RCAAP Repository

FUNDAMENTO: O sucesso no aprendizado da emergência depende de muitos fatores que podem ser resumidos como: aluno, instrutores e curso. OBJETIVO: Avaliar a influência do subsídio financeiro e do local da realização do curso no aprendizado da emergência cardiovascular. MÉTODOS: Analisaram-se dados referentes aos cursos de Suporte Avançado de Vida em Cardiologia (ACLS) no período de dezembro de 2005 a dezembro de 2006. De acordo com o subsídio financeiro, foram divididos em: grupo 1 - subsídio integral; grupo 2 - subsídio de 50%; e grupo 3 - sem subsídio. Quanto ao local do curso, foram divididos em: local A - curso em cidade com > 1 milhão de habitantes; e local B - curso em cidade com < 1 milhão de habitantes. Compararam-se a aprovação prática e teórica e a média teórica. RESULTADOS: Participaram do ACLS 819 alunos: 199 (24%) no grupo 1, 122 (15%) no 2 e 498 (61%) no 3. A aprovação prática e teórica e a média na prova teórica foram maiores no grupo 3 que nos demais grupos (p<0,05). Quatrocentos e oitenta e dois fizeram o curso no local A (59%) e 337 (41%) no local B. A aprovação prática foi semelhante para ambos os grupos (p = 0,33), entretanto a aprovação teórica foi maior no local A (73% vs. 65% - p = 0,021 - OR = 1,44 e IC: 1,05 - 1,97). A média teórica foi maior no local A (87,1 ± 10,4 e 86 ± 11, respectivamente p<0,05). CONCLUSÃO: O subsídio financeiro e o local da realização do curso influenciaram na aprovação teórica e prática.

FUNDAMENTO: O teste ergométrico precoce após infarto do miocárdio, realizado antes da alta hospitalar, é útil na estratificação de risco, na prescrição de exercício e na avaliação do prognóstico e do tratamento. OBJETIVO: O objetivo deste estudo foi comparar os achados do teste ergométrico precoce pós-infarto aos resultados do ecocardiograma, da monitorização eletrocardiográfica pelo sistema holter (24 horas) e da cinecoronariografia. MÉTODOS: Avaliaram-se 60 casos (51,42 ± 9,34 anos), 46 do sexo masculino (77%). O teste ergométrico foi máximo sintoma limitante, realizado pelo protocolo de Naughton, entre o sexto dia de internação e a alta hospitalar, realizado em uso de medicação. Durante a internação, os pacientes foram submetidos a ecocardiograma, eletrocardiografia dinâmica e cinecoronariografia. Adotou-se o nível de significância de 0,05 (a=5%). RESULTADOS: O desempenho do teste ergométrico na detecção de doença coronária multiarterial foi reduzido (sensibilidade, 42%; especificidade, 69%). Não houve diferenças significativas quando se comparou a presença de isquemia no teste ergométrico com doença coronária de múltiplos vasos, arritmias ventriculares complexas na eletrocardiografia dinâmica e ocorrência de fração de ejeção inferior a 60% no ecocardiograma (p = 0,56), bem como com a presença de lesões multiarteriais, arritmias ventriculares complexas na eletrocardiografia dinâmica e fração de ejeção anormal no ecocardiograma (p = 0,36). CONCLUSÃO: Durante o teste, a presença de isquemia se associou à ocorrência de arritmias ventriculares na eletrocardiografia dinâmica, à redução da fração de ejeção no ecocardiograma e à presença de lesões coronárias multiarteriais, o que representou um indicador de elevado risco coronário.

