Brief communicationCongenital anomalies of the coronary arteries, occurring in 1-2% of the population 1 , are classified as anomalies at the origin (abnormal exit from the pulmonary trunk of the left coronary artery), terminal (coronary fistulae) and distributive (one coronary artery only) 2 . Congenital atresia of the ostium of the left coronary artery is a rather rare occurrence that is not even mentioned in the above-cited literature. Classically, it consists of total ostial atresia of the left coronary artery, possibly in association with atresia of the trunk of this vessel. Clinically, during the first months of life such patients may present with cardiac insufficiency (infantile form) or a delayed (including adults) picture of coronary insufficiency (adult form). We report below two patients of different ages and clinical presentations, having congenital atresia of the ostium of the left coronary artery of difficult diagnosis, who underwent successful surgical myocardial revascularization. Case reportsCase 1 -A nine-month-old boy from Divinolândia, SP, with a clinical history of tiredness on sucking, accompanied by discrete diaphoresis from the first month of life on. At six months of age, after a case of pneumonia, a sudden worsening of his condition occurred accompanied by cardiac insufficiency. A noninvasive investigation diagnosed dilated myocardiopathy. The patient showed significant improvement following medication, receiving a discharge from the hospital with a prescription of digoxin, furosemide and captopril. At nine months of age, he was referred to clinical examination at the Heart Hospital of Ribeirão Preto and he was found to be in excellent general condition (weight: 10 kg). On physical examination, he had a normal pulse and upon cardiac auscultation a ++/6 systolic murmur on the 2 nd -3 rd left intercostal space with normal heart sounds. Thoracic antero-posterior radiography showed significant cardiomegaly ( fig.1 upper side). The electrocardiogram showed unequivocal signs of anterolateral infarction ( fig. 2 A). In view of this consistent clinical evidence, an initial diagnosis of anomalous origin of the left coronary artery from the pulmonary atretik was made. Due to lack of evidence of an anomalous coronary artery on a previously performed echocardiogram, a diagnostic hemodynamic study was indicated. Depressed left ventricular function was observed during this procedure. The right coronary artery was dilated, and collateral circulation nourished the left coronary, which was atretic in its ostium. No shunting to the pulmonary artery was detected ( fig. 3). Once the diagnosis of congenital atresia of the ostium of the left coronary artery had been established, the infant immediately underwent surgical treatment by revascularization of the left coronary artery with a graft from the internal thoracic artery. The postoperative period was uneventfull, and 11 months following surgery the patient remains asymptomatic, in good general condition and under the use of digoxin. Thoracic radiography sh...

Our data showed that 4DCT had a better performance as a preoperative localization procedure of the parathyroid lesion in patients with NPHPT.

Summary: A 57-year-old woman developed severe substernal chest pain rddiating to the left arm accompanied hy pallor and marked diaphoresis. These symptoms appeared at rest, lasted 45 minutes, and terminated spntaneously. The patient had been treated for mild hypertension during the last 6 months. An ECG tracing obtained at the beginning of treatment was unremarkable. However, an ECG tracing recorded shortly after the end of the symptoms showed T-wave inversion in all anterior leads. Coronary arteriography was then performed and showed no fixed obstructive coronary artery disease. Nonetheless, a lengthened and constricted myocardial bridging of both the left anterior descending coronary artery and its major diagonal branch was detected. Also, he left anterior descending coronary artery was observed very short. terminating before the cardiac apex. The kft ventricle was hypertrophied. The patient was treated with a beta-blocking agent which eliminated all symptoms.ECG tracing obtained about three months after the onset of the clinical picture was nornial. Our findings suggest that marked myocardial ischemia at rest does occur in patients having myocardial bridges under special circumstances, such as lengthened and constricted myocardial bridging of a short coronary artery which supplies a hypertrophied ventricle. This anomaly should be taken into account as a possible cause of a threatened myocardial infarction, which may be successfully treated with a beta-blocking agent.

The objective of this paper was to describe the outcomes in patients submitted to arterial switch operation and to analyze the predictors of in-hospital mortality and further need of re-operation at a single-center institution. Between September 1995 and January 2014, 128 consecutive arterial switch operations were performed. Surgical mortality during this period was analyzed retrospectively, and a follow-up analysis of the survivors was conducted. Surgical era, cardiopulmonary bypass time (p = 0.001), and diagnosis category (p = 0.025) influenced in-hospital mortality. The estimated overall survival for the 91 hospital survivors was 96.8, 96.4, and 96.2 % at 5, 10, and 15 years, respectively. The median follow-up time was 67 months (range 0.71-222 months). Three patients (5 %) presented severe aortic regurgitation. Right ventricle outflow tract systolic gradient by echocardiography was above 60 mmHg in 2 %. Late re-interventions occurred in 12 (13 %) patients with mean time of 64 ± 34 months after the initial procedure. Actuarial freedom from re-interventions at 5, 10, and 15 years was 96.4, 69.7, and 61.9 %, respectively. Arterial switch operation remains the procedure of choice in patients with transposition of great arteries. It can be performed even in middle-volume institutions, leading to the same middle- and long-term outcomes of high-volume institutions. Early high mortality rate may occur due not only to learning curve, but also to cardiopulmonary bypass time and ventricular septal defect closure.

