mild in nine (60%) patients, moderate in three (20%) patients, and severe in three (20%) patients. The results also showed that the systolic right ventricle function was normal in 13 (86.7%) and that there was mild dysfunction in two (13.3%). Eleven (73.4%) patients did not present any gradient in the right ventricular outflow tract and four (26.6%) presented mild stenosis. The mobility of the cusps were normal in all cases and there was no thickness larger than 1,5mm. There was no calcification; 14 patients (93,3%) presented Z score between -1 and 0,7 and one patient presented dilated pulmonary annulus with a Z score of + 2.5. Conclusion: In midium-term follow-up, the decellularized allograft seemed to be a good option for right ventricle outflow tract enlargement in patients underwent Tetralogy of Fallot.

Keywords: Tetralogy of Fallot/surgery. Heart defects, congenital. Treatment outcome. Child. Follow-up studies. Transplantation, homologous.

Objective: To evaluate short-term and medium-term results of intracardiac correction of Tetralogy of Fallot in the first year of life. Methods: From January 1996 to October 2004, 67 consecutive infants ranging in age from 1 to 11 months (mean: 7.2 months) and weighing from 4 to 10 kilograms (mean: 7.1 kilograms) underwent elective total correction of Tetralogy of Fallot. The surgery was accomplished with conventional cardiopulmonary bypass and moderate hypothermia. Right ventriculotomy was performed in 60 (89.5%) cases and an atriopulmonary approach was used in the other seven (10.5%) cases. Results: Cardiopulmonary bypass time ranged from 35 to 147 minutes (mean: 78.8 ± 21 minutes), and aortic clamping time ranged from 25 to 86 minutes (mean: 51.8 ± 15.6 minutes). Transannular enlargement of the right ventricular outflow tract was needed in 50 (64.1%) patients. Gradient between the right ventricle and pulmonary artery after correction varied from 0 to 54 mmHg (mean: 15.5 ± 10.8 mmHg). There were two (2.98%) early deaths. Follow-up of the 65 survivors ranged from 7 to 115 months (mean:44.0 ± 35 months). There was one late noncardiac death. All other patients are asymptomatic. The actuarial survival curve at 12 years, including operative mortality, was 97%. Ten patients were evaluated by magnetic nuclear angioresonance. Conclusions: Intracardiac correction of Tetralogy of Fallot in the first year of life may be performed with low morbidity and mortality and good late results.

Keywords: Tetralogy of Fallot/surgery. Heart defects, congenital. Treatment outcome. Child. Follow-up studies.

Objectives: To study technical feasibility and early results of the technical modification suggested by Caliani et al. for correction of aortic coarctation and aortic arc. Methods: Between January 2005 and July 2006, nine newborn patients with aortic coarctation and significant aortic hypoplasia were selected, and underwent a new surgical approach in order to correct this aortic defect. The definition of aortic arch hypoplasia according to Moulaert's criteria is an aortic arch with a diameter that is less than 50% of the diameter of the ascending aorta. In this study, only patients with proximal and distal aortic hypoplasia were selected. Many techniques were previously used, but significant residual gradients were observed, as well as the incovenience of definitive occlusion of the left subclavian artery. The aim of this study is to describe a new surgical technique that includes left posterolateral thoracotomy, wide mobilization of descending aorta with occlusion of the first two intercostal branches, transection of the left subclavian artery at its base, wide resection of the hypoplastic area and the surronding regions of the ductus arteriosus; end-to-end anastomosis between the aortic arch and descending aorta, with 7-0 PDS thread and reimplantation of the subclavian artery into the left carotid artery with side-to-end anastomosis. Results: There were no perioperative or late deaths. The mean residual gradient was 5 mmHg. Up to now, there were no cases of recoarctation or medullary neurological lesions. Conclusion: Despite the small number of cases and the short follow-up, this technique modification may be an excellent option for the treatment of this complex situation.

Keywords: Aortic coarctation/surgery. Heart defects, congenital. Cardiac surgical procedures/methods. Infant, newborn.

A 47 year-old man with aortic coarctation had undergone extra-anatomic bypass through a left thoracotomy. He presented 10 years later with uncontrolled arterial hypertension due to residual aortic coarctation, graft obstruction and multiple collateral artery aneurysms between the subclavian artery and the aorta. He underwent extra-anatomic correction between the ascending aorta to descending aorta through a median sternotomy with the aid of conventional cardiopulmonary bypass. His postoperative recovery was unremarkable, and there was complete involution of all aneurysmal collateral arteries after the operation.

Keywords: Aortic coarctation/surgery. Heart defects, congenital. Collateral circulation.

The treatment for closure of persistent ductus arteriosus (PDA) in adults still controversial. The endovascular approach has been shown as an effective alternative to surgical treatment. We report a case of 45 years old pacient submitted to endovascular approach for PDA closure.

Keywords: Ductus arteriosus. Heart Defects, congenital. Ductus arteriosus, patent.