FUNDAMENTO: A levosimendana é um novo agente inodilatador que aumenta a contratilidade cardíaca pela sensibilização ao Ca(2+) e induz vasodilatação por meio da ativação dos canais KATP/BKCa. OBJETIVO: Estudar a eficácia e segurança da levosimendana em uma coorte brasileira portadora de insuficiência cardíaca descompensada e em pacientes resistentes a agonistas b-adrenérgicos. MÉTODOS: O BELIEF (Brazilian Evaluation of Levosimendan Infusion Efficacy) foi um estudo aberto, prospectivo, multicêntrico e observacional realizado com 182 portadores de ICD de alto risco, todos tratados com levosimendana. O desfecho primário do estudo era alta hospitalar sem terapia inotrópica adicional (pacientes que responderam ao tratamento). Os desfechos secundários eram alterações nos parâmetros clínicos e hemodinâmicos e nos níveis de peptídeo natriurético cerebral (BNP). RESULTADOS: A taxa de mortalidade foi de 14,8%, e 139 dos 182 pacientes responderam ao tratamento. Entre os que não responderam, a taxa de mortalidade foi de 62,8%. A pressão arterial sistólica foi um preditor de resposta ao tratamento. No grupo resistente aos agonistas b-adrenérgicos, 55,8% responderam ao tratamento. Ao todo, 54 pacientes tiveram pelo menos um evento adverso, a maioria dos quais desapareceu espontaneamente ou após redução da dose da levosimendana. Houve uma melhora significativa na qualidade de vida entre 2 e 6 meses do acompanhamento (p < 0,0001). CONCLUSÃO: Nossos resultados indicam que a infusão de levosimendana é uma terapia alternativa de curto prazo para tratamento de pacientes com ICD. A gravidade da insuficiência cardíaca pode influenciar a resposta ao tratamento com levosimendana. São necessários estudos prospectivos com uma coorte brasileira que inclua também pacientes com doença de Chagas.

FUNDAMENTO: Ainda hoje os casos de amiloidose cardíaca, em sua maioria, não são diagnosticados. OBJETIVO: Revelar fatores relacionados à dificuldade no diagnóstico de amiloidose. MÉTODOS: Comparação entre os dados clínicos, eletrocardiográficos e ecocardiográficos de 17 pacientes nos quais a amiloidose foi detectada apenas à necrópsia (grupo I) e os de outros 9, nos quais a doença foi percebida em vida (grupo II). As variáveis quantitativas foram avaliadas pelo teste t e as qualitativas, pelo teste exato de Fisher, com nível de significância de p < 0,05. RESULTADOS: Houve diferenças quanto a idade (grupo I: 75,29 + 11,61 anos; grupo II: 58,67 + 11,07 anos), associação com outra doença cardíaca (grupo I: 52,94%; grupo II: 0%), baixa voltagem à eletrocardiografia (grupo I: 17,65%; grupo II: 66,67%) e disfunção diastólica à ecocardiografia (grupo I: 7,69%; grupo II: 62,50%). Algum grau de espessamento da parede ventricular esquerda ("hipertrofia") foi encontrado em 75% dos casos de diagnóstico post-mortem e em 100% dos casos in vivo, porém a espessura da parede foi menor no grupo I (parede livre: 1,20 + 0,28 cm no grupo I vs. 1,53 + 0,18 cm no grupo II). Disfunção sistólica estava presente em 57,89% dos casos, sem diferença significativa entre os grupos. CONCLUSÃO: A amiloidose é diagnosticada quando os padrões clínico, eletrocardiográfico e ecocardiográfico são "típicos", mas na maioria dos casos o quadro não é assim, especialmente em idosos, em decorrência de associação com outras doenças, de falta de disfunção diastólica à ecocardiografia e de hipertrofia de grau leve.

