Análise do estudo anatomopatológico de pacientes submetidos a cirurgia valvar no InCór - HC FMUSP

Fabri, Hélio A; Pomerantzeff, Pablo M. A; Monteiro, Ana Cristina M; Gutierrez, Paulo; Violante, Raimunda; Auler Júnior, José Otávio C; Grinberg, Max; Verginelli, Geraldo; Jatene, Adib D

doi:10.1590/S0102-76381992000400002

Resumos

Das 44 necropsias realizadas em pacientes submetidos a cirurgia valvar no ano de 1990 no InCór, foram encontradas como causas clínicas de óbito nos pacientes mitrais: coagulopatia e sangramento em 11 casos; baixo débito em 7; choque cardiogênico em 5; choque séptico em 3; falência de múltiplos órgãos em 3; síndrome da angústia respiratória do adulto (S.A.R.A.) em 2; arritmia ventricular severa em 2; tromboembolismo pulmonar (T.E.P.) em 1. Nos pacientes aórticos: coagulopatia e sangramento em 5; choque cardiogênico em 2; septicemia em 3; aneurisma micótico roto em 1; acidente vascular cerebral hemorrágico (A.V.C.H.) em 1; arritmia venticular em 1. Nos pacientes mitro-aórticos: coagulopatia e sangramento em 2; T.E.P. em 2; septicemia em 1; arritmia ventricular severa em 1; S.A.R.A. em 1. Encontramos como causas anatomopatológicas de óbito nos pacientes mitrais: choque hemorrágico em 13; falência de múltiplos órgãos em 4; choque séptico em 3; broncopneumonia (B.C.P.) em 4; infarto agudo do miocárdio (I.A.M.) em 3; choque cardiogênico em 3; hemorragia cerebral em 1; S.A.R.A. em 1. Nos pacientes aórticos: endocardite em 3; choque hemorrágico em 2; hemorragia cerebral em 2; I.A.M. em 1; choque cardiogênico em 1; septicemia em 1; S.A.R.A. em 1; dissecção aguda de aorta com coagulopatia em 1. Nos pacientes mitro-aórticos: falência de múltiplos órgãos em 2; T.E.P. em 2; S.A.R.A. em 1; choque hemorrágico em 1; endocardite em 1. Concluímos haver correlação entre diagnóstico clínico e anatomopatológico em 36 pacientes, correspondendo a 82% dos casos, sendo a principal causa de óbito o choque hemorrágico. Uma observação importante: 11 (25%) pacientes apresentavam alguma forma de hepatopatia crônica, não diagnosticada anteriormente pelo estudo clínico-laboratorial, e que alguns pacientes que evoluíram em baixo débito, não explicado clinicamente, tiveram como achado anatomopatológico infarto subendocárdico.

valvas cardíacas

Of the 44 necropsies which were carried out in patients submitted to valvar surgery in 199 0 at InCór (Instituto do Coração), the following clinical causes of death were found in Mitral patients: coagulopathy and bleeding in 11 cases; low cardiac output in 7; cardiogenic shock in 5; septic shock in 3; failure of multiple organs in 3; acute respiratory distress syndrom (ARDS) in 2; severe ventricular arrythmia in 2, and pulmonary thromboembolism in 1. In aortic patients: coagulopathy and bleeding in 5 cases; cardiogenic shock in 2; septicaemia in 3; ruptured micotic aneurism in 1; stroke in 1, and ventricular arrhythmia in 1. In mitroaortic patients: coagulopathy and bleeding in 2 cases; pulmonary thromboembolism in 2; septicaemia in 1; severe ventricular arrythmia in 1, and ARDS in 1. The following anatomopathological causes of death were observed. In mitral patients: hemorrhagic shock in 13 cases; failure of multiple organs in 4; septic shock in 3; broncopneumonia in 4; acute myocardial infarction (AMI) in 3; cardiogenic shock in 3; cerebral hemorrahage in 1, and ARDS in 1. In aortic patients: endocarditis in 3 cases: hemorrhagic shock in 2; cerebral hemorrhage in 2; AMI in 1; cardiogenic shock in 1; septicaemia in 1; acute respiratory distress syndrom (ARDS) in 1, and acute dissection of the aorta, with coagulopathy in 1. In mitroaortic patients: failure of multiple organs in 2 cases; pulmonary thromboembolism in 2; ARDS in 1; hemorrhagic shock in 1, and endocarditis in 1. We concluded that there was correlation between the clinical and anatomopathological diagnoses in 36 patients, corresponding to 82 % of the cases, the principal cause of death being due to hemorrhagic shock. An important observation which was made in this study, was that 11 (25%) patients had some form of chronic hepatopathy which had not previously diagnosed from the clinical laboratory study. Some of the patients which developed clinically unexplained low cardiac output presented subendocardial infarct as an anatomopathological finding.

