Encerramento de Foramen Oval Patente com Dispositivo Bioabsorvível "BioSTAR"

Os autores apresentam o caso clínico de uma doente de 35 anos, sexo feminino, que recorreu ao hospital da área da residência por parésia do membro superior direito, tendo sido diagnosticado AVC isquémico por Ressonância Magnética Nuclear Cranio-Encefálica (RMN-CE). A investigação da fonte embólica levou ao diagnóstico, por ecocardiograma transesofágico, de foramen oval patente (FOP), com shunt direito-esquerdo espontâneo. Em Maio de 2009 foi efectuado encerramento percutâneo do FOP com dispositivo bioreabsorvível “BioSTAR®”, sob controlo ecocardiográfico. Efectuou ecocardiograma transtorácico após o primeiro, terceiro e sexto mês pós-procedimento e ecocardiograma transesofágico aos nove meses, mostrando sempre adequada colocação do dispositivo, sem presença de shunt residual, sem qualquer intercorrência clínica durante este período. Os autores discutem a importância do desenvolvimento de dispositivos bioabsorvíveis para encerramento de FOP, e as suas vantagens em comparação com os dispositivos sintéticos previamente utilizados.

Síndrome do Coração Esquerdo Hipoplásico com Encerramento in Utero do Foramen Ovale: Caso Clínico

Apresenta-se o caso clínico de um recém- -nascido (RN) do sexo masculino, com diagnóstico pré-natal de síndrome do coração esquerdo hipoplásico (SCEH), referenciado às 37 semanas de gestação. No ecocardiograma fetal apresentava SCEH clássico com atrésia da aorta, válvula mitral permeável e septo interauricular espessado, mas com foramen ovale (FO) aparentemente permeável. Parto eutócico de termo, PN = 2540g, necessidade de intubação endotraqueal com ventilação assistida e prostaglandina E1 intravenosa. Imediatamente após o parto verificou-se agravamento clínico com deterioração dos valores gasimétricos. O ecocardiograma confirmou o diagnóstico, levantando a suspeita de encerramento do FO, que se confirmou no exame hemodinâmico, feito de seguida. Tentativa de atrioseptostomia de Rashkind, sem sucesso. O RN faleceu, tendo a autópsia revelado SCEH com FO encerrado, seio coronário aumentado e extensas linfangiectasias pulmonares. O aumento do seio coronário levou, neste caso, ao diagnóstico pré-natal errado de FO permeável com shunt esquerdo-direito.

