Resultado tardio da reconstrução da via de saída do ventrículo direito com prótese pulmonar bicúspide na correção da tetralogia de Fallot: relato de caso

We present a case of a 19 year-old female patient, with tetralogy of Fallot and hypoplastic pulmonary ring. Diagnosis was performed by echocardiography and cardiac catheterization. The surgical repair was performed at the age of 2 years old. A right ventricular outflow tract remodeling was performed using a porcine pulmonary bicuspid prosthesis. The patient presented a uneventful follow-up during 17 years. Postoperative assessment has shown: mild pulmonary insufficiency and mild pulmonary ventricle gradient, satisfactory right ventricular performance and prosthesis not presenting calcification. This is an option to correct the tetralogy of Fallot adopted by our Institution in the last two decades.EPM, UNIFESP, Disciplina Cirurgia Cardiovasc, Sao Paulo, BrazilEPM, UNIFESP, Disciplina Cirurgia Cardiovasc, Sao Paulo, BrazilWeb of Scienc

Operação de um ventrículo e meio como uma alternativa para o ventrículo direito hipoplásico

Objective: Patients with complex congenital heart disease, characterized by right ventricle hypoplasia, had a palliative surgical option with one and a half ventricular repair.Methods: From July 2001 to March 2009, nine patients (mean age 5.2 years, range 3 to 9 years) with hypoplastic right ventricle, underwent correction with one and a half ventricle technique. Preoperative diagnoses included: pulmonary atresia with intact ventricular septum, in six and Ebstein's anomaly, in three cases. Six patients had bidirectional cavo-pulmonary shunt (Glenn operation) previously. the surgical approach was performed with cardiopulmonary bypass to correct intracardiac defects: atrial septal defect closure (nine cases); right ventricle outlet tract reconstruction with porcine pulmonary prosthesis (seven cases); tricuspid valvuloplasty (three cases).Results: There was one (11.1%) hospital death. All the patients left the hospital in good clinical conditions. One patient presented pulmonary stenosis at distal prosthesis anastomosis and needed surgical correction. There was one (12.5%) late deaths after reoperation. At mean follow-up of 39.8 months (range 16 months to 8.4 years) seven patients are alive in functional class I (NYHA).Conclusions: Surgical treatment of congenital cardiac anomalies in the presence of a hypoplastic right ventricle by means of one and a half ventricle repair has the advantages of reducing the surgical risk of biventricular repair compared to the Fontan circulation; it maintains a low right atrium pressure, a pulsatile pulmonary blood flow and improves the systemic oxygen saturation with short and medium-term promising results. Longer follow-up is needed to prove the efficacy of such a repair in the long term.UNIFESP EPM, Disciplina Cirurgia Cardiovasc, São Paulo, BrazilUNIFESP EPM, Disciplina Cirurgia Cardiovasc, São Paulo, BrazilWeb of Scienc

Assessment of splanchnic perfusion with gastric tonometry in the immediate postoperative period of cardiac surgery in children

OBJECTIVE - A prospective, nonrandomized clinical study to assess splanchnic perfusion based on intramucosal pH in the postoperative period of cardiac surgery and to check the evolution of patients during hospitalization. METHODS - We studied 10 children, during the immediate postoperative period after elective cardiac surgery. Sequential intramucosal pH measurements were taken, without dobutamine (T0) and with 5mcg/kg/min (T1) and 10 (T2) mcg/kg/min. In the pediatric intensive care unit, intramucosal pH measurements were made on admission and 4, 8, 12, and 24 hours thereafter. RESULTS - The patients had an increase in intramucosal pH values with dobutamine 10mcg/kg/min [7.19± 0.09 (T0), 7.16±0.13(T1), and 7.32±0.16(T2)], (p=0.103). During the hospitalization period, the intramucosal pH values were the following: 7.20±0.13 (upon admission), 7.27±0.16 (after 4 hours), 7.26±0.07 (after 8 hours), 7.32±0.12 (after 12 hours), and 7.38±0.08 (after 24 hours), (p=0.045). No deaths occurred, and none of the patients developed multiple organ and systems dysfunction. CONCLUSION - An increase in and normalization of intramucosal pH was observed after dobutamine use. Measurement of intramucosal pH is a type of monitoring that is easy to perform and free of complications in children during the postoperative period of cardiac surgery.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

Hemostatic changes in children undergoing heart surgery with cardiopulmonary bypass