heart valves; heart valves

ARTIGOS ORIGINAIS

Análise do estudo anatomopatológico de pacientes submetidos a cirurgia valvar no InCór - HC FMUSP

Anatomopathological study of patients submitted to valvar surgery at InCór-HC FMUSP

Hélio A. Fabri; Pablo M. A. Pomerantzeff; Ana Cristina M. Monteiro; Paulo Gutierrez; Raimunda Violante; José Otávio C. Auler Júnior; Max Grinberg; Geraldo Verginelli; Adib D. Jatene

Do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

^{Endereço para separatas} Endereço para separatas: Hélio A. Fabri Divisão Cirúrgica Av. Dr. Enéas Carvalho de Aguiar, 44 05403 São Paulo, SP, Brasil

RESUMO

Das 44 necropsias realizadas em pacientes submetidos a cirurgia valvar no ano de 1990 no InCór, foram encontradas como causas clínicas de óbito nos pacientes mitrais: coagulopatia e sangramento em 11 casos; baixo débito em 7; choque cardiogênico em 5; choque séptico em 3; falência de múltiplos órgãos em 3; síndrome da angústia respiratória do adulto (S.A.R.A.) em 2; arritmia ventricular severa em 2; tromboembolismo pulmonar (T.E.P.) em 1. Nos pacientes aórticos: coagulopatia e sangramento em 5; choque cardiogênico em 2; septicemia em 3; aneurisma micótico roto em 1; acidente vascular cerebral hemorrágico (A.V.C.H.) em 1; arritmia venticular em 1. Nos pacientes mitro-aórticos: coagulopatia e sangramento em 2; T.E.P. em 2; septicemia em 1; arritmia ventricular severa em 1; S.A.R.A. em 1. Encontramos como causas anatomopatológicas de óbito nos pacientes mitrais: choque hemorrágico em 13; falência de múltiplos órgãos em 4; choque séptico em 3; broncopneumonia (B.C.P.) em 4; infarto agudo do miocárdio (I.A.M.) em 3; choque cardiogênico em 3; hemorragia cerebral em 1; S.A.R.A. em 1. Nos pacientes aórticos: endocardite em 3; choque hemorrágico em 2; hemorragia cerebral em 2; I.A.M. em 1; choque cardiogênico em 1; septicemia em 1; S.A.R.A. em 1; dissecção aguda de aorta com coagulopatia em 1. Nos pacientes mitro-aórticos: falência de múltiplos órgãos em 2; T.E.P. em 2; S.A.R.A. em 1; choque hemorrágico em 1; endocardite em 1. Concluímos haver correlação entre diagnóstico clínico e anatomopatológico em 36 pacientes, correspondendo a 82% dos casos, sendo a principal causa de óbito o choque hemorrágico. Uma observação importante: 11 (25%) pacientes apresentavam alguma forma de hepatopatia crônica, não diagnosticada anteriormente pelo estudo clínico-laboratorial, e que alguns pacientes que evoluíram em baixo débito, não explicado clinicamente, tiveram como achado anatomopatológico infarto subendocárdico.

Descritores: valvas cardíacas, estudo anatomopatológico.