Avaliação clínica na disfunção fronto-estriatal : movimento e cognição

RESUMO: Os circuitos fronto-estriatais constituem um sistema em ansa fechada que une diversas regiões do lobo frontal aos gânglios da base, participando, com outras áreas cerebrais, no controlo do movimento, cognição e comportamento. As Distonias Primárias, a Doença de Parkinson e a Hidrocefalia de Pressão Normal, são doenças do movimento caracterizadas por disfunção do circuito fronto-estriatal motor. A conectividade funcional entre as diversas ansas do sistema fronto-estriatal, permite prever que as doenças do movimento possam também acompanhar-se de sintomas da esfera cognitiva e comportamental, cuja avaliação seria importante no manejo diagnóstico e terapêutico dos doentes. Objectivos Os nossos objectivos foram avaliar, por estudos clínicos, a relação entre sintomas motores, cognitivos e comportamentais em três doenças do movimento com fisiopatologias diversas - distonias Primárias, Doença de Parkinson e Hidrocefalia de Pressão Normal - analisando os dados sob a perspectiva teórica fornecida pelo conhecimentos dos vários circuitos frontoestriatais. Os nossos objectivos específicos para cada doença foram: a) Distonias Primárias: avaliação de disfunção executiva em doentes com Distonia Primária e relação com a gravidade dos sintomas motores b) Doença de Parkinson: 1. avaliação breve das funções mentais nas fases iniciais da doença, incluindo análise longitudinal para determinação de factores preditivos para declínio cognitivo; 2. relação entre a função motora e cognitiva e a Perturbação do Comportamento do sono REM, incluindo análise longitudinal; 3.avaliação de sintomas psiquiátricos, de um ponto de vista global e especificamente com incidência sobre as Perturbações do Controlo do Impulso (PCI). c) Hidrocefalia de Pressão Normal: 1. caracterização das alterações da marcha, incluindo comparação com a Doença de Parkinson; 2. caracterização das alterações cognitivas e da relação entre estas e a disfunção da marcha; 3. estudo evolutivo das alterações da marcha e cognitiva em doentes submetido a cirurgia e doentes não submetidos a cirurgia. Métodos: A Distonia Primária, a Doença de Parkinson e a Hidrocefalia de Pressão Normal foram diagnosticadas segundo critérios clínicos validados. Sempre que justificado, foram recrutados grupos de controlo, com indivíduos sem doença, emparelhados para idade, sexo e grau de escolaridade. Os doentes foram avaliados com instrumentos de aplicação clinica directa, incluindo escalas de função motora, testes neuropsicológicos globais e dirigidos às funções executivas e escalas de avaliação psiquiátrica. Testes aplicados nas Distonias Primárias: Unified Dystonia Rating Scale, Wisconsin Card Sorting Test, teste de Stroop, teste de cubos da WAIS, Teste de Retenção Visual de Benton; na Doença de Parkinson: Unified Parkinson's Disease Rating Scale, Frontal Assessment Battery (FAB), Mini-Mental State Examination (MMSE), REM-sleep behaviour disorder Questionnaire; Symptom Chek-list 90-R, Brief Psychiatric Rating Scale, FAS (fluência verbal lexical) Nomeação de Animais (Fluência verbal semântica), prova de repetição de dígitos (WAIS), Rey auditory verbal learning test, teste de Stroop, matrizes progressivas de Raven, Questionnaire for Impulsive-Compulsive Disorders; na HPN: prova cronometrada de marcha,MMSE, prova de memória imediata da WAIS, prova de repetição de dígitos (WAIS), FAB, desenho complexo de Rey, teste de Stroop, cancelamento de letras, teste Grooved Pegboard. Os doentes com HPN foram também submetidos a estudo imagiológico. A avaliação estatística foi adaptada às características de cada um dos estudos.Resultados Distonias Primárias: encontrámos défices de função executiva, envolvendo dificuldade na mudança entre sets cognitivos, bem como correlação significativa entre as pontuações nos testes cronometrados e a gravidade dos sintomas motores. Doença de Parkinson: os doentes com DP obtiveram pontuações significativamente inferiores na FAB e em sub-testes do MMSE (memória e função visuo-espacial). A pontuação no MMSE encontrava-se significativamente correlacionada com itens da função motora não relacionados com o tremor. A disfunção da marcha, a disartria, o fenótipo não tremorígeno, a presença de alucinações e pontuação abaixo do ponto de corte na MMSE, foram factores preditivos de demência na avaliação longitudinal. A rigidez e a disartria foram factores preditivos de declínio nas funções frontais. A disfunção frontal foi factor preditivo de declínio na pontuação do MMSE. Encontrámos uma prevalência elevada de RBD nas fases iniciais da DP, que o estudo longitudinal mostrou ser factor preditivo de declínio motor, nomeadamente por agravamento da bradicinésia. Encontrámos também uma prevalência elevada de sintomas psiquiátricos, nomeadamente psicose, depressão, ansiedade, somatização e sintomas obsessivo-compulsivos. As PCI não se encontravam relacionadas com o fenótipo motor, com as complicações motoras do tratamento dopaminérgico ou com a disfunção cognitiva. HPN: os doentes com HPN e os DP apresentaram um padrão disfunção da marcha semelhante, caraterizado por passos curtos, lentidão e dificuldades