Introduction Congenitally corrected transposition of the great arteries (CCTGA) is a rare anomaly. Current data available regarding adult cases is derived from small series, information simultaneously presented in pediatric publications, and one classical multicenter study. This review, not aimed to exhaust the subject, has the purpose to examine the literature addressing presentation, diagnostic methodology, and management of afflicted adult patients. Methods A comprehensive search was undertaken in three major databases (PubMed, Cochrane, SciELO), using the keywords “congenitally corrected transposition of the great arteries” and “adults”. Relevant articles in English, Spanish, and Portuguese were extracted and critically appraised in this review. Steps for study selection were: (1) identification of titles of records through databases searching, (2) removal of duplicates, (3) screening and selection of abstracts, (4) final inclusion in the study. Results Four hundred sixty-five publications on CCTGA in adult patients were retrieved, and 166 were excluded; 299 studies were used for this review including 76 full-text articles, 70 studies related to general aspects of the subject, and, due to the small number of publications, 153 case reports. Sixty-one articles referring to combined experiences in pediatric and adult patients and judged to be relevant, but retrieved from another sources, were also included. Conclusion Albeit clinical presentation and diagnostic criteria have been well stablished, there seems to be room for discussion related to clinical and surgical management of CCTGA in adults. Considering the rarity of the disease, well designed multicenter studies may provide answers.

RESUMO: Artigo de revisão sobre as principais manifestações clínicas das cardiopatias congênitas, que se manifestam no período neonatal. A partir da presença de dados clínicos, como sopro cardíaco, cianose, taquipnéia e arritmia, são discutidos os principais elementos clínicos associados, assim como as entidades mais provavelmente a eles relacionadas. Informações sobre diagnóstico e terapêutica são também sumariamente apresentadas.

Descrevem-se duas experiências realizadas com o objetivo de verificar se estudantes de Medicina de etapas avançadas podem ser utilizados em Osce para avaliar habilidades clínicas básicas de alunos iniciantes. Na primeira experiência, 6 internos e 6 professores avaliaram 59 alunos do currículo tradicional em Osce com 6 estações focadas na anamnese, exame físico e comunicação com o paciente. As notas dadas pelos professores foram maiores que as dos estudantes em todas as estações, exceto uma (comunicação), mas não houve diferenças significantes entre elas, exceto numa estação de exame físico (p < 0,001) (teste de Wilcoxon). Na segunda experiência, 15 internos do currículo tradicional e 9 professores avaliaram 58 estudantes do 1º ano, currículo PBL, em Osce com 3 estações para avaliar anamnese, exame físico e manipulação de luvas esterilizadas. Os estudantes foram pareados aos professores, e cada um fez sua avaliação individualizada usando o mesmo protocolo. Em metade das estações, os valores médios das notas de professores e estudantes foram significativamente diferentes. Isso aparentemente se deveu à variação significativa entre as notas dos professores, o que não ocorreu com relação às notas dadas pelos estudantes avaliadores (p < 0,05) (teste de Wilcoxon e Anova - Turkey, Dunn). Conclui-se que estudantes em fase de treinamento podem ser utilizados como examinadores confiáveis em exame de habilidades clínicas de estudantes iniciantes, sendo que a variabilidade entre as notas que atribuem para a mesma tarefa parece ser inferior à que se verifica nas notas dos professores.

Objective: To report the institution experience with the surgical treatment of adults with congenital heart disease due to the increasing number of these patients and the need for a better discussion of the subject.Methods: Retrospective analysis describing demographic data, risk factors and results.Results: 191 patients between 16 and 74 years old were operated on. Primary correction was done in 171 cases, 93 (55%) for atrial septal defect repair. Among 20 (12%) reoperations, pulmonary valve replacement was done in six cases. The mean intensive care and hospital stay were 2.7 and 8.5 days respectively, significantly greater for the reoperated cases (P=0.001). The mean bypass and clamping times were 68.6 and 44.7 minutes respectively, greater for the reoperated cases (P<0.0001 and P=0.0003 respectively). Hospital mortality was 4.2% and male sex, functional class III-IV and older age at operation were predictive risk factors. Significant complications were more frequent in the reoperated cases (P<0.003), mainly atrial flutter and fibrillation. Among 183 patients discharged, 149 (82%) are being followed and atrial flutter and fibrillation are common. The mean functional class value improved significantly after operation (1.66 to 1.11; P<0.0001). The estimated survival was 96.2% in six years. Conclusion:Heart surgery in adults with congenital heart disease can be accomplished with low mortality and functional class improvement. Immediate and late complications are frequent. Multicenter studies are important to better characterize this patient population in the country.Descriptors: Heart defects, congenital. Adult. Cardiac surgical procedures.Resumo Objetivo: Relatar a experiência da instituição com o tratamento cirúrgico de adultos com cardiopatia congênita devido ao crescente aumento no número desses pacientes e consequentes necessidades de maior discussão do tema.Métodos: Análise retrospectiva dos pacientes operados, com análise de dados demográficos, fatores de risco e resultados.Resultados: Cento e noventa e um pacientes, com idade entre 16 e 74 anos, foram operados. Cirurgia primária foi realizada em 171 pacientes, 93 (55%) com comunicação interatrial. Dentre 20 (12%) reoperações, substituição de valva pulmonar ocorreu em seis casos. Os tempos médios de unidade de terapia intensiva e hospitalar foram 2,7 e 8,5 dias, respectivamente, maiores nas reoperações (P=0,001). Os tempos médios de cir- 372Rev Bras Cir Cardiovasc | Braz J Cardiovasc Surg Rev Bras Cir Cardiovasc 2013;28(3):371-9Amaral FTV, et al. -Adult congenital heart disease: experience with the surgical approach city area (n=40, 20%) or in the region (n=133, 70%) while 17 (10%) were referred from other states. An Excel data base was created containing general information of the patients, possible preoperative risk factors such as diabetes, cyanosis, smoking, systemic hypertension, obesity and chronic lung disease, detailed information regarding the surgical procedure, hospital complications and follow up information.The preoperative data collec...