Pulmonary arteriovenous fistula.
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Arteriovenous Fistula↗
Biomedical subjects
F B Jatene
Publications and source records attributed to F B Jatene.
Hepatic hydrothorax.
Hepatic hydrothorax (HH) is an uncommon manifestation of cirrhosis with ascites. Pleural effusions form when ascitic fluid moves through diaphragmatic defects that have been opened by increased peritoneal pressure. The diagnosis is established clinically by finding a serous transudate and is confirmed by radionuclide imaging demonstrating communication between the peritoneal and pleural spaces. In end-stage liver disease, the management of hepatic hydrothorax is problematic and often does not respond to medical therapy. Therapeutic options for a refractory hepatic hydrothorax include therapeutic thoracentesis, talc slurry through a chest tube, peritoneovenous and pleurovenous shunting, thoracoscopic talc poudrage, transjugular intrahepatic portosystemic shunt (TIPS), thoracosopic diaphragmatic defect repair followed by talc poudrage, and lastly, liver transplant. TIPS can be used as a bridge for transplantation but is often complicated by encephalopathy. Video assisted thoracic surgery (VATS) with patching the defect and talc poudrage may provide symptomatic relief; however, the morbidity and mortality in these extremely ill patients is high. The only definitive treatment for refractory hepatic hydrothorax associated with end-stage cirrhosis is liver transplantation.
Journal Article↗
Thoracoscopy talc poudrage : a 15-year experience.
OBJECTIVES: To review our experience with thoracoscopy and talc poudrage during the previous 15 years with regards to efficacy, side effects, morbidity, and mortality. METHODS: Six hundred fourteen consecutive patients (58.6% female; mean age, 54.5 years) underwent thoracoscopy with talc poudrage from August 1983 to May 1999. Of these, 457 patients had malignant pleural effusions, 108 patients had benign pleural effusions, and 49 patients had spontaneous pneumothorax. RESULTS: Sixty-four patients were excluded from evaluation for efficacy: 30 patients (4.9%) because the lung did not expand at the time of the procedure and 34 patients (5.5%) because they died within 30 days of the thoracoscopy. All exclusions were in the malignant group. The overall success rate of the 393 patients with malignant pleural effusions was 93.4%, while the overall success for the 108 patients with benign effusions was 97%, although 7 patients (7%) with benign effusions required a second thoracoscopy. The success rate with pneumothorax was 100%. Major morbidity included empyema in 4%, reexpansion pulmonary edema in 2.2%, and respiratory failure 1.3%. CONCLUSION: Thoracoscopy with talc poudrage is effective in producing a pleurodesis in malignant and benign pleural effusion and in spontaneous pneumothorax. However, it should be noted that the insufflation of talc has a systemic distribution associated with a low rate of morbidity and perhaps does induce ARDS, which is sometimes fatal in a small percentage of patients. Because of these side effects, the search for a better agent should be continued.
Female↗
Effects of bronchial transection and reanastomosis on mucociliary system.
STUDY OBJECTIVES: The mechanisms involved in the impairment of mucociliary function after lung transplantation are not completely understood. The purpose of the present study was to isolate the effects of unilateral bronchial transection and reanastomosis in a rat model. DESIGN: In situ bronchial mucociliary transport (MCT) was determined proximal and distal to the bronchial anastomosis, as well as in the right bronchus, in 48 rats classified into six groups: intact rats, and rats at 1 day, 2 days, 7 days, 15 days, and 30 days after bronchial transection and reanastomosis of the left main stem bronchus. In vitro mucus transportability and mucus contact angle were studied in another group of eight rats after 1 week of surgery. RESULTS: Distal to the anastomosis site, left bronchus in situ MCT (mean +/- SD) was 0.26 +/- 0.19 mm/min for the intact group, and 0.11 +/- 0.13 mm/min, 0.07 +/- 0.04 mm/min, 0.03 +/- 0.04 mm/min, 0.07 +/- 0.12 mm/min, and 0.05 +/- 0.06 mm/min for 1 day, 2 days, 7 days, 15 days, and 30 days after surgery, respectively (all significantly reduced, p < 0.05). No intergroup differences were found proximal to the anastomosis (p = 0.30). When comparing the left and right bronchi, differences were detected in both distal (p < 0.0001) and proximal sides (p = 0.0001). No significant differences in mucus transportability in vitro were found (p = 0.15). Mucus contact angle of the left bronchus (52.8 +/- 20.5 degrees ) was significantly greater than that of the mucus from the right bronchus (34.4 +/- 12.9 degrees; p < 0.05). CONCLUSIONS: We conclude that bronchial transection and reanastomosis lead to a marked impairment of MCT in distal airways, which can in part be explained by alterations in the surface properties of mucus.