OBJECTIVE: Evaluate coronary angiogenic response to transmural injection of plasmid encoding VEGF 165 in acute myocardial infarction (AMI) zones in a canine model. METHODS: The heart of eleven dogs was exposed and AMI was induced by occlusion of the diagonal branch of anterior descending coronary artery. For each of 10 selected points in the infarction area and its peripheral zone injections of 1 ml of saline solution (control group: five dogs) or 1 ml of plasmid encoding VEGF 165 solution (200 µg/ml) (VEGF group: six dogs) were introduced. Tecnecium myocardial scintigraphy was performed immediately after animal recovery and 14 days later to evaluate the myocardial perfusion. The animals were sacrificed and the hearts were submitted to a histological study of the infarcted area, peripheral zone and normal posterior ventricular wall, to evaluate the number of arterioles and capillaries. RESULTS: Immediate modifications in myocardial perfusion found in scintigraphic studies were similar in both groups. In the second evaluation at 14 days, hypoperfusion of ischemic area had recovered by 70% to 90% when compared to the day of AMI. Histologic evaluation of the peripheral area of AMI indicated a larger number of vessels in the VEGF group when compared to controls (mean: 123.81 + 21.48 and 40 + 6.13, p < 0.01, respectively). This increase resulted mainly from an increase in the number of capillaries (97.5 + 16.04 in the VEGF group and 22.18 + 3,25 in control group, p < 0.01), as the number of arterioles did not increase significantly. In the VEGF group, a comparison in the number of vessels of the AMI peripheral area and normal myocardium revealed a non-significant increase of vessels in the ischemic area (123.81 + 21.48 and 95.14 + 41.19). CONCLUSION: An intramural injection of plasmid VEGF 165 resulted in a significant increase in the number of capillaries in the peripheral AMI area. This increase may have a beneficial effect in the reduction and recovery of the ischemic area secondary to AMI.

PURPOSE: Bicuspid aortic valve (BAV) is associated with increased prevalence of annulo-aortic ectasia, dissection and ascending aortic aneurysm. This study was undertaken to compare the amount of fibrillin-1 and elastin in the media of great vessels of patients with bicuspid and tricuspid aortic valve disease. METHOD: Tissue samples of ascending aorta and pulmonary artery were obtained from 22 patients with bicuspid aortic valve disease (BAV) and 17 patients with tricuspid aortic valve disease (TAV), including 6 normal valves from the transplant program. Indirect immunofluorescence and computerized image analyses were used to quantify fibrillin-1 and elastin of the media of the arteries. The results were expressed as the mean integrated optical density (IOD). RESULTS: In the ascending aorta, the IOD for fibrillin-1 was 15 ± 8 in the BAV group and 24 ± 7 in the TAV group (p = 0.001). In the pulmonary artery, the IOD for fibrillin-1 was 18 ± 10 in the BAV group and 25 ± 9 in the TAV group (p = 0.07). In respect to the elastin measurements of the aorta, the specific IOD was 34 ± 13 in the BAV group and 29 ± 14 in the TAV group. In the pulmonary artery the IOD for elastin was 30 ± 12 in the BAV group and 29 ± 14 in the TAV group (p = 0.34). CONCLUSIONS: Patients with BAV were found to have less fibrillin-1 in the ascending aorta and pulmonary artery than patients with TAV. These findings may explain aortic root dilation and ascending aortic dissection in patients with BAV disease.

OBJECT: This paper aims to define the prescribility (therapeutic efficacy and bio-safety) of generic microemulsion Cyclosporin (Sigmasporin Microral®). METHOD: Casuistic: Twenty heart transplantation patients, 13 males and 7 females, with a mean age of 49.6 years, began immunosuppression treatment with generic microemulsion cyclosporin (Sigmasporin Microral®). They underwent clinical and laboratory evaluation during a minimum of three months. Procedures included clinic evaluation with electro and echocardiogram, endomyocardial biopsy, routine biochemical and hematological tests. RESULTS: The mean follow-up was 10 months with a maximum of 16 months. A total of 151 endomyocardial biopsies were evaluated: 31.7% were degree 0, 43.7% 1a and 23.1% 1b. We had only one case of acute clinical rejection confirmed by biopsy as IIIa, and one patient with mediastinitis, both of whom had a good evolution. The mean cyclosporin blood level was 303 Ng/mL. All other parameters also showed a good evolution. CONCLUSION: Generic microemulsion cyclosporin (Sigmasporin Microral®) shows therapeutic efficacy and an excellent bio-safety profile. Its Prescribility is confirmed.