ABSTRACT

Of the 44 necropsies which were carried out in patients submitted to valvar surgery in 199 0 at InCór (Instituto do Coração), the following clinical causes of death were found in Mitral patients: coagulopathy and bleeding in 11 cases; low cardiac output in 7; cardiogenic shock in 5; septic shock in 3; failure of multiple organs in 3; acute respiratory distress syndrom (ARDS) in 2; severe ventricular arrythmia in 2, and pulmonary thromboembolism in 1. In aortic patients: coagulopathy and bleeding in 5 cases; cardiogenic shock in 2; septicaemia in 3; ruptured micotic aneurism in 1; stroke in 1, and ventricular arrhythmia in 1. In mitroaortic patients: coagulopathy and bleeding in 2 cases; pulmonary thromboembolism in 2; septicaemia in 1; severe ventricular arrythmia in 1, and ARDS in 1. The following anatomopathological causes of death were observed. In mitral patients: hemorrhagic shock in 13 cases; failure of multiple organs in 4; septic shock in 3; broncopneumonia in 4; acute myocardial infarction (AMI) in 3; cardiogenic shock in 3; cerebral hemorrahage in 1, and ARDS in 1. In aortic patients: endocarditis in 3 cases: hemorrhagic shock in 2; cerebral hemorrhage in 2; AMI in 1; cardiogenic shock in 1; septicaemia in 1; acute respiratory distress syndrom (ARDS) in 1, and acute dissection of the aorta, with coagulopathy in 1. In mitroaortic patients: failure of multiple organs in 2 cases; pulmonary thromboembolism in 2; ARDS in 1; hemorrhagic shock in 1, and endocarditis in 1. We concluded that there was correlation between the clinical and anatomopathological diagnoses in 36 patients, corresponding to 82 % of the cases, the principal cause of death being due to hemorrhagic shock. An important observation which was made in this study, was that 11 (25%) patients had some form of chronic hepatopathy which had not previously diagnosed from the clinical laboratory study. Some of the patients which developed clinically unexplained low cardiac output presented subendocardial infarct as an anatomopathological finding.

Descriptors: heart valves, anatomopathological study; heart valves, surgery.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Trabalho realizado no Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, SP, Brasil.

Apresentado ao 19º Congresso Nacional de Cirurgia Cardíaca. São Paulo, SP, 7 a 9 de maio, 1992.