Anastomosis, Surgical↗
Influence of ischemic preconditioning in myocardial protection in patients undergoing myocardial revascularization with intermittent crossclamping of the aorta. Analysis of ions and blood gases.
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.
Adult↗
Video-assisted pericardioscopy. How to improve diagnostic efficacy in pericardial effusions.
OBJECTIVE: To assess, in a prospective way, the experience with video-assisted pericardioscopy obtained in patients with pericardial effusion of unclear etiology in the preoperative period. METHODS: From January 1998 to June 2000, 20 patients were operated upon with the aid of video-assisted pericardioscopy. On echocardiography, 17 of these patients had significant pericardial effusion, and 3 had moderate pericardial effusion. Video-assisted pericardioscopy was performed through a small incision of the Marfan type. RESULTS: The diagnosis of pericardial effusion was established as follows: idiopathic in 9 (45%) patients, neoplastic in 4 (20%), resulting from hypothyroidism in 3 (15%), tuberculous in 2 (10%), due to cholesterol in 1 (5%), and chylopericardial in 1 (5%). The biopsy was positive in 30% of the patients, and the etiology could not be defined in 45% of the patients. CONCLUSION: Video-assisted pericardioscopy proved to be a method with low morbidity and a high index of diagnostic positivity. A high percentage of pericardial effusions are caused by viral infections, which are not diagnosed through current methods, being, therefore, classified as idiopathic.
Adolescent↗
Complete myocardial revascularization using arterial grafts.
BACKGROUND: Complete arterial revascularization is important in younger patients to reduce the likelihood of future reoperation. We assessed the short-term outcome of a strategy to provide complete arterial revascularization in a cohort of young patients. METHODS: Three hundred and eighty-five patients underwent myocardial revascularization using artery grafts alone and were followed up for 30 months. One hundred fourteen patients (29.6%) had single-vessel disease, 118 (30.6%) had two-vessel disease, and 153 (39.7%) had three or more obstructed coronary arteries. Eight of the patients had undergone previous surgical revascularization. The left internal thoracic artery (LITA) was routinely used for the left anterior descending branch (LAD). In 103 patients (28.1%), the in situ right internal thoracic artery (RITA) was used for revascularization of the right coronary artery (RCA) and its branches. The RITA was sometimes used as a free graft from the aorta or as an artificial "Y" from the LITA to the diagonal and marginal branches. Other arterial conduits included the radial artery (RA) in 215 patients (55.8%), the right gastroepiploic artery (RGEA) in 24 patients (6.3%), and the inferior epigastric artery (IEA) in four patients (1.1%). RESULTS: In patients having lesions in three or more arteries, the mean number of distal anastomoses was 3.2 per patient. There were no intraoperative deaths. Hospital mortality was 1.8% (n = 7). Of the fatal cases, two were redos and two underwent combined procedures (one for left ventricular aneurysm and one for double valve replacement), while only three of the fatal cases underwent revascularization as a primary and isolated procedure. CONCLUSIONS: Complete arterial reconstruction carries an acceptably low operative mortality and excellent short-term follow-up. This strategy is particularly important for young patients to reduce the probability of future reoperation.
Adult↗
Angiographic evaluation of graft patency in minimally invasive direct coronary artery bypass grafting.
BACKGROUND: The objective of this report is to describe our experience using minimally invasive direct coronary artery bypass grafting and to evaluate angiographic patency of anastomoses. METHODS: A total of 120 patients (86 men) were operated on, with ages ranging from 30 to 83 years (mean = 61.2 years). Two access routes were used: for single left anterior descending coronary artery lesions an 8 cm anterior minithoracotomy was performed at the fourth left intercostal space. Extracorporeal circulation was not used. In the last 82 patients a restraining device was used for the regional reduction of heart beats. Coronary cineangiography was carried out between postoperative days 1 and 3 in 84 (70%) patients. Anastomoses were graded: grade A, no blocks; grade B, blocks of more than 50%; grade C, occlusion. This evaluation was performed for two different periods: in the first period a restraining device was not used and in the second period a restraining device was used. RESULTS: In the first study period (38 anastomoses) coronary cineangiography showed grade A, 79%, grade B, 5.2%, and grade C, 15.8%. In the second study period (62 anastomoses), angiography showed grade A, 90.4%, grade B, 6.4%, and grade C, 3.2%. Early mortality was 1.6%. CONCLUSIONS: Minimally invasive coronary artery bypass grafting is a good alternative for some groups of patients. Anastomotic results seem to be better when a restraining device is used.