de equilíbrio, sendo os sintomas mais graves na HPN. Os doentes de Parkinson com maior duração de doença, maior dose de dopaminérgicos e fenótipo motor acinético-rígido apresentaram um padrão de disfunção da marcha de gravidade semelhante ao encontrado na HPN. As alterações vasculares da substância branca, em particular as encontradas na região frontal, encontravam-se negativamente correlacionadas com a melhoria da marcha após PL. O estudo das funções cognitivas mostrou um padrão de atingimento global, com valores mais baixos na cópia do desenho complexo de Rey. Os resultados nas provas de função cognitiva não se encontravam significativamente correlacionados com os resultados na prova da marcha. A progressão na disfunção da marcha encontrava-se relacionada com o tratamento não cirúrgico, idade superior na primeira avaliação, presença de lesões da substância branca, e presença de factores de risco vascular, ao passo que não foram encontrados factores que predissessem de modo significativo o agravamento da função cognitiva. Conclusões: Os resultados dos diversos estudos, evidenciam a presença de alterações cognitivas e comportamentais nas três doenças de movimento. O padrão destas alterações e o modo como estas se relacionaram com os sintomas motores variou de doença para doença. Nas Distonias primárias, a perseveração cognitiva poderá ser o sintoma correspondente à perseveração motora própria da doença, sugerindo disfunção no circuito dorso-lateral frontoestriatal. A correlação entre a gravidade motora da doença e o resultado nos testes cognitivos cronometrados, poderá ser o efeito da relação entre bradicinésia e bradifrenia. Na Doença de Parkinson, o espectro de alterações é mais acentuado, espelhando a disseminação do processo degenerativo no SNC. Para além dos sintomas de disfunção executiva, sugerindo disfunção das tês ansas não motoras, existem sinais de disfunção cognitiva global, estas com uma influência mais significativa no desenvolvimento da demência. A relação entre os diferentes sintomas motores e cognitivos é também complexa, embora se evidencie uma dissociação significativa entre o tremor, sem relação com os sintomas não motores, e os sintomas motores não tremorígenos, relacionados com o declínio cognitivo. Enquanto que a presença de RBD parece ser um factor preditivo de agravamento motor, os sintomas psiquiátricos, também muito frequentes, apresentam uma relação menos clara com a função motora. Destes, os sintomas obsessivo-compulsivos são aqueles que com mais frequência se atribuem a disfunção do sistema fronto-estriatal, nomeadamente da ansa orbito-frontal. As PCI também não mostraram ter relação com os sintomas motores ou cognitivos. Na HPN, é patente o carácter fronto-estriatal das alterações da marcha, demonstrado tanto na sua caracterização quanto no efeito deletério das lesões vasculares da substância branca do lobo frontal na recuperação da marcha após PL. As alterações cognitivas parecem ter um padrão mais difuso, o que talvez explique a falta de correlação com os sintomas motores - esta dissociação pode ser causada quer por diferença nos mecanismos fisiopatológicos quer por presença de comorbilidades cognitivas. --------- ABSTRACT: Fronto-striatal circuits constitute a closed loop system which connects different parts of the frontal lobes to the basal ganglia. They are engaged in motor, cognitive and behavioural control. Primary Dystonia, Parkinson's Disease and Normal-Pressure Hydrocephalus are movement disorders caused by disturbance of the motor fronto-striatal circuit. The existence of cognitive and behavioural dysfunction in these movement disorders is predictable, given the functional connectivity between the several distinct loops of the circuit. Evaluation of cognitive and behavioural dysfunction in these three disorders is thus both of clinical and theoretical relevance. Objectives Our objectives were to evaluate, by clinical means, the relation between motor, cognitive and behavioural symptoms in three movement disorders with different pathophysiological backgrounds - Primary Dystonia, Parkinson's Disease and Normal-Pressure Hydrocephalus - and to analyse the study results under the theoretical framework formed by present knowledge of the fronto-estriatal system. Specific objectives: a) Primary Dystonia: executive dysfunction assessment and correlation analysis with motor dysfunction severity; b) Parkinson's Disease: 1. brief cognitive assessment in the early stages of disease, including a longitudinal analysis for determination of predictive factors for cognitive decline; 2. to investigate the relation between RBD and cognitive and motor dysfunction, including a longitudinal analysis; 3. psychiatric symptom assessment, with particular incidence on Impulse Control Disorders; c) Normal-Pressure Hydrocephalus: 1. gait dysfunction characterization and comparison with Parkinson's Disease patients; 2. determination of cognitive dysfunction profile and its relation with gait dysfunction; 3. follow-up study of cognitive and motor outcome in patients submitted and not submitted to shunt surgery. Methods: Primary Dystonia, Parkinson's Disease and Normal Pressure Hydrocephalus