PURPOSE: We evaluated hemostasic changes in children undergoing open heart surgery with cardiopulmonary bypass (CPB). METHODS: We studied 17 children before, during surgery, in the immediate, first and between the 4th and 7th postoperative days, measuring hematocrit, prothrombin time, activated partial thromboplastin time, fibrinogen, platelet count, factor V and euglobulin lysis time. Children were divided in those with and without excessive bleeding in the postoperative period. RESULTS: We observed significant prolongation of prothrombin time and activated partial thromboplastin time, reduction of fibrinogen and factor V, and shortening of euglobulin lysis time. Six (35%) children bled excessively. Platelet count reduction was greater in the intra operative period in these cases and the duration of CPB was longer in this group. CONCLUSION: Changes in hemostasis during open heart surgery are due to coagulation cascade disorders as well as fibrinolysis. The incidence of excessive bleeding is higher in the pediatric group. Prolonged CPB time and greater reduction in platelet count differentiated both groups.OBJETIVO: Avaliar as alterações de hemostasia encontradas em crianças submetidas a cirurgia cardíaca com circulação extracorpórea (CEC). MÉTODOS: Estudamos 17 crianças no pré e pós-operatório (PO) imediato, no 1° PO e entre o 4º e 7º PO, analisando o hematócrito, tempo de protrombina (TP), tempo de tromboplastina parcial ativado, fibrinogênio, contagem de plaquetas, fator V e tempo de lise de euglobulina (TLE). Os pacientes foram divididos em grupos com e sem sangramento excessivo no PO. RESULTADOS: Houve alterações significantes no intra-operatório com aumento do TP e tempo de tromboplastina parcial ativado e redução do fibrinogênio, fator V e do TLE. Seis (35%) crianças sangraram excessivamente. A contagem de plaquetas foi significantemente menor no intra-operatório; neste grupo o tempo de CEC foi maior. CONCLUSÃO: Alterações de hemostasia no intra e PO ocorrem como conseqüência da ativação da cascata de coagulação e fibrinólise. A incidência de sangramento excessivo é alta nesta faixa etária. Os grupos com e sem sangramento excessivo diferenciaram-se pelo maior tempo de CEC e contagem reduzida de plaquetas.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

Measles vaccine: induced specific antibody in normal and undernourished infants

Two hundred and twenty tree children were studied regarding their response to the measles vaccine. The antibody response was measured by hemaglutination inhibition technique. Among the variables studied only the children's age at the time the vaccine was done had influence on the seroconvertion. Sex and nutritional status had no influence on the seroconvertion. A theoric model was designed to find at what age the vaccine had the best effect in preventing mortality. The age predicte was seven months.Foi estudada a indução de anticorpos anti-sarampo em 223 crianças nutridas e desnutridas vacinadas entre 6 e 24 meses e naquelas que permaneceram soronegativas com 1 dose da vacina realizada antes dos 12 meses que foram revacinadas após os 12 meses. A determinação de anticorpos anti-sarampo foi realizada pelas técnicas de inibição da hemaglutinação e de soroneutralização. Observamos que a taxa de soroconversão aumentou progressivamente com a idade, sendo de 43% aos 6 meses e de 80% aos 15 meses. A taxa de soroconversão em crianças marasmáticas foi semelhante à obtida em crianças nutridas, concordando com a literatura que vem demonstrando que crianças desnutridas não apresentam alteração na capacidade de resposta humoral à vacina. Utilizando os dados de mortalidade por sarampo e as taxas de soroconversão à vacina, idealizou-se um modelo hipotético para a avaliação da aplicação da vacina em diferentes idades e suas conseqüências em têrmos de mortalidade, e observou-se que quando a vacina é realizada em idades precoces (6-7 meses) o número de óbito esperado é inferior ao esperado quando a vacina é realizada em idades posteriores (9-11 meses), indicando que a proposta atual do Ministério da Saúde de aplicar dose única aos 9 meses, teoricamente aumentaria o risco de mortalidade. Considerando o número de crianças protegidas com 1 dose de vacina aplicada antes dos 12 meses e o número de crianças protegidas com a revacinação a taxa de soroconversão foi de 84,3%

Inquérito sorológico de sarampo em crianças de 5 a 15 meses de idade, em Curitiba e São José dos Pinhais, Estado do Paraná, Brasil, 1983

A serological survey intended to evaluate the causes of the high incidence of frequent outbreaks of measles in the cities of Curitiba and S. José dos Pinhais, Paraná, shows that of children vaccinated between 7 and 10 months of age, only 44% are protected, whereas in those vaccinated between the 11th and 15th months, the level of protection rises to 65.1%. Samples taken in non-vaccinated children at the 5th, 6th and 7th months of age showed protection level of 56.7%, 28.6% and 14.8% respectively. The children vaccinated during the 7th and 8th months of age had a percentage of protection of 50.8, and those vaccinated from the 9th month on, a percentage of 75.75. The geometric averages of antibody titers are also lower in those vaccinated before 9 months of age as compared to those vaccinated after this age.Inquérito sorológico, realizado para avaliar os motivos da alta incidência e surtos freqüentes de sarampo nas cidades de Curitiba e São José dos Pinhais - Paraná (Brasil), revela que entre 7 e 10 meses de idade só 44% das crianças vacinadas estão protegidas e que entre o 11º e 15º mês o índice de proteção se eleva para 65,1%. As não vacinadas, ao 5º, 6º e 7º mês de idade apresentaram percentuais de proteção de 56,7, 28,6 e 14,8, respectivamente. As crianças que foram vacinadas ao 7º e 8º mês apresentaram percentuais de proteção de 50,8 e as vacinadas a partir do 9º mês, de 75,75%. As médias geométricas dos títulos de anticorpos também foram menores nas vacinadas antes dos 9 meses, em relação às vacinadas a partir desta idade