PURPOSE: To retrospectively evaluate the survival rate of patients that underwent dynamic cardiomyoplasty, determining the influence of pre-, intra- and post-operative factors and the evolution of left ventricle ejection fraction according to the stimulation mode. METHOD: Forty-three patients that underwent dynamic cardiomyoplasty between May 1988 and September 1997 were analyzed. Functional class III was predominant (81.4%). The mean left ventricle ejection fraction was 19.37 ± 3.48%. Hospital death was 2.2% and 39 patients who completed the conditioning period had a mean follow up of 46 ± 26 months. Twenty-eight patients were predominantly maintained under stimulation mode 1:1 and 11 under 1:2 stimulation mode. RESULTS: Survival rate at nine years of follow up was 9%. The causes of death were progression of the heart failure and sudden cardiac death. Functional class, the pulmonary vascular-resistance index and stimulation mode were identified as risk factors. The maintenance of the increase of the left ventricle ejection fraction when compared to the preoperative values was more consistent during the studied period when the graft was stimulated in the 1:2 mode. CONCLUSION: Late results of dynamic cardiomyoplasty are limited by the high incidence of deaths by progression of the heart failure and sudden cardiac death. Survival rate is influenced by the preoperative clinical condition and by the stimulation mode. Muscle graft performance is higher at late follow up with the 1:2 stimulation mode.

OBJECTIVE: To report on the experience achieved with the surgical treatment of 361 patients with acute infectious endocarditis who were operated on in the Heart Institute of the University of São Paulo. METHOD: The ages of the patients ranged from 3 to 81 years, with an average age of 38 ± 8.3 years. There were 230 male patients. It was possible to identify the etiologic agent in 311 (86.20%) patients. The diagnosis of acute infectious endocarditis was obtained by clinical, echocardiographic and microbiological evaluations. Two hundred and five patients had lesions of heart valves and 156 patients had lesions of cardiac valvular prostheses. Ninety had annular abscesses and 11 had fistulae. Of the group of diseased native valves, 104 (50.73) were operated on because of severe heart failure and 87 (42.44%) because of progressive sepsis. All natural aortic valves (136) were replaced by artificial valves. There were 107 diseased native mitral valves. In this group partial resections of infected tissue (vegetations) were carried out in 13 patients while maintaining the valvar apparatus. Of the 16 infected tricuspid valves, 8 were replaced. All the prostheses were substituted. The abscesses were cleaned and closed when their diameter was less than 10 mm. The larger abscesses were cleaned and closed with a pericardial graft, which was the support for the artificial valve. RESULTS: There were 75 (20.78%) hospital deaths, most of which caused by heart problems and their complications. There were 15 cases of postoperative endocarditis, 10 of which were re-operated on. The late follow-up showed good functional and clinical results, with 222 (77.62%) patients as NYHA Class I. CONCLUSIONS: When indicated, the surgical treatment must be instituted as early as possible. All diseased and infected tissue must be removed to achieve good results.

OBJECTIVE: This work aimed at establishing scientific criteria using the valve size mismatch to predict the transvalvar gradient resultant of aortic valve replacement. METHOD: Thirty-one consecutive patients who survived aortic valve replacement surgeries using Labcor porcine stented prosthesis, in the period from March 1993 to June 2002 were studied. Each patient was submitted to an echocardiogram within three postoperative months at the same institution. The mean transvalvar gradient pressure was compared with the diameter of the prosthesis and the patient's body surface area. RESULTS: The p-value for the diameter of the prosthesis was 0.81 and 0.59 for the R Index. CONCLUSION: No relation at all was found to help to predict the postoperative pressure gradient, based on the prosthesis size and the body surface area of the patients.

The case of a 49-year-old man who suffered a car accident responsible for several chest injuries including fractures of the left ribs, large subcutaneous emphysema and left hemopneumothorax arrived in shock in the Emergency Room of the Real Hospital Português de Beneficência in Pernambuco (RHPBPE). He was hospitalized for 30 days including some time in the intensive care unit and but did not show signs of diastolic murmur or heart failure. He was submitted to an echocardiography examination that diagnosed slight aortic incompetence, good left ventricular function and was discharged after clinical improvement. Three months later he started to feel symptoms of heart failure and returned to cardiac Emergency Room of the same Hospital. He repeated transthoracic and transesophageal echocardiography examinations presenting severe aortic incompetence due to leaflet disruption, rupture of atrial septum with enlargement of the right cardiac chambers and poor left ventricular function. He underwent surgical treatment of these lesions, with direct approach of the atrial septum and the aortic valve was replaced with a mechanical prosthesis, with a good result.