Adult↗
Right heart circulatory support facilities coronary artery bypass without cardiopulmonary bypass.
BACKGROUND: Revascularization of the posterior wall often causes hemodynamic instability in beating heart coronary artery bypass (CAB). Our previous clinical studies have shown that tilting the heart primarily alters right-heart hemodynamics. The purpose of this study was to evaluate right-heart support in clinical cases. METHODS: Seventeen patients underwent beating heart CAB with right-heart support. The right-heart support system (A-Med Systems, West Sacramento, CA) consisted of a coaxial cannula placed through the right atrium and the tip of the cannula positioned in main pulmonary artery. Blood was removed from the right atrium and returned to the main pulmonary artery. RESULTS: Elective beating heart CAB was accomplished successfully in 17 patients with right-heart support. Anastomoses performed were left anterior descending coronary artery (11), diagonal (3), circumflex (5), obtuse marginal artery (11), and right coronary artery (10). Right-heart support between 1 and 3 L/min improved hemodynamics especially in the circumflex position. No device-related patient incidents occurred, nor were there incidents of infection or air embolism. All 17 patients were discharged to their homes. CONCLUSIONS: The right-heart support system was safe without complications. Exposure of the posterior wall was possible in all cases without hemodynamic compromise.
Aged↗
Diagnosis and treatment of mediastinal tumors by thoracoscopy.
OBJECTIVES: Thoracoscopic management of mediastinal tumors is still subject to analysis. Seventy-three patients underwent thoracoscopy for treatment of mediastinal masses and were analyzed retrospectively in order to evaluate the effectiveness and complications of the procedure. METHODS: Between 1983 and 1999, 21 conventional thoracoscopies and 52 video-assisted thoracic surgeries were performed (33 for diagnostic purposes and 40 for therapy). Patient ages ranged from 2 to 81 years (mean, 43.8 years) with a slight predominance of girls and women over men and boys (41 vs 32, respectively). All patients underwent general anesthesia using simple intubation (22 patients) or double-lumen intubation (51 patients). RESULTS: The histologic type of tumors was obtained in all patients. For therapeutic purposes, a change of procedure to thoracotomy was necessary in nine patients. The reasons for this change were tumor size, tumor invasion of nearby structures, difficulties in continuing the dissection, the performance of an upper lobectomy, and suturing the iatrogenic lesion of the diaphragm. Four patients died during the first 30 postoperative days as a consequence of their primary pathology. CONCLUSION: Thoracoscopy was confirmed as an effective diagnostic and therapeutic alternative for the treatment of mediastinal disorders.
Adolescent↗
Thoracoscopy and talc poudrage in the management of hepatic hydrothorax.
STUDY OBJECTIVE: To determine indications, limitations, morbidity and mortality of surgical thoracoscopy for management of hepatic hydrothorax, a rare, but often recurrent, complication in cirrhotic patients. PATIENTS AND METHODS: From May 1985 through May 1999, 10 men and 8 women, with a mean age of 57.6 years (range, 26 to 76 years), underwent 21 therapeutic thoracoscopies to achieve pleurodesis by application of talc. RESULTS: The procedure was effective in 10 of 21 procedures. There were four recurrences (19. 1%) that were retreated, with only one being successful. In this specific group, we detected high morbidity (57.1%) and mortality (38.9%) during the follow-up period of 3 months. Diaphragmatic defects were localized and closed five times (23.8%). Hospital stay was approximately 15 days (range, 5 to 41 days). CONCLUSION: The procedure appears to be indicated for these fragile patients, especially when medical therapy fails. Immediate efficacy was 47.6%, increasing to 60% with videothoracoscopy and suture of the diaphragmatic defect. However, morbidity and mortality were high.
Adult↗
Descending necrotizing mediastinitis: a retrospective surgical experience.