1 BERGGREN, H. R. E.; HERLITZ, J.; HJALMARSON, A.; WALDENSTROM, A.; WALDENSTROM, J.; OLSSON, G. W. - Improved myocardial protection during cold cardioplegia by means of increased myocardial glycogen stores. Thorac. Cardiovasc. Surgeon, 30: 389-392, 1982.
2 COLAPINTO, N. D. & SILVER, M. D. - Prosthetic heart valve replacement: causes of early postoperative death. J. Thorac. Cardiovasc. Surgeon, 61: 938-944, 1971.
3 GONZALEZ - LAVIN, L.; GONZALEZ - LAVIN, J.; McGRATH, L B.; AMINI, S.; GRAF, D. - Factors determining in-hospital or late survival after aortic valve replacement. Chest, 95: 38-42, 1989.
4 HUSEBYE, D. G.; PLUTH J. R., PIEHLER, J. M.; HARTZELL, V. S.; ORSZULAK, T. A.; PUGA, F. J.; DANIELSON, G. K. - Reoperation on prosthetic heart valves: an analysis of risk factors in 552 patients. J. Thorac. Cardiovasc. Surg, 86: 543-552, 1983.
5 KIRKLIN, J. W.; CONTI, V. R.; BLACKSTONE, E. H. - Prevention of myocardial damage during cardiac operations. N. Engl. J. Med, 301: 135-141, 1979.
6 KIRKLIN, J. K.; NAFTEL, D. C.; BLACKSTORE, E. H.; KIRKLIN, J. W.; BROWN, R. C.: Risk factors for mortality after primary combined valvular and coronary artery surgery. Circulation, 79 (Supl. 1) I-185-I-190, 1989
7 KYOSOLA, K. T.; BRAIMBRIDGE, M. W.; DANACOTT - CANKOVIC, S.; CHAMBERS, D. J. - Myocardial catecholamines following cold cardioplegic arrest during open - heart surgery. Scand. J. Thor. Cardiovasc, 18: 209-215, 1984.
8 LAURINDO, F. R. M.; GRINBERG, M.; ASSIS, R. V. C.; JATENE, A. D.; PILEGGI, F. - Perioperative acute myocardial infarction after valve replacement. Am. J. Cardiol, 59: 639-642, 1987.
9 LUND, O. - Preoperative risk evaluation and stratification of long-term survival after valve replacement for aortic stenosis; reasons for earlier operative intervention. Circulation, 82: 124-139, 1990.
10 McGREGOR, C. G. A.; MAC LEOD , M. D.; MUIR, A. L; SAITH, A. F.; HANNAN, W. J.; MILLER, H. C. - Myocardial infarction related to valve replacement surgery. Br. Heart J, 51: 612-617, 1984.
11 MORALES, A. R.; FINE, G.; TABER, R. E. - Cardiac surgery and myocardial necrosis. Arch. Path, 83: 71-79, 1967.
12 POMERANTZEFF, P. M. A.; ABREU, M. C. S.; AMATO, M.; MORETTI, M.; AULER JR., J. O. C.; GRINBERG, M.; TARASOUTCHI, F.; MANSUR, A.; DIAS, A. R.; BITTENCOURT, D.; STOLF, N.; VERGINELLI, G.; JATENE, A. D. - Retroca valvular. Rev. Bras. Cir. Cardiovasc, 2: 180-188, 1987.
13 POMERANTZEFF, P. M. A.; KIOKA, Y.; KAWABE, L. T.; AULER JR, J. O. C.; LOPES, E. A.; VERGINELLI, G.; JATENE, A. D. - Obstrução da via de saída de ventrículo esquerdo por prótese mitral: relato de seis casos. Rev. Bras. Cir. Cardiovasc, 5: 120-124, 1990.
14 ROBERTS, W. C. & HAMMER, W. J. - Cardiac pathologic after valve replacement with a tilting disc prosthesis. (Björk - Shilley type): a study of 46 necropsy patients and 49 (Björk - Shilley prosthesis. Am. J., Cardiol, 37: 1024-1033, 1976.
15 ROBERTS, W. C. & MORROW, A. G. - Causes of early postoperative death following cardiac valve replacement, clinic - pathologic correlations in 64 patients studied at necropsy. J. Thoracic. Cardiovasc, Surg, 54: 422-437, 1967.
16 ROBERTS, W. C. & MORROW, A. G. - Late postoperative pathological findings after cardiac valve replacement. Circulation, 35 e 36, (Supl. 1) I-48-I-62, 1967.
17 ROBERTS, W. C. & SULLIVAN, M. F. - Clinical and necropsy observations early after simultaneous replacement of the mitral and aortic valves. Am. J. Cardiol, 58: 1067-1084, 1986.
18 ROBERTS, W. C.& SULLIVAN, M. F. - Combined mitral valve stenosis and tricuspid valve stenosis: morphologic observations after mitral and tricuspid valve replacement or mitral replacement and tricuspid valve commissurotomy. Am. J. Cardiol, 58: 850-852, 1986.
19 ROSE, A. G. & PATH, M. R. C.. - Etiology of acquired valvular heart disease in adults; a survey of 18,132 autopsies and 100 consecutive valve replacement operations. Arch. Pathol. Lab. Med, 110: 385-388, 1986.
20 SALOMON, N. W.; STINSON, E. B.; GRIEPP, R. B.; SHUNWAY, N. E. - Mitral valve replacement: long-term evaluation of prosthesis related mortality and morbidity. Circulation, 56 (Supl.3) II-94 II-101, 1977.
21 SCHOEN, F. J.; TITUS, J. L.; LAWRIE, G. M. - Autopsy - determined causew of death after cardiac valve replacement. JAMA, 249: 899-902, 1983.
22 SCHWARZ, F.; FLAMENG, W.; SCHARPER, J.; LANGEBARTELS, F.; SESTO, M.; HEHRLEIN, F.; SCHLEPPER, M. - Miocardial structure and function in patients with aortic valve disease and their relation to postoperative results. Am. J. Cardiol, 41: 661-669, 1978.
23 SULLIVAN, M. F. & ROBERTS, W. C. - Clinical and morphologic observations after simultaneous replacement of the tricuspid, mitral and aortic valves. Am. J. Cardiol, 58: 781-789, 1986.
24 TEASDALE, S. J.; ZULYS, V. J.; MYCYK, T.; BAIRD, R. J.; GLYNN, M. F. - Ancrod anticoagulation for cardiopulmonary bypass in heparin - induced thrombocytopenia and thrombosis. Ann. Thorac. Surg, 48: 712-713, 1989.
25 ZEIEN, L. B. & KLATT, E. C. - Cardiac valve prosthesis at autopsy. Arch. Pathol. Lab. Med, 114: 933-937, 1990.