We report a case and evolution of a patient in whom the coronary sinus was damaged and reconstructed through the mitral annulus. The surgical accident happened during a degenerated biological valve prosthesis instrumentation. An almost complete left circumflex coronary artery division was our first hypothesis. A coronary probe introduced through the vascular injury was distally detected inside the right atrium confirming a coronary sinus lesion. The surgical correction was performed using running polypropylene 7-0 sutures through the mitral ring. After fourteen months, a coronary sinus angiographic image was taking observing the venous phase of selective left coronary arteriography. The image demonstrated an acceptable narrowing of the local venous repair. In our opinion the single coronary sinus division or its repair, in this iatrogenic situation, is a matter of speculation.

OBJECTIVE: This study evaluates a new technique of an extracardiac conduit in total cavopulmonary connection in complex congenital heart disease. METHODS: Between May 2000 and October 2002, 18 extracardiac conduit surgeries were performed. The patients' weights ranged from 11 to 29 kilograms, the ages ranged from 1 to 12 years old and 10 patients were male. There were eight patients with tricuspid atresia, eight with univentricular heart, and two with unbalanced total atrioventricular septal defect. There were 17 patients who had been submitted to a previous palliative surgery. The surgery was performed at over 32º centigrade without aortic ischemia. Ten PTFE, 4 Hemashield and 4 bovine pericardium tubes were used with diameters ranging from 16 to 22 mm. RESULTS: There were four cases of tube thrombosis and these patients were a reoperation was performed with one death. In one patient a takedown was performed on the 69th postoperative day. There were three deaths, one due to tube thrombosis and two due to low cardiac output. CONCLUSION: Extracardiac conduit is already used for total cavopulmonary connection, but despite encouraging early results, a longer follow-up is necessary to prove its real advantages.

OBJECTIVES: To evaluate the prognostic implications of myocardial creatine kinase and troponin I (cTn I) in blood samples from the coronary sinus of patients submitted to coronary artery bypass surgery both with and without ischemic preconditioning. METHODS: From October 1998 to May 1999, 35 patients with coronary artery disease who were submitted to coronary artery bypass surgery were studied. Samples containing creatine kinase and cTn I were obtained from the great cardiac vein during surgery at the onset of cardiopulmonary bypass, at the end of the first anastomosis, and at the end of cardiopulmonary bypass. In May 2002, 29 patients were evaluated in regards to the angina functional class, congestive heart failure, number of hospitalizations, myocardial infarction and death. There were 15 patients in the Preconditioned group and 14 in the Control group. Each group was subdivided into patients with and without cardiovascular symptoms. RESULTS: The Control and Preconditioned groups were not significantly different in relation to frequency of cardiovascular symptoms. There were progressive increases of the creatine kinase and cTn I levels at different Interval s of the study. The cTn I in the Preconditioned group was 1.21 ± 0.64 ng/mL and 3.19 ± 3.21 ng/mL in the Control group (p<0.05). The Control group with symptoms had the highest level for cTn I of 5.07 ± 3.69 ng/mL, significantly higher than all other groups (p<0.05). CONCLUSIONS: The Preconditioned group had the lowest level of cTn I. The cTn I may be a marker for late evolution in patients submitted to coronary artery bypass surgery.

OBJECTIVES: The present study is aimed at evaluating the long-term outcomes (up to 12 years of follow-up) of patients undergoing aortic valve replacement using bovine pericardial prostheses. METHOD: From March 1992 to January 2003, 287 patients underwent aortic valve replacement as a single procedure, using bovine pericardial prostheses. Of these, 189 (65.9%) were males. Ages ranged from 15 to 82 years with a mean and standard deviation of 53.6 ± 15.1 years and median of 56 years. The diameters of the bioprostheses ranged from 21 to 29 mm, of which 23 mm (105 cases, 36.6%) and 25 mm (105 cases, 36.6%) were the most prevalent sizes. Only in 1 patient was a 29-mm prosthesis implanted. The assessed variables were late overall survival, comparative survival of patients < 70 years and ³ 70 years of age and the percentage of patients free from reoperations due to primary valve failure. Statistical analysis was performed with the aid of actuarial curves (Kaplan-Meier). RESULTS: The overall actuarial survival at the end of 12 years was 91.7 ± 2.2%. Separate analysis of patients < 70 years (Group A= 252 patients) and ³ 70 years (Group B= 35 patients) showed the overall survival in Group A was 94.7 ± 1.7% and 58.1 ± 17.2% in Group B (Logrank test P= 0.0005; Hazard Ratio 0.20 95% CI 0.01 to 0.29). The rate free from reoperation due to primary valve failure was 96.1 ± 2.0% at the end of 12 years. The 4 patients with implantation failure were in Group A and had a mean age of 49.7 years. CONCLUSIONS: The use of bovine pericardial prostheses in patients with aortic valve disease provides an excellent survival rate over 12 years of follow-up. Patients with 70 years and over had a significantly lower survival, but dysfunctions were only observed in the younger group of patients.

