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We report a patient admitted to our hospital with aortic valve rupture due to blunt chest trauma. The aortic rupture was accurately identified by the transesophageal echocardiogram, allowing a better surgical approach.

In children, chylothorax occurs mainly after cardiac and thoracic surgeries. One of the recommended postsurgery treatments is ligation of the thoracic tract, when all other conservative treatments have failed. We report 4 cases of chylothorax in patients who were successfully treated with this approach, which resulted in a decrease in pleural drainage without recurrent chylothorax.

The patient was a 4-month-old infant, who underwent persistent ductus arteriosus interruption with titanium clips at the age of 13 days and, since the age of 2 months, had crises of hypoxia and hypertonicity. After clinical investigation, the presence of pulmonary hypertension was confirmed and left ventricular inflow tract obstruction was suspected. The patient underwent surgical treatment at the age of 4 months, during which right and left ventricular endocardial fibrosis was identified. The fibrosis was resected, but the infant had an unfavorable clinical evolution with significant diastolic restriction and died on the sixth postoperative day. Anatomicopathological and surgical findings suggested endomyocardial fibrosis, although that pathology is very rare at the patient's age.

Objective: To test the hypothesis that short periods of ischemia may increase the myocardial protection obtained with intermittent crossclamping of the aorta., Methods: In the control group (18 patients), surgery was performed with systemic hypothermia at 32 degrees C and intermittent crossclamping of the aorta. Extracorporeal circulation was used. In the preconditioning group (17 patients), 2 crossclampings of the aorta lasting 3min each were added prior to the intermittent crossclamping of the conventional technique with an interval of 2min of reperfusion between them. Blood samples for analyses of pH, pCO2, pO2, sodium, potassium, calcium, and magnesium were obtained from the coronary sinus at the beginning of extracorporeal circulation (time 1), at the end of the first anastomosis (time 2), and at the end of extracorporeal circulation (time 3)., Results: No difference was observed in the results of the 2 groups, except for a variation in the ionic values in the different times of blood withdrawal; sodium values, however, remained stable. All patients had a good clinical outcome., Conclusion: The results of intermittent crossclamping of the aorta with moderate hypothermia were not altered by the use of ischemic preconditioning.

Objective: To determine the risk factors for mortality related to myocardial revascularization when performed in association with coronary endarterectomy., Methods: We assessed retrospectively 353 patients who underwent 373 coronary endarterectomies between January '89 and November '98, representing 3.73% of the myocardial revascularizations in this period of time. The arteries involved were as follows: right coronary artery in 218 patients (58.45%); left anterior descending in 102 patients (27.35%); circumflex artery in 39 patients (10.46%); and diagonal artery in 14 patients (3.74%). We used 320 (85.79%) venous grafts and 53 (14.21%) arterial grafts., Results: In-hospital mortality among our patients was 9.3% as compared with 5.7% in patients with myocardial revascularizations without endarterectomy (p=0.003). Cause of death was related to acute myocardial infarction in 18 (54.55%) patients. The most significant risk factors for mortality identified were as follows: diabetes mellitus (p=0.001; odds ratio =7.168), left main disease (<0.001; 9.283), female sex (0.01; 3.111), acute myocardial infarction (0.02; 3.546), ejection fraction <35% (<0.001; 5.89), and previous myocardial revascularization (<0.001; 4.295)., Conclusion: Coronary endarterectomy is related to higher mortality, and the risk factors involved are important elements of a poor outcome.

Objective: To analyze the initial clinical experience of transmyocardial laser revascularization (TMLR) in patients with severe diffuse coronary artery disease., Methods: Between February, 1998 and February, 1999, 20 patients were submitted to TMLR at the Heart Institute (InCor), University of São Paulo Medical School, Brazil, isolated or in association with conventional coronary artery bypass graft (CABG). All patients had severe diffuse coronary artery disease, with angina functional class III/IV (Canadian Cardiovascular Society score) unresponsive to medical therapy. Fourteen patients were submitted to TMLR as the sole therapy, whereas 6 underwent concomitant CABG. Fifty per cent of the patients had either been previously submitted to a CABG or to a percutaneous transluminal coronary angioplasty (PTCA). Mean age was 60 years, ranging from 45 to 74 years., Results: All patients had three-vessel disease, with normal or mildly impaired left ventricular global function. Follow-up ranged from 1 to 13 months (mean 6.6 months), with no postoperative short or long term mortality. There was significant symptom improvement after the procedure, with 85% of the patients free of angina, and the remaining 15% of the patients showing improvement in functional class, as well as in exercise tolerance., Conclusion: This novel technique can be considered a low risk alternative for a highly selected group of patients not suitable for conventional revascularization procedures.