Introduction: Congenital heart defects can often be corrected through surgery, providing for parents to expect a normal life, but the hospitalization experience often early, causes more pain, for which surgery is the worst moment. Objective: The aim of this study was to analyze the experience of families of children undergoing cardiac surgery and to identify the coping resources used by the families. Methods: A qualitative approach was the metodology of choice for this study, which took place with six semi-structured interviews and 100 hours of observation. Thematic analysis was used to understand the data. Results: The results were categorized into four themes: feelings and emotions facing the illness of the child; heart disease under the watchful mother, mother and child on the ICU and coping resources. The speech of mothers demonstrated the importance of the heart due to its symbolism that enhances their emotional fragility in the face of illness. Religiosity and a solid social network of support were contributing factors for the maintenance of the adaptive behaviors. The presence of mothers in all stages of the child's treatment contributed to minimizing the suffering generated by hospitalization. Conclusion: The experience of families was characterized by ambivalent feelings such as fear of death, guilt and helplessness against the different stages of treatment. The anguish and anxiety prevailed in the face of unknown situations when information were required before therapeutic procedures, hospital routines and the actual life situation of the families.

Keywords: Heart Defects, Congenital. Adaptation, Psychological. Mothers.

Objective: To evaluate the impact of congenital heart diseases in growth of children with Down syndrome (DS) and the weight-height recovery after surgical correction. Methods: Retrospective study of the DS patients between 1984 and 2007. Excluding the mosaics and/or patients with associated morbidities (n=165). Calculated Z scores for weight (Zwb) and length (Zlb) at birth. Those patients submitted to surgical correction (n= 60) these scores (Zw/Zh) were evaluated before surgery and in subsequent periods to five years. Malnutrition was defined as weight/height Z-score < 2.5. Used Chi-square test to verify the relation between weight/length and age at the time of surgery and Student T test to evaluate the postoperative (PO) time of recovery (P < 0.05). Results: Means Zwb (n = 162) and Zlb (n = 156) were -0.95 ± 1.27 and -1.348 ± 1.02. From the total data (n = 165), 65.5% (n = 108) presented heart disease. Those submitted to cardiac surgery (n = 60), Zw was below -2.5 in 55% (n = 33) and Zh in 60% (n = 36). After six months PO, 67.4% achieved Zw > 2.5. In one year, 85.7% achieved Zh > 2.5. Dividing this group by age in tertiles at time of surgery no difference was found. Conclusions: We concluded that malnutrition common in children with DS since birth. DS children with congenital heart and surgical indication were smaller and lighter than those without or with mild disease. PO recovery occurred in 6 months for weight and one year for height, with no difference in the age at the time of surgery.

Keywords: Heart Defects, Congenital. Down Syndrome. Body Weight. Body Height. Growth.

Objective: To analyze 34 patients submitted to surgical treatment of patent arterial duct with age beyond 18 years old. Methods: Retrospective data collected from patient's charts with more than eighteen years old, submitted to surgical correction of patent arterial duct between 1997 and 2008 at Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo. Results: The mean age was 28.7 (18 a 53) years and 22 (64.7%) were female. The more prevalent symptom was dyspnea (76.5%). Left lateral thoracotomy was used in 33 (97.1%); the DA was sectioned and sutured in 25 (73.5%) cases and one patient needed cardiopulmonary bypass support. There were eight (23.5%) calcified arterial duct and 12 (35.3%) previous treatment with transcatheter devices were performed. The complication rate was 32%, with one (2.9%) permanent vocal cord palsy. Two (5.8%) patients had residual shunt less than 2mm. Transient left cord voice palsy was observed in 3 (8.8%) The procedure improves functional class (P< 0.0001) and no mortality was observed. Conclusion: In this series, the surgical treatment of patent arterial duct in adults could be done without mortality and low incidence of complications.

Keywords: Ductus Arteriosus, Patent. Adult. Heart Defects, Congenital.

INTRODUCTION: Although hypoplastic left heart syndrome (HLHS) be extensively studied, this disease still has a high mortality rate compared to other diseases treated as univentricular physiology. In this way, morphological differences between phenotypes within the spectrum of HLHS may be risk factors and their identification can assist in choosing treatment between subgroups.
OBJECTIVE: To identify the most prevalent form of coronary artery dominance in hearts with HLHS groups with mitral atresia (MA) and mitral stenosis (MS).
METHODS: Analysis of coronary anatomy according to the distribution of epicardial branches and the pattern of dominance, classified as right, left or balanced. The control group was composed of nine pieces of morphologically normal hearts, the HLHS group consisted of 9 pieces with MA and 24 pieces with MS. For statistical analysis we used the x² test.
RESULTS: There were significant differences between the two groups in relation to coronary artery dominance (x² = 9.298, P = 0.01). Left dominance was present in 75% of cases of MS, and balanced one was only observed in pieces with MS. The control group had right dominance in all cases (P <0.01).
CONCLUSIONS: Left dominance is more common in HLHS than in the control group of normal hearts and, in HLHS, the left coronary dominance is more frequent in the subgroup with MS.

Keywords: Heart/anatomy & histology. Coronary vessels. Hypoplastic left heart syndrome. Heart defects, congenital.