OBJECTIVE: Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces. We reviewed the last 10 years of our surgical experience in DNM and commented on early diagnosis and aggressive surgical treatment in these patients. METHODS: Five males (71%) and two females (29%), mean age 34 years, with DNM, were surgically treated. Primary oropharyngeal infection occurred in three (43%) and odontogenic abscess in four (57%) patients. All had serious cervical and mediastinal infections with severe respiratory and hemodynamic repercussions, i.e. bacteremia, systemic arterial hypotension and obnubilation. Diagnosis was confirmed by computerized chest tomography. RESULTS: All patients underwent surgical drainage of the cervical region by bilateral transverse cervicotomy with debridement of the necrotic and infected tissues, associating ample mediastinal drainage with or without thoracotomy. Six patients (86%) evolved well and were discharged after a mean of 35 days. Two patients (29%) required reoperation due to local surgical complications: empyema and dehiscence of the sternum. One patient (14%) died on the second postoperative (p.o.) day due to renal and respiratory insufficiency. Cultures of DNM showed the development of associated aerobic and anaerobic flora in 71% of the operated patients and only aerobic in 29%. CONCLUSION: Early diagnosis by CAT scan of the neck and thorax aids in rapid indication of a surgical approach of DNM. Performing ample cervicotomy with mediastinal drainage generally associated with thoracotomy can significantly reduce the mortality rate for this condition to 14%.
Adolescent↗
Systemic distribution of talc after intrapleural administration in rats.
STUDY OBJECTIVES: Many reports have shown the efficacy of talc to induce an effective pleurodesis. However, there is little information about the side effects related to this sclerosing agent. The objective of this experimental study is to recognize the systemic distribution of talc after its instillation into the pleural space of rats. DESIGN: Forty animals were assigned to receive talc through a catheter placed in a left minimal thoracotomy. They were randomly divided in two groups: group 1 received 20 mg of talc and group 2 received 10 mg in the same total volume of 1 mL of saline solution. Half of the animals in each group were killed 24 h and the other half 48 h after the procedure. BAL was collected and histologic sections of both lungs, chest wall, liver, kidneys, spleen, heart, and brain were examined. Crystals were tracked using polarized light and we have used a "birefringent particles index of deposition" in an attempt to quantify the amount or talc encountered in different organs. RESULTS: Talc crystals were found in every organ of all animals studied (100%). There was no statistical difference either on the dose of talc used or in the time of death. The amount of talc was statistically different in the organs, which made us divagate about a route of absorption. CONCLUSIONS: We conclude that there is a progressive deposition of talc particles in the organs examined after its administration into the pleural space of normal rats. This report suggests that there is a rapid absorption of talc through the pleural surface and that the systemic distribution thereafter is not dose related. Further studies are necessary to assess the amount of crystals and the clinical correlation to these findings.
Animals↗
Aortic valve assessment. Anatomical study of 100 healthy human hearts.
PURPOSE: To assess anatomical characteristics of the aortic valve, so that they may be useful in diagnostic situations and surgical treatment. METHODS: The study analyzed 100 healthy fixed human hearts; 84% of them obtained from males, 61% of them from Caucasian individuals. The ages of the individuals ranged from 9 to 86 years (mean 30 +/- 15.5 years). The characteristics assessed related to age, sex, and race were the following: number and height of the cusps, size of the lunulae, internal and external intercommissural distance, position of the coronary ostium in relation to the aortic valve, position of the ventricular septum in relation to the aortic valve, thickness of the cusps. RESULTS: All hearts assessed had a tricuspidal aortic valve. In regard to the height of the cusps and size of the lunula, the left coronary cusp was larger, followed by the right coronary cusp and the noncoronary cusp. The internal and external intercommissural distances had mean values of 24.6 +/- 5.7 mm and 19.7 +/- 7 mm, respectively. In regard to the position of the coronary ostia, in one heart two ostia emerged from the left coronary sinus, and in another, the ostium was supracommissural. The mean diameter of the aorta was 21.8 +/- 3.6 mm, and there were no significant sexual or racial differences, but the diameter increased progressively with the increase in age. The thickness of the cusps did not show any significant difference in the 3 points assessed. CONCLUSION: The aortic valve annulus did not show a perfect circumference, with some variations in the measurements of the annulus, in the cusps and in the relation with the ventricular septum.
Adolescent↗
Chylothorax after myocardial revascularization with the left internal thoracic artery.
A 38-year-old male underwent coronary artery bypass grafting (CABG). A saphenous vein graft was attached to the left marginal branch. The left internal thoracic artery was anastomosed to the left anterior descending artery (LAD). The early recovery was uneventful and the patient was discharged on the 5th postoperative day. After three months, he came back to the hospital complaining of weight loss, weakness, and dyspnea on mild exertion. Chest X-rays showed left pleural effusion. On physical examination, a decreased vesicular murmur was detected. After six days, the diagnosis of chylothorax was made after a milky fluid was detected in the plural cavity and total pulmonary expansion did not occur. On the next day, both anterior and posterior pleural drainage were performed by videothoracoscopy, and prolonged parenteral nutrition (PPN) was instituted for ten days. After seven days the patient was put on a low-fat diet for 8 days. The fluid accumulation ceased, the drains were removed and the patient was discharged with normal pulmonary expansion.