A 65 year-old man with dilated cardiomyopathy and long history of high blood pressure and a previous cerebral vascular accident had a giant left atrial myxoma as an echocardiographic finding.

Purpose: In order to associate the major benefits of the coronary artery bypass graft (CABG) with a less aggressive procedure minimally invasive coronary artery bypass graft (MICABG) has been utilized. The aim of the work is to report our initial experience with this technical approach, using video assisted thoracic surgery (VATS) to facilitate the operation., Methods: Twenty-six patients, 19 males with ages from 44 to 83 years old, and having isolated lesion of the anterior descending artery were operated upon. Left anterior minithoracotomy of 8-10 cm was performed at the fourth intercostal space. Through this incision the optical device for VATS as well as the surgical instruments were placed in order to provide the complete left internal mammary artery (LIMA) dissection. Bypass circulation was not used and cardiac rate was decreased with the use of intravenous betablockers. For LIMA--anterior descending artery anastomosis, proximal and distal tourniquets were used and 1.5 mg/kg of heparin was intravenously administered., Results: All patients presented satisfactory postoperative evolution, being discharged from the hospital at 72 h after surgery in the majority of the cases. There were delay in two patients healing of incisions and 25 patients have remained asymptomatic, with a mean in postoperative follow-up of four months. One patient died in the second postoperative month due to stroke., Conclusion: MICABG makes the surgery possible with better esthetic effect, lower cost and enables faster recovery than the conventional one. The use of VATS through the thoracotomy itself, allows the LIMA dissection without other incisions. It also permitted more ample dissection of the LIMA when compared to minithoracotomy without VATS.

A 52-year-old man with left atrial myxoma, in whom postoperative angiographic control revealed a coronary-cavitary fistula originated from a previous atrial branch from the circumflex coronary artery. These fistulas should be considered in cases of revascularized atrial myxoma.

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.

The clinical evolution of mitral valve disfunction caused by papillary muscle necrosis in patients with anomalous origin of the left coronary artery from the pulmonary trunk was analysed in three children (one 42-day-old male, one five-month-old female and one seven-year-old female). Two patients had been submitted to surgical repair of the anomalous origin of the coronary artery; one of them without mitral repair had a bad evolution in the postoperative period, was reoperated for mitral valve replacement and died two days after surgery. The other patient with plastic of mitral valve had a good outcome. The data indicated that the surgical repair of mitral valve should be provided in cases of mitral valve incompetence secondary to anomalous origin of the left coronary artery from the pulmonary trunk.

Female infant, presenting with flexion spasms, skin hypochromatic spots and systolic ejection murmur. A clinical diagnosis of tuberous sclerosis, supported by computerized brain tomography and neurosonographic data, was made. Echocardiographic and cineangiocardiographic studies disclosed an associated tumor in left ventricle outlet. After resection of the rhabdomyoma, the patient is asymptomatic with neural manifestations controlled under valproic acid.

The report of these two cases show the accentuated and progressive increase in the ventricular contractility in the late postoperative period in patients who underwent surgical correction of left coronary artery with origin at the pulmonary trunk. Male and female infants, both developed congestive heart failure not controlled by medical treatment. The diagnosis was made by EKG and confirmed by coronary angiogram. They were surgically treated by translocation of the left coronary artery from the pulmonary artery to the aorta. Nine and seven years later, respectively both patients are free of symptoms with marked recovery of the left ventricle function without alteration in height and weight and in excellent clinical conditions. The early surgical treatment in these cases, even with unfavourable clinical status is the only way to change the natural history of this pathology, with an increase of the ventricular contractility.