were diagnosed according to clinically validate criteria. Where warranted, we recruited control groups formed by healthy individuals, matched for age, sex and educational level. Patients were evaluated with instruments of direct clinical application, including motor function scales, neuropsychological tests aimed at global and executive functions and psychiatric rating scales. Tests used in Primary Dystonia: Unified Dystonia Rating Scale, Wisconsin Card Sorting Test, Stroop Test, Cube Assembly test (WAIS), Benton’s Visual Retention Test; in Parkinson's Disease: Unified Parkinson's Disease Rating Scale, Frontal Assessment Battery (FAB) , Mini-mental State Examination (MMSE), REM-sleep behavior disorder Questionnaire, Symptom Check-list 90- R, Brief Psychiatric Rating Scale, FAS (phonetic verbal fluency), semantic verbal fluency test, digit span test (WAIS), auditory verbal learning test,Stroop test, Raven's progressive Matrices, Questionnaire for Impulsive-Compulsive Disorders; in NPH: timed walking test, MMSE, immediate memory task (WAIS), digit span test (WAIS), FAB, Rey’s Complex Figure test, Stroop test, letter cancellation test, Perdue Pegboard test. NPH patients were also subjected to an imaging study. Statistics were adapted to the characteristics of each study.Results: Primary Dystonia: we found set-shifting deficits as well as significant correlation between timed neuropsychological tests and dystonia severity. Parkinson's Disease: PD patients had significantly lower scores on the FAB and on the memory and visuo-spatial tests of the MMSE; MMSE scores were significantly correlated to non-tremor motor scores; gait dysfunction and speech scores, non-tremor motor phenotype, hallucinations and scores bellow cut-off on the MMSE were predictive of dementia at follow-up; speech and rigidity scores were predictive of frontal type decline; frontal dysfunction was predictivy of decline in MMSE scores; RBD bradykinesia worsening; psychiatric symptoms were prevalent, particularly Psychosis, Depression, Anxiety, Somatisation and Obsessive-Compulsive Symptoms; Impulse Control Disorders were unrelated to motor phenotype,motor side effects of dopamine treatment and executive function; NPH: gait dysfunction was worse in NPH when compared to PD patients, although the pattern was similarly characterized by slowness, short steps and disequilibrium; PD patients whose gait disturbance was as severe as that of NPH patients were characterized by longer disease duration, predominance of non-tremor motor scores, more advanced disease stage and higher dopamine dose; frontal white matter lesions correlated negatively with improvement after LP; cognitive function assessment revealed wide spread deficits, with lower results on the drawing of the complex figure of Rey, which were not significantly correlated to gait dysfunction; older age, white matter lesions and the presence of vascular risk factors were predictive factors for motor but not cognitive function worsening. Conclusion: Results from our studies highlight the presence of cognitive and behavioural dysfunction in all three movement disorders. Symptom pattern and the relation with ovement derangement varied according to the disease. In Primary Dystonia, set-shifting difficulties could be the cognitive counterpart of motor perseveration characteristic of this disorder, suggesting dysfunction of the dorso-lateral circuit. The relation between timed tests and dystonia severity could suggest a relation between bradyphrenia and bradykinesia in Primary Dystonia. In Parkinson's Disease patients, the spectrum of non-motor symptoms is wider, probably reflecting the spread of neurodegeneration beyond the fronto-striatal circuits. While frontal type deficits predominate, suggestive of dorso-lateral and orbito-frontal dysfunction, non-frontal deficits were also apparent in the initial stages of disease, and were predictive of dementia at follow-up. The relationship between cognitive and motor symptoms is complex, although the results strongly suggest a dissociation between tremor symptoms, which bore no relation with non-motor symptoms, and non-tremor symptoms,whichwas frequent, and a predictive factor for which were related with cognitive decline. While RBD was found to be a predictive factor for bradykinesia worsening, psychiatric symptoms, which were also frequent, showed no apparent relation with motor dysfunction. Relevant to our theoretical consideration was the high prevalence of OCS, which have been attributed to orbito-frontal dysfunction. As to the particular case of ICD, we found no relation either with motor or cognitive dysfunction. The fronto-striatal nature of gait dysfunction in NPH is suggest by the clinical characterization study and by the effects of frontal white matter lesions on gait recovery after LP, whereas cognitive dysfunction presented a more diffuse pattern, which could explain the lack or relation with gait assessment results and also the different outcome on the longitudinal study - this dissociation could be caused by a real difference in pathophysiological mechanisms or, in alternative, be due to the existence of cognitive comorbidities.