Endereço para separatas:

Hélio A. Fabri

Divisão Cirúrgica

Av. Dr. Enéas Carvalho de Aguiar, 44

05403 São Paulo, SP, Brasil

Datas de Publicação

Publicação nesta coleção
17 Fev 2011
Data do Fascículo
Dez 1992

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1 BERGGREN, H. R. E.; HERLITZ, J.; HJALMARSON, A.; WALDENSTROM, A.; WALDENSTROM, J.; OLSSON, G. W. - Improved myocardial protection during cold cardioplegia by means of increased myocardial glycogen stores. Thorac. Cardiovasc. Surgeon, 30: 389-392, 1982.

[2] 2 COLAPINTO, N. D. & SILVER, M. D. - Prosthetic heart valve replacement: causes of early postoperative death. J. Thorac. Cardiovasc. Surgeon, 61: 938-944, 1971.

[3] 3 GONZALEZ - LAVIN, L.; GONZALEZ - LAVIN, J.; McGRATH, L B.; AMINI, S.; GRAF, D. - Factors determining in-hospital or late survival after aortic valve replacement. Chest, 95: 38-42, 1989.

[4] 4 HUSEBYE, D. G.; PLUTH J. R., PIEHLER, J. M.; HARTZELL, V. S.; ORSZULAK, T. A.; PUGA, F. J.; DANIELSON, G. K. - Reoperation on prosthetic heart valves: an analysis of risk factors in 552 patients. J. Thorac. Cardiovasc. Surg, 86: 543-552, 1983.

[5] 5 KIRKLIN, J. W.; CONTI, V. R.; BLACKSTONE, E. H. - Prevention of myocardial damage during cardiac operations. N. Engl. J. Med, 301: 135-141, 1979.

[6] 6 KIRKLIN, J. K.; NAFTEL, D. C.; BLACKSTORE, E. H.; KIRKLIN, J. W.; BROWN, R. C.: Risk factors for mortality after primary combined valvular and coronary artery surgery. Circulation, 79 (Supl. 1) I-185-I-190, 1989

[7] 7 KYOSOLA, K. T.; BRAIMBRIDGE, M. W.; DANACOTT - CANKOVIC, S.; CHAMBERS, D. J. - Myocardial catecholamines following cold cardioplegic arrest during open - heart surgery. Scand. J. Thor. Cardiovasc, 18: 209-215, 1984.

[8] 8 LAURINDO, F. R. M.; GRINBERG, M.; ASSIS, R. V. C.; JATENE, A. D.; PILEGGI, F. - Perioperative acute myocardial infarction after valve replacement. Am. J. Cardiol, 59: 639-642, 1987.

[9] 9 LUND, O. - Preoperative risk evaluation and stratification of long-term survival after valve replacement for aortic stenosis; reasons for earlier operative intervention. Circulation, 82: 124-139, 1990.

[10] 10 McGREGOR, C. G. A.; MAC LEOD , M. D.; MUIR, A. L; SAITH, A. F.; HANNAN, W. J.; MILLER, H. C. - Myocardial infarction related to valve replacement surgery. Br. Heart J, 51: 612-617, 1984.

[11] 11 MORALES, A. R.; FINE, G.; TABER, R. E. - Cardiac surgery and myocardial necrosis. Arch. Path, 83: 71-79, 1967.

