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ARTIGO ORIGINAL

Resultado clínico tardio da anuloplastia mitral sem suporte em crianças e adolescentes

Solange BordignonI; Renato A. Karan KalilI; João Ricardo M Sant'AnnaI; Paulo Roberto PratesI; Edemar Manuel PereiraI; Ivo A NesrallaI

DOI: 10.1590/S0102-76381996000100007

RESUMO

O resultado clínico pós-operatório (p.o.) tardio da reconstrução da valva mitral sem suporte em crianças e adolescentes é analisado através da observação de uma série de 70 pacientes operados. Objetivou-se acompanhar a evolução clínica tardia após o tratamento de insuficiência mitral pelas técnicas reparadoras nos pacientes em fase de crescimento, avaliar a eficácia, a durabilidade e a reprodutibilidade do procedimento, bem como morbidade e mortalidade nas fases hospitalar e tardia. Consideraram-se, ainda, os resultados em relação à etiologia da doença e as causas de falha do método. De 1977 a 1995, foram operados 70 pacientes, sendo 36 casos do sexo feminino e 34 do masculino. A média de idade foi de 12,4 ± 4,8 anos (6m a 18a). Houve predomínio da etiologia reumática (71,4%) sobre a congênita (18,6%), a degeneração mixomatosa (8,6%) e a infecciosa (1,4%). A classe funcional pré-operatória era 11 em 32 (45,7%) casos, 111 em 18 (25,7%) casos e IV em 20 (28,6%) casos. A técnica cirúrgica utilizada foi a anuloplastia simples tipo Wooler isolada em 58 (82,9%) casos e associada a encurtamento de cordoalha em 12(17,1%). Em 21 (30%) pacientes foram realizados procedimentos associados. O período de acompanhamento foi de 7 m a 17 anos, no p.o. A mortalidade hospitalar foi 4,3%. Regurgitação mitral foi descrita no intra-operatório em 21,4%. Sopro sistólico de regurgitação mitral residual foi notado em 35 (49,9%) pacientes, a maioria sem repercussão hemodinâmica. A classe funcional pós-operatória foi I em 73,9%, II em 21,7% e III em 4,4%. As curvas de análise atuarial mostraram aos 5 e 10 anos, respectivamente, probabilidade de sobrevida global de 89% e 79% e estimativa de permanecer livre de eventos cirúrgicos no período de 87% e 61 % no grupo total, 88% e 56% no grupo de etiologia reumática e 91 % no grupo de etiologia congênita para 5 e 10 anos. A insuficiência mitral pode ser tratada efetivamente por anuloplastia sem suporte anular profético, com resultados tardios comparáveis àqueles obtidos por técnicas mais complexas. Isto tem importância no tratamento de crianças e adultos jovens, especialmente no sexo feminino, quando se deseja evitar o implante de próteses mecânicas.

ABSTRACT

Late post-operative clinical results fortreatmentof mitral regurgitation (MR) in patients under 18 years-old by annuloplasty without ring or posterior support are presented. From 1977 to 1995,70 patients: 36 female and 34 male, mean age 12.4 ± 4.8 y (6m to 18y), with pure MR were submitted to an Wooler type of annuloplasty. None received ring or annular support. Twelve (17.1%) had chordal shortening associated. Ethiology was rheumatic 71.4%, congenital 18.6%, myxomatous 8.6% and infectious 1.4%. Preoperative functional class was II: 32 cases (45.7%), III: 18 (25.7%), IV: 20 (28.6%). Twenty-one patients (30%) had associated procedures: on aortic valve 12 (15.2%), tricuspid 4 (5.7%), ASD 4 (5.7%) and aortic and tricuspid 1 (1.4%). Mean perfusion time was 45.2 ± 18.3 min for the whole group and 37.2 ± 11.3 min for annuloplasty alone. Mean ischemic time was 28.4 ± 14.3 min and 21.8 ± 7.1 min respectively. Follow-up time ranged from 7 months to 18 years. Mortality was 4.3% (3 cases) in the early postoperative and 8.6% (6 cases) in the late follow up. Early residual regurgitation was found in 15 patients (21.4%) and 50.0% in 35. Thirteen (18.6%) were reoperated at a mean p.o. time of 56.2 ± 46.2 m. Causes for reoperation: primary MR 5 (38.5%), endocarditis 4 (30.7%), stenosis 2 (15.4%), aortic valve disfunction 1 (7.7%), pulmonary embolism 1 (7.7%). Late evaluation in 46 non-operated survivors: 34 were in functional class I (73.9%), 10 in II (21.7%) and 2 in III (4.3%). Actuarial survival was 93 ± 3% at 5 years and 80 ± 7% at 10 years. Event-free survival was 89 ± 4% and 61 ± 10% at 5 and 10 years. For rheumatic ethiology, event-free survival was 80 ± 8% and 55 ± 16% and, for congenital MR, 90 ± 9% at 5 and 10 years p.o. Simple, unsupported annuloplasty (Wooler type), alone or associated to chordal shortening is an effective and reproducible procedure for MR in children and adolescents. Morbidity and mortality are low in relation to other techniques and prosthetic replacement. Failures were mainly related to rheumatic carditis and infective endocarditis. In growing up patient under 18 years old, this technique would be recommended because it may allow unrestricted development of the mitral orifice.
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