Purpose: To follow-up a group of patients during a period of time after either clinical or surgical approach., Patients and Methods: A hundred and twenty-one patients were studied retrospectively with endomyocardial fibrosis (EMF) for a period that varied from one month to 11 years (mean = 32 months). Upon entrance, patients had from 5 to 64 years of age (mean = 30), being 41 male and 80 female. Biventricular involvement were present in 70 cases, whereas 36 showed pure left and 15 pure right ventricular involvement. The patients were divided in two groups: 62 treated clinically, and 59 surgically, the latest defined as fibrosis resection added to atrioventricular valve rebuilding or replacement. All surgical cases had a prior III to IV functional class (NYHA)., Results: In the clinical group there were 24 fatalities, 21 who were in class IV, 1 in class III, and 2 in class II. In the surgical group there were 18 fatalities, 12 early and 6 late., Conclusions: (1) All the patients who survived the operation showed functional class improvement; (2) surgical mortality decreased in the latest years; (3) clinical treatment is indicated to patients in classes I and II, groups with low mortality rates; (4) surgical treatment is indicated to patients in classes III and IV, provided that clinical mortality is high in these groups of patients.

Percutaneous transluminal coronary angioplasty is unusual in acute myocardial infarction after left main coronary artery occlusion. We applied this therapy in two cases. The first, a 54-year-old man, submitted to mechanical reperfusion and left main coronary artery angioplasty 145 minutes after the beginning of the symptoms and coronary artery surgery 12 hours later; the second, a 77-year-old woman, submitted to both procedures but not to surgery. In the first case there was a satisfactory follow-up but in the second, the patient died twelve hours later.

Four different clinical cases in which the myocardial reperfusion occurred after acute myocardial infarction, and was followed by significant hemorrhagic ventricular damage. We discuss some possible etiologic mechanism of the problem and present some methods of myocardial protection which are meant to lessen those negative effects of the reperfusion. We conclude setting the difficulty to determine the critical moment after which the myocardial reperfusion turns inefficient or even harmful.

Purpose: To compare the effects of two methods for myocardial preservation during coronary artery by pass graft (CABG): the intermittent aortic cross-clamping (IACC) and the cold hyperkalemic solution (CHS)., Patients and Methods: One hundred and sixty-three patients operated for CABG between October/83 to May/84 were studied retrospectively. Those operated in emergency situations, reoperations and those who required concomitant additional procedures were excluded. The surgical technique used in both groups was essentially the same. Group I comprised 93 cases (40-70 years-old, median 57.7% y; 86% male) in which IACC were used. Group II comprised 70 cases (37-72 years old, median 67.7 y; 80% male) in which CHS (St. Thomas) was injected into the aortic root. The patients were evaluated in the immediate postoperative period at 3, 6, 12 months and then in variable periods until the 61 months of late follow-up. Myocardial ischemia and infarction, the use of drugs and the hospital time recovery were evaluated. The occurrence of symptoms, return to work, physical capacity, reinternations, reoperations and late deaths were evaluated in the late follow-up., Results: During hospital period, no death was observed. Perioperative myocardial infarct was similar in both groups (group I = 2.1% and group II = 1.4%) statistical difference in the others parameters was observed. Of 95.5% of the patients who had postoperative observations, 80% had a late follow-up ranged from 30 to 61 months (median 38 months). One patient of each group had a cardiac death. In both groups (group I--1 patient and group II--4 patients) coronary insufficiency symptoms related were present and no statistical difference in the others parameters was observed., Conclusion: CHS or IACC were efficient and similar methods for myocardial protection in an elective group of patients submitted to a CABG in the immediate and late follow-up.

The authors report on three pregnant patients with mitral stenosis with heart failure in functional class IV (NYHA) unresponsive to clinical treatment. They were submitted to mitral valvuloplasty, with significant clinical improvement, and were, hence, asymptomatic. Despite the small number of cases, it may be concluded that the procedure is simple and safe, which can be attested by the successful results.