[12] 12 POMERANTZEFF, P. M. A.; ABREU, M. C. S.; AMATO, M.; MORETTI, M.; AULER JR., J. O. C.; GRINBERG, M.; TARASOUTCHI, F.; MANSUR, A.; DIAS, A. R.; BITTENCOURT, D.; STOLF, N.; VERGINELLI, G.; JATENE, A. D. - Retroca valvular. Rev. Bras. Cir. Cardiovasc, 2: 180-188, 1987.

[13] 13 POMERANTZEFF, P. M. A.; KIOKA, Y.; KAWABE, L. T.; AULER JR, J. O. C.; LOPES, E. A.; VERGINELLI, G.; JATENE, A. D. - Obstrução da via de saída de ventrículo esquerdo por prótese mitral: relato de seis casos. Rev. Bras. Cir. Cardiovasc, 5: 120-124, 1990.

[14] 14 ROBERTS, W. C. & HAMMER, W. J. - Cardiac pathologic after valve replacement with a tilting disc prosthesis. (Björk - Shilley type): a study of 46 necropsy patients and 49 (Björk - Shilley prosthesis. Am. J., Cardiol, 37: 1024-1033, 1976.

[15] 15 ROBERTS, W. C. & MORROW, A. G. - Causes of early postoperative death following cardiac valve replacement, clinic - pathologic correlations in 64 patients studied at necropsy. J. Thoracic. Cardiovasc, Surg, 54: 422-437, 1967.

[16] 16 ROBERTS, W. C. & MORROW, A. G. - Late postoperative pathological findings after cardiac valve replacement. Circulation, 35 e 36, (Supl. 1) I-48-I-62, 1967.

[17] 17 ROBERTS, W. C. & SULLIVAN, M. F. - Clinical and necropsy observations early after simultaneous replacement of the mitral and aortic valves. Am. J. Cardiol, 58: 1067-1084, 1986.

[18] 18 ROBERTS, W. C.& SULLIVAN, M. F. - Combined mitral valve stenosis and tricuspid valve stenosis: morphologic observations after mitral and tricuspid valve replacement or mitral replacement and tricuspid valve commissurotomy. Am. J. Cardiol, 58: 850-852, 1986.

[19] 19 ROSE, A. G. & PATH, M. R. C.. - Etiology of acquired valvular heart disease in adults; a survey of 18,132 autopsies and 100 consecutive valve replacement operations. Arch. Pathol. Lab. Med, 110: 385-388, 1986.

[20] 20 SALOMON, N. W.; STINSON, E. B.; GRIEPP, R. B.; SHUNWAY, N. E. - Mitral valve replacement: long-term evaluation of prosthesis related mortality and morbidity. Circulation, 56 (Supl.3) II-94 II-101, 1977.

[21] 21 SCHOEN, F. J.; TITUS, J. L.; LAWRIE, G. M. - Autopsy - determined causew of death after cardiac valve replacement. JAMA, 249: 899-902, 1983.

[22] 22 SCHWARZ, F.; FLAMENG, W.; SCHARPER, J.; LANGEBARTELS, F.; SESTO, M.; HEHRLEIN, F.; SCHLEPPER, M. - Miocardial structure and function in patients with aortic valve disease and their relation to postoperative results. Am. J. Cardiol, 41: 661-669, 1978.

[23] 23 SULLIVAN, M. F. & ROBERTS, W. C. - Clinical and morphologic observations after simultaneous replacement of the tricuspid, mitral and aortic valves. Am. J. Cardiol, 58: 781-789, 1986.

[24] 24 TEASDALE, S. J.; ZULYS, V. J.; MYCYK, T.; BAIRD, R. J.; GLYNN, M. F. - Ancrod anticoagulation for cardiopulmonary bypass in heparin - induced thrombocytopenia and thrombosis. Ann. Thorac. Surg, 48: 712-713, 1989.

[25] 25 ZEIEN, L. B. & KLATT, E. C. - Cardiac valve prosthesis at autopsy. Arch. Pathol. Lab. Med, 114: 933-937, 1990.