Tratamento cirúrgico da hipertensão porta na esquistossomose mansoni

Define-se a hipertensão porta pela presença de um gradiente de pressão venosa hepática superior a 5mmHg. Ela é causada geralmente pelo aumento da resistência do leito vascular porta-hepático em decorrência de obstrução ao fluxo sanguíneo. Nas formas graves da esquistossomose há aumento progressivo da pressão porta e o desenvolvimento de varizes nos órgãos intra-abdominais, no retroperitônio e na parede do abdômen. A principal complicação desse processo é o sangramento digestivo, proveniente, na maioria dos casos, das varizes esofágicas e gástricas. Para o tratamento, diversos procedimentos clínicos (propranolol, somatostatina e octeotrida), endoscópicos (escleroterapia, clipes e ligaduras de varizes), vasculares (TIPS - shunt intra-hepático transjugular portasistêmico) e cirúrgicos (derivações portassistêmicas e desconexões portavarizes) têm sido propostos. Neste artigo, o autor apresenta revisão crítica sobre os vários tratamentos propostos, enfatizando os procedimentos cirúrgicos.

Size of gastroesophageal varices: its behavior after the surgical treatment of portal hypertension

The size of gastroesophageal varices is one of the most important factors leading to hemorrhage related to portal hypertension. An endoscopic evaluation of the size of gastroesophageal varices before and after different operations for portal hypertension was performed in 73 patients with schistosomiasis, as part of a randomized trial: proximal splenorenal shunt (PSS n=24), distal splenorenal shunt (DSS n=24), and esophagogastric devascularization with splenectomy (EGDS n=25). The endoscopic evaluation was performed before and up to 10 years after the operations. Variceal size was graded according to Palmer's classification: grade 1 -- up to 3 mm, grade 2 -- from 3 to 6 mm, grade 3 -- greater than 6 mm, and were analyzed in four anatomical locations: inferior, middle or superior third of the esophagus, and proximal stomach. The total number of points in the pre-operative grading minus the number of points in the post-operative grading gave a differential grading, allowing statistical comparison among the surgical groups. Good results, in terms of disappearance or decrease of variceal size, were observed more frequently after PSS than after DSS or EGDS - 95.8%, 83.3%, and 72%, respectively. When differential grading was analyzed, a statistically significant difference was observed between PSS and EGDS, but not between proximal and distal splenorenal shunts. In conclusion, shunt surgeries were more efficient than devascularization in diminishing variceal size.

Desenvolvimento de um filtro ativo paralelo monofásico compacto e didático utilizando MOSFETs

Dissertação de mestrado integrado em Engenharia Eletrónica Industrial e Computadores

Desenvolvimento de um filtro ativo paralelo com CSI e controlo de corrente no barramento CC

Dissertação de mestrado integrado em Engenharia Eletrónica Industrial e Computadores

Comunicação interatrial do tipo seio coronário, comunicação interventricular e ausência de veia cava superior esquerda

Relatamos um caso raro de um paciente de 21 meses, portador de comunicação interatrial do tipo seio coronário, associada a comunicação interventricular perimembranosa, e ausência de veia cava superior esquerda. O diagnóstico foi realizado através da ecocardiografia e confirmado pela angiografia. O paciente foi operado sem intercorrências, ambos os defeitos foram fechados com patch de pericárdio bovino e o fluxo das veias coronárias ficou direcionado para o átrio esquerdo. Um ecocardiograma mostrou ausência de shunt residual através dos defeitos.

Experiência global no fechamento percutâneo do canal arterial

OBJETIVO: Avaliar a experiência global da nossa instituição com o fechamento percutâneo do canal arterial. MÉTODOS: Desde dezembro/92, 150 pacientes foram submetidos a 178 procedimentos (85 - técnica de Rashkind; 87 - coils de Gianturco; 6 - coils Duct Occlud). A mediana de idade foi de 6,5 anos (1 a 57). A média do diâmetro mínimo do canal foi de 3,05±1,24mm (1 a 8). Avaliações clínicas e ecocardiográficas foram realizadas seriadamente. RESULTADOS: Implantes adequados ocorreram em 143 (95,3%) pacientes. A prevalência de shunt residual imediato foi de 52,1%, decrescendo para 15,9% no seguimento. Esta taxa caiu para 5,2% após a realização de procedimentos adicionais. Embolização de coils ocorreu em 12 procedimentos e de umbrella em 1. Um paciente apresentou hemólise e outro estenose discreta da artéria pulmonar esquerda. Não houve mortalidade. CONCLUSÃO: Esta modalidade terapêutica é segura e eficaz, proporcionando bons resultados a longo prazo.