OBJECTIVE: Inflammatory response and metabolic disturbances in coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) and without (OFF-PUMP) have been researched. Apoptosis in ischemic reperfusion and chronic disease models has been shown in recent studies. The objective of this study is to compare the apoptosis intensity detected in cardiac myocytes before and after CABG with and without cardiopulmonary bypass. METHOD: Eighteen patients undergoing elective CABG were divided in two groups: the first group underwent cardiopulmonary bypasses and the second group did not. Auricle myocardial samples were obtained at the beginning and at the end of the surgery. Specimens were examined for apoptosis using the TUNEL method. RESULTS: There was no significant difference between the two groups in the surgical, demographic and postoperative data. The number of grafts was statistically different. There was no significant difference between the numbers of cells undergoing apoptosis in the two groups at the beginning of the procedure. There was no significant difference in the number of cells undergoing apoptosis from the beginning to the end of CABG in the OFF-PUMP group. There was a significant difference between the number of cells undergoing apoptosis at the beginning and the end of the CABG in the CPB group (p<0.01). CONCLUSION: The smaller number of cells undergoing apoptosis in the OFF-PUMP group is in accordance with published data that suggest CPB is capable of promoting cell lesion. Having shown that, another favorable argument can be added to the indication of the CABG without CPB.

INTRODUCTION: Pharmacological cardioplegic solution aims to eliminate the consequences of ischemic damage, which results from the misbalance between the offer and consumption of energy during the arrest of the heart beats during cardiac surgery with cardiopulmonary bypass. OBJECTIVES: This research experimentally evaluates the structural and ultrastructural changes in isolated rabbit hearts submitted to arrest protected by a Low Volumetric Cardioplegic Solution (LVCS). MATERIAL AND METHOD: The study counted with a control group and two experimental groups. In group I the cardiac arrest was obtained by infusion of the LVCS for 2 hours. In group II the experiment was conducted in the same way until the arrest protected by LVCS for 2 hours, and immediately after reperfusion was performed with the Ringer Locke (RL) oxygenated solution for 1 hour. In the control group the hearts were perfused with the RL oxygenated solution for 2 hours. After the experiments, 8 samples of the left ventricle were fixed in 10% formaldehyde and 2.5% glutaraldehyde for histological and ultrastructural analysis. RESULTS: The myocardial cells, the fibroblasts and the endothelial cells which were observed in the experimental groups I and II, presented with marginalization of the heterochromatin, compaction of the nucleolus, change in the morphology of the mitochondria and compaction of the cristae. Also there was an increase of the density of the mitochondrial matrix. This indicates that the nuclear structure as well as the structure of the cytoplasmic organelles were altered when compared to the cells of the control group. CONCLUSION: The structural modifications were due a physiological adaptation of the cell, and not an indication of oncosis or apoptosis, suggesting that the cardioplegic solution used was efficient for the preservation of the cells.