Adult↗
Coronary artery bypass graft surgery in patients with ischemic cardiomyopathy and severe left ventricular dysfunction: short and long-term results.
BACKGROUND: We evaluated the prognostic value of preoperative parameters, surgical risk, functional benefits and long-term survival after myocardial revascularization in patients with established ischemic cardiomyopathy. METHODS: Seventy-one patients with ischemic cardiomyopathy, severe left ventricular dysfunction (left ventricular ejection fraction < 30%), and myocardial perfusion evaluated by Thallium-201 scintigraphy, were studied before and after myocardial revascularization, during hospitalization and throughout 48 months (average) of late follow-up. RESULTS: The early postoperative mortality was 2.8% and the five-year survival rate was 62.8%. When the survival rate was studied, there was no correlation with 1) the presence of Q-waves on preoperative cardiogram, 2) the presence of ischemia on Tl-201 scintigraphy, 3) the degree of left ventricular ejection fraction, or 4) the presence of angina. There was a statistically significant difference for survivors and non-survivors in the following parameters: 1) functional class IV of CHF, and 2) the presence of left bundle-branch block (LBBB). CONCLUSIONS: Our surgical results confirm that myocardial revascularization is a safe procedure, and that it increases late survival and improves the quality of life in patients with ischemic cardiomyopathy and severe left ventricular dysfunction. We also observed that due to heterogeneous coronary and myocardial patterns of ischemic cardiomyopathy, preoperative prognostic parameters are difficult to establish. Preoperative functional class IV congestive heart failure, and LBBB were the main predictors of poor outcome following surgical revascularization for ischemic cardiomyopathy.
Aged↗
Repair of congenital sternal cleft in infants and adolescents.
BACKGROUND: Clinical and surgical aspects of sternal cleft repair are presented. Primary repair in the neonatal period is the best management for this rare condition, but none of the patients in this report were referred to us during that period. Autologous repair is suitable for older patients because it avoids problems related to the implant of prosthetic materials. METHODS: This article reviews 8 cases of sternal cleft not associated with ectopia cordis in patients presenting between October 1979 and November 1997. Surgical repair consisted of three sliding chondrotomies, three posterior sternal wall repairs, one combination with the Ravitch technique for pectus excavatum repair, and one posterior sternal wall repair associated with total repair of Cantrell's pentalogy. RESULTS: All patients who submitted to surgical correction had good aesthetic and structural results. The postoperative period was uneventful except that a subcutaneous fluid collection developed in 1 patient. The mean hospital stay was 5.8 days. The patients were followed up from 4 months to 18 years. CONCLUSIONS: Whether dealing with older children or young adults, the technique of reconstructing a new sternum with a posterior periosteal flap from sternal bars and chondral grafts is a simple, quick, inexpensive, and effective option.
Adolescent↗
Upregulation of collagen messenger RNA expression occurs immediately after lung damage.
BACKGROUND: Mortality of ARDS still exceeds 50%. Though pulmonary fibrosis is a marker of severe prognosis in the evolution of ARDS, its onset is not yet established. Cardiopulmonary bypass (CPB), usually utilized in patients with a previously normal lung, can cause ARDS and often causes alveolar damage, the earliest lesion observed in ARDS, thus providing a unique opportunity to study the molecular mechanisms of fibrogenesis. OBJECTIVE: To measure immediately after CPB, at the onset of alveolar damage, the expression of messenger RNAs (mRNAs) for collagen type I. METHODS: Pre-CPB and post-CPB lung biopsy specimens were obtained from patients submitted to myocardial revascularization for coronary artery disease. Alveolar damage was characterized by comparison between before and after specimens and quantified by point counting of polymorphonuclear cells (PMN). Type I collagen mRNAs were quantified by scanning densitometry of Northern blot autoradiographs, corrected for RNA loading by 18S ribosomal RNA hybridization. RESULTS: Alveolar damage was characterized by lung interstitial edema and by polymorphonuclear cell infiltration after CPB (PMN pre-CPB 0.010+/-0.004xPMN post-CPB 0.052+/-0.022; n=7; p=0.0017, t test). Type I collagen mRNA increased 91.1+/-68.2% (Ln pre-CPBxLn post-CPB; n=15; p<0.00001, t test) immediately after CPB (mean CPB time, 108.8+/-37.2 min). CONCLUSION: Fibrogenesis, as measured at the molecular level, is a very early event following diffuse alveolar damage, attributable mainly to resident fibroblast activation.
Adult↗