Percutaneous closure of atrial septal defects. The role of transesophageal echocardiography

PURPOSE: Evaluation of the role of transesophageal echocardiography in percutaneous closure of atrial septal defects (ASD) with the Amplatzer septal occluder. METHODS: Patients were selected for percutaneous closure of ASD by transesophageal echocardiography (TEE), which was also used to monitor the procedure, helping to select the appropriate size of the Amplatzer device, to verify its position, and to access the immediate results of the procedure. During the follow-up, TEE was used to evaluate the presence and magnitude of residual shunt (RS), device position, and right cardiac chamber diameters. RESULTS: Twenty-two (40%) of a total of 55 studied patients were selected. Thirteen underwent Amplatzer device implantation, eight are still waiting for it, and one preferred the conventional surgical treatment. All procedures were successful, which was mainly due to proper patient selection. Six (23%) patients acutely developed RS, which spontaneously disapeared at the three-month follow-up examination in three patients. There was a significant reduction in the right ventricle diastolic diameter, from 27mm (average) to 24mm and 20mm, one and three months after the procedure, respectively (p<0.0076). CONCLUSION: With the aid of TEE, percutaneous closure of ASD can be successfully, safely, and effectively performed.

Invasive hemodynamic monitoring in the postoperative period of cardiac surgery

OBJETIVE: To assess the hemodynamic profile of cardiac surgery patients with circulatory instability in the early postoperative period (POP). METHODS: Over a two-year period, 306 patients underwent cardiac surgery. Thirty had hemodynamic instability in the early POP and were monitored with the Swan-Ganz catheter. The following parameters were evaluated: cardiac index (CI), systemic and pulmonary vascular resistance, pulmonary shunt, central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), oxygen delivery and consumption, use of vasoactive drugs and of circulatory support. RESULTS: Twenty patients had low cardiac index (CI), and 10 had normal or high CI. Systemic vascular resistance was decreased in 11 patients. There was no correlation between oxygen delivery (DO2) and consumption (VO2), p=0.42, and no correlation between CVP and PCWP, p=0.065. Pulmonary vascular resistance was decreased in 15 patients and the pulmonary shunt was increased in 19. Two patients with CI < 2L/min/m² received circulatory support. CONCLUSION: Patients in the POP of cardiac surgery frequently have a mixed shock due to the systemic inflammatory response syndrome (SIRS). Therefore, invasive hemodynamic monitoring is useful in handling blood volume, choice of vasoactive drugs, and indication for circulatory support.

New percutaneous techniques for perforating the pulmonary valve in pulmonary atresia with intact ventricular septum

We report new percutaneous techniques for perforating the pulmonary valve in pulmonary atresia with intact ventricular septum, in 3 newborns who had this birth defect. There was mild to moderate hypoplastic right ventricle, a patent infundibulum, and no coronary-cavitary communications. We succeeded in all cases, and no complications related to the procedure occurred. The new coaxial radiofrequency system was easy to handle, which simplified the procedure. Two patients required an additional source of pulmonary flow (Blalock-Taussig shunt) in the first week after catheterization. All patients had a satisfactory short-term clinical evolution and will undergo recatheterization within 1 year to define the next therapeutic strategy. We conclude that this technique may be safely and efficiently performed, especially when the new coaxial radiofrequency system is used, and it may become the initial treatment of choice in select neonates with pulmonary atresia and intact ventricular septum.