OBJECTIVE: To analyze the behavior of troponin (TROP I) and CKMB mass (CKMBm) in regards to the addition of magnesium in cardioplegic solutions; and also the influence of per-operative factors. METHOD: A total of 28 children with ages ranging from 3 to 108 months were studied. The mean weight was 11.8 kg. Eighteen were male. The patients were divided into two groups. Sixteen children in group I (GI) and 12 in group II (GII). The patients in GI received cold blood cardioplegic solution with magnesium (12 mEq/L) and potassium chloride (20 mEq/L) at 20 mL/kg. The patients in GII received the same solution without magnesium. Six blood samples were collected for serum analysis of the concentration of TROP I and CKMBm. The blood samples were collected before clamping the aorta and at 1, 6, 24, 48 and 72 hours after aorta clamping termination. RESULTS: There were no statistical differences in the TROP I and CKMBm levels between the two groups. Among the per-operative factors cyanosis influenced the TROP I and CKMBm levels. Additionally, the aorta clamping time influenced the TROP I levels. CONCLUSIONS: The addition of magnesium in the cardioplegic solution was not associated with different levels of TROP I and CKMBm. Cyanosis and aorta clamping time interfered with peak TROP I levels.

INTRODUCTION: Prevention of recurrent cryptogenic strokes or transient ischemic attacks in adults with patent foramen ovale (PFO) represents a therapeutic challenge. Antithrombotic pharmacological treatment is widely used, but its indication is limited because of its significant complications. OBJECTIVE: To demonstrate the efficacy of the surgical closure of patent foramen ovale (PFO) as prophylaxis secondary to cryptogenic strokes or transient ischemic attacks of undetermined origin. METHOD: In this study, 31 men and 16 women with previous ischemic cerebral events underwent direct surgical closure of the PFO. Mean age was 40 years (from 27 to 59 years). No coexisting cause of the stroke was found after extensive investigation, including blood coagulation tests, transesophageal contrast echocardiography (TEE), extracranial and transcranial doppler ultrasonography, 24-hour electrocardiographic monitoring, brain magnetic resonance (BMR) and CT scan. Criteria for operation also included at least two of the following: atrial septal aneurysm, multiple cerebral infarcts, multiple cerebral events and a history of Valsalva strain before stroke. Before operation, only one patient had two shunts (1 PFO and 1 intrapulmonary shunt). RESULTS: No complications occurred during or after the operation, but a few hours after the operation transient arrhythmias developed in four patients without atrial fibrillation, hemodynamic instability nor embolism. All patients survived in class I (NYHA) and during a mean follow-up of 36 months, no patient had recurrence of the stroke or transient ischemic attacks. All patients prospectively underwent BMR and contrast TEE with simultaneous transcranial doppler ultrasonography. A residual right-to-left shunt, smaller than the preoperative one, was observed in only one patient, whereas no lesion was seen on the BMR. CONCLUSION: It is concluded that surgical closure of PFO in patients with presumed paradoxical embolism is safe and avoids recurrent stroke.

OBJECTIVES: To study the influence of geometric factors upon the function of modified Blalock-Taussig anastomoses (mBT) using a computational dynamic code based upon the method of finite elements. METHODS: The mBT operation, performed in 10 patients, was graphically reconstructed to create a parametric 3-dimensional geometric model. Using Streamline Upwind/Petrov-Galerkin approximations, blood flow and distribution were evaluated in different diameters of subclavian arteries and polytetrafluoroethylene grafts (PTFE) and angles of proximal anastomoses. RESULTS: The percentage of blood flow derived through the PTFE grows as its diameter increases in relation to subclavian artery diameter. Variations in the PTFE diameter do not interfere with pulmonary artery flow distribution. An angle of 110º in proximal anastomoses results in a high percentage of blood derivation to the graft, while angles of 30º, 60ºand 90º present with almost similar flow rates. However, angles of 30º and 110º produce an excessive flow to one of the pulmonary arteries, in detriment of the other. Peak pressure in the PTFE is affected by the proximal angle of anastomosis, with 30º resulting in higher and 110º in lower values. As the angle increases, the region of higher pressure shifts from the PTFE to subclavian artery. CONCLUSION: In the experimental model, percentage of flow derived in the PTFE is directly related to the diameter of the graft. The ratio between the diameters of subclavian artery and graft is an important regulator of flow deviation to the anastomosis. Angles of the anastomosis between the subclavian artery and the PTFE of 60º to 90º result in favorable pulmonary artery flow distribution and the location of the peak pressure.