Related articles - 152 Articles
Related articles to: Risk factors for mediastinitis after coronary artery bypass grafting surgery, Vol.: 26 Ed.: 1, 2011, for the criterion, Risk Factors, Mediastinitis, Myocardial Revascularization
ORIGINAL ARTICLE
Dyego José de Araújo Brito; Vinicius José da Silva Nina; Rachel Vilela de Abreu Haickel Nina; José Albuquerque de Figueiredo Neto; Maria Inês Gomes de Oliveira; João Victor Leal Salgado; Joyce Santos Lages; Natalino Salgado Filho
Rev Bras Cir Cardiovasc 2009;24(3):297-304
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OBJECTIVE: To determine the prevalence, risk factors, and the clinical outcome of patients undergone coronary artery bypass grafting who progressed with Acute Renal Failure (ARF). METHODS: A retrospective cohort prospective study was performed from data of 186 patients undergone surgery from January 2003 through June 2006. The stored data were analyzed using the software STATA 9.0. RESULTS: The prevalence of ARF was of 30.6% (57/186). In 7.0% (4/57) dialysis therapy was needed. The mean age of patients with and without ARF progression was 62.8 (±9.4) years and 61.3 (±8.8) years respectively (P=NS). CPB time >115 min (p= 0.011) and cross-clamp time >85 min (p=0.044) were related to ARF by the univariate analysis. The need for intra-aortic balloon (P= 0.049), mechanical ventilation >24h (P = 0.006), Intensive Care Unit (ICU) stay > three days (P< 0.0001), bradycardia (P= 0.002), hypotension (P= 0.045), arrhythmia (P=0.005) and inotropic infusion (P= 0.0001) were higher in the ARF group. Only the ICU stay longer > 3 days showed statistical correlation with ARF by the multivariate analysis (P=0.018). The mortality rate with and without ARF was 8.8% (five cases) and 0.8% (one case) respectively (P=0.016), but it reached 50% (2/4) in dialytic patients. CONCLUSION: ARF was a frequent and severe postoperative complication associated with higher mortality and longer ICU stay, which presented as risk factors: longer CPB and cross-clamp times, mechanical ventilation > 24h and hemodynamic instability
Keywords: Myocardial revascularization. Risk factors. Renal insufficiency, acute.
Mateus W de Bacco; Ana Paula Sartori; João Ricardo Michelin Sant'anna; Marisa F Santos; Paulo Roberto Prates; Renato A. K Kalil; Ivo A Nesralla
Rev Bras Cir Cardiovasc 2009;24(3):334-340
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Objective: Identification of risk factors for cardiac surgery can improve surgical results. Our aim is to identify factors related to increased hospital mortality for patients who underwent mechanical cardiac prosthesis implant. Methods: Prospective study with retrospective data acquirement study including 335 consecutive patients who underwent at least one implant of St. Jude Medical mechanical prosthesis between December 1994 and September 2005 at the Cardiology Institute of RS. Valve implants were 158 (47.1%) in aortic position, 146 (43.6%) in mitral and 31 (9.3%) in aortic and mitral. The following characteristics were analyzed in relation to hospital death: gender, age, body mass index, NYHA functional class, ejection fraction, type of valve lesion, hypertension, diabetes mellitus, serum creatinine, preoperative arrhythmias, prior heart surgery, CABG surgery, concomitant tricuspid valve surgery and operative priority (elective, urgent or emergent). Logistical regression was used to analyze data and odds-ratio was calculated for individual factors. Results: During the follow-up there were 13 (3.88%) deaths. In-hospital mortality risk was associated with serum creatinine (P<0.05), ejection fraction < 30% (P<0.001), mitral valve lesion (P<0.05), concomitant CABG surgery (P<0.01), prior cardiac surgery (P<0.01) and reoperation (P<0.01). Increased odd-ratio were related to previous cardiac surgery (5.36; IC95% 0.94-30.56), combined revascularization (5.28; IC95% 1.51-18.36), valvar reoperation (4.69; IC95% 0.93-23.57) and concomitant tricuspid annulosplasty (3.72; IC95% 0.75- 18.30). Conclusion: The mortality rate is within the parameters found in the literature, identifying recognized factors which neutralization by changes in surgical indication and medical management may enable risk reduction.
Keywords: Cardiac surgical procedures. Risk factors. Prostheses and implants. Heart valve prosthesis. Mortality.