Percutaneous closure of ductus arteriosus with the amplatzer prosthesis. The Brazilian experience

OBJECTIVE - To report the results of percutaneous occlusion of persistent ductus arteriosus with the Amplatzer prosthesis in 2 Brazilian cardiological centers. METHODS - From May 1998 to July 2000, 33 patients with clinical and laboratory diagnosis of persistent ductus arteriosus underwent attempts at percutaneous implantation of the Amplatzer prosthesis. The median age was 36 months (from 6 months to 38 years), and the median weight was 14kg (from 6 to 92kg). Sixteen patients (48.5%) were under 2 years of age at the time of the procedure. All patients were followed up with periodical clinical and echocardiographic evaluations to assess the presence and degree of residual shunt and possible complications, such as pseudocoarctation of the aorta and left pulmonary artery stenosis. RESULTS - The minimum diameter of the arterial ducts ranged from 2.5 to 7.0mm (mean of 4.0±1.0, median of 3.9). The rate of success for implantation of the prosthesis was 100%. Femoral pulse was lost in 1 patient. The echocardiogram revealed total closure prior to hospital discharge in 30 patients, and in the follow-up visit 3 months later in the 3 remaining patients. The mean follow-up duration was 6.4±3.4 months. All patients were clinically well, asymptomatic, and did not need medication. No patient had narrowing of the left pulmonary artery or of the aorta. No early or late embolic events occurred, nor did infectious endarteritis. A new hospital admission was not required for any patient. CONCLUSION - The Amplatzer prosthesis for persistent ductus arteriosus is safe and highly effective for occlusion of ductus arteriosus of varied diameters, including large ones in small symptomatic infants.

Late Clinical Outcomes of the Fontan Operation in Patients with Tricuspid Atresia

OBJECTIVE: Evaluation of the long-term clinical results of the Fontan operation in patients with tricuspid atresia. METHODS: A retrospective analysis was made at the Instituto de Cardiologia do Rio Grande do Sul (Institute of Cardiology of Rio Grande do Sul), from August 1980 through January 2000, of 25 patients with a long-term follow-up, out of a series of 36 patients who underwent the Fontan operation or one of its variants due to tricuspid atresia. Their mean age at surgery was 5.4±3.1 years, and their mean weight was 15.8±6.1 kg, the majority of them (63.9%) being males. Four patients underwent the classical Fontan operation, 12 the Kreutzer variant, 6 the Björk variant, 9 total cavopulmonary shunt with a fenestrated tube, and 5 total cavopulmonary shunt with a nonfenestrated tube. RESULTS: The patients were followed-up on an outpatient basis, with a mean long-term survival time of 5.5±4.2 years (50 days to 17.8 years) and a late mortality rate of 8%. Arterial saturation increased from 77.2±18.8% in the preoperative period to 91±6.7% upon the last outpatient visit (p>0.05). At the final check, most (67%) patients were asymptomatic and 87% could tolerate exercise. Ten (40%) patients experienced some kind of complication during the long-term follow-up, such as cardiac arrhythmia, cyanosis, protein-losing enteropathy, neurological events, right heart failure, intolerance to exercise and reoperation. CONCLUSION: The results indicate that, once the immediate postoperative period is over, during which the adaptations to the new circulatory physiology occur, the evolution of patients with tricuspid atresia who underwent the Fontan operation is satisfactory, in spite of a low, yet significant, morbidity.

Initial experience in Brazil with the Helex septal occluder for percutaneous occlusion of atrial septal defects

OBJECTIVE: To evaluate the initial clinical experience with the Helex septal occluder for percutaneous closure of atrial septal defects. METHODS: Ten patients underwent the procedure, 7 patients with ostium secundum atrial septal defects (ASD) with hemodynamic repercussions and 3 patients with pervious foramen ovale (PFO) and a history of stroke. Mean age was 33.8 years and mean weight was 55.4 kg. Mean diameter by transesophageal echocardiography and mean stretched ASD diameter were 11.33 ± 3.3mm, and 15.2 ± 3.8mm, respectively. The Qp/Qs ratio was 1.9 ± 0.3 in patients with ASD. RESULTS: Eleven occluders were placed because a patient with 2 holes needed 2 devices. It was necessary to retrieve and replace 4 devices in 3 patients. We observed immediate residual shunt (< 2mm) in 4 patients with ASD, and in those with patent foramen ovale total occlusion of the defect occurred. No complications were noted, and all patients were discharged on the following day. After 1 month, 2 patients with ASD experienced trivial residual shunts (1mm). In 1 patient, we observed mild prolapse in the proximal disk in the right atrium, without consequences. CONCLUSION: The Helex septal occluder was safe and effective for occluding small to moderate atrial septal defects. Because the implantation technique is demanding, it requires specific training of the operator. Even so, small technical failures may occur in the beginning of the learning curve, but they do not involve patient safety.