Alfredo José Rodrigues; Paulo Roberto Barbosa Evora; Solange Bassetto; Lafaiete Alves Júnior; Adilson Scorzoni Filho; Wesley Ferreira Araújo; Walter Vilella Andrade Vicente
Rev Bras Cir Cardiovasc 2009;24(4):441-446
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OBJECTIVE: The aim of the present study was to identify risk factors for acute renal failure in patients with normal levels of serum creatinine who had undergone coronary artery bypass graft (CABG) surgery and/or valve surgery. METHODS: Data from a cohort of 769 patients were assessed using bivariate analyses and binary logistic regression modeling. RESULTS: Three hundred eighty one patients underwent CABG, 339 valve surgery and 49 had undergone both simultaneously. Forty six percent of the patients were female and the mean age was 57 ± 14 years (13 to 89 years). Seventy eight (10%) patients presented renal dysfunction postoperatively, of these 23% needed hemodialysis (2.4% of all patients). The mortality for the whole cohort was 10%. The overall mortality for patients experiencing postoperative renal dysfunction was 40% (versus 7%, P < 0.001), 29% for those who did not need dialysis and 67% for those who needed dialysis (P = 0.004). The independent risk factors found were: age (P < 0.000, OR: 1.056), congestive heart failure (P = 0.091, OR: 2.238), COPD (P = 0.003, OR: 4.111), endocarditis (P = 0.001, OR: 12.140), myocardial infarction < 30 days (P = 0.015, OR: 4.205), valve surgery (P = 0.016, OR: 2.137), cardiopulmonary bypass time > 120 min (P = 0.001, OR: 7.040), peripheral arterial vascular disease (P = 0.107, 2.296). CONCLUSION: Renal dysfunction was the most frequent postoperative organ dysfunction in patients undergone CABG and/or valve surgery and age, congestive heart failure, COPD, endocarditis, myocardial infarction < 30 days, valve surgery, cardiopulmonary bypass time >120 min, and peripheral arterial vascular disease were the risk factors independently associated with acute renal failure (ARF).
Keywords: Cardiovascular surgical procedures. Kidney failure, acute. Cardiac Surgical Procedures. Risk Factors.
Fernando José de Oliveira; Reinaldo Wilson Vieira; Otávio Rizzi Coelho; Orlando Petrucci; Pedro Paulo Martins de Oliveira; Nilson Antunes; Ivone Pires F. de Oliveira; Edson Antunes
Rev Bras Cir Cardiovasc 2010;25(1):51-58
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OBJECTIVE: Infectious and inflammatory processes mediated by bacteria in distant sites have been described as a risk factor for acute ischemic heart disease (AIHD). METHODS: One hundred one patients with AIHD with and without chronic periodontitis (CP) were included in this study. Patients were admitted to the HC UNICAMP and stratified into three groups: in group 1, we selected patients with severe chronic periodontitis (31 men and 19 women, mean age 55.1 ± 11.29 years old); the group 2 with mild chronic periodontitis (40 men and 28 women, mean age 54.8 ± 10.37 years old) and group 3 represented by the toothless (43 men and 20 women, mean age 67.5 ± 8.55 years old). Blood samples were collected to measure the lipid profiles, hematological and blood glucose levels. In addition, biopsies of seventeen coronary arteries with atherosclerosis and an equal number of internal mammary arteries without atherosclerotic degeneration in group 1 were investigated. Statistical analysis by analysis of variance (ANOVA) and Scheffé test for multiple comparisons was performed. RESULTS: Triglyceride and LDL levels were elevated in group 1 than in group 2. HDL were reduced by 20% in group 1 and remained reduced by 8% in toothless. Blood glucose was higher in group 1. DNA of periodontal bacteria was detected in 58.8% of the coronary arteries. CONCLUSIONS: Patients with (AIHD) and severe chronic periodontitis may have altered lipid profile, as well as microorganisms associated with CP can permeate into coronary vessels.
Keywords: Periodontitis. DNA, bacterial. Risk factors. Atherosclerosis. Coronary disease.
Rosa Cecília Pietrobon; Juarez Neuhaus Barbisan
Rev Bras Cir Cardiovasc 2010;25(1):79-84
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Background: Tobacco use is an important modifiable risk factor for cardiovascular disease. Few studies have investigated the frequency of smoking cessation among patients submitted to heart surgery. Objective: To determine the frequency of smoking cessation in patients submitted to coronary artery bypass graft surgery. Methods: In this cohort study, 203 consecutive patients, aged above 18, submitted to coronary artery bypass graft surgery in the period from January 2006 to March 2007, were interviewed in relation to the use of cigarettes in the pre- and postoperative period. Smokers were stratified according to the levels of nicotine dependence with the use of Fagerström Nicotine Dependence Test. They were followed as outpatients during 60 and 90 days for the occurrence of smoking. Results: The mean age of the group was 62 ± 10 years, and 134 (66%) were male. Before surgery, 146 (71.9%) patients were smokers. A significant number of patients stopped smoking in the postoperative period: 136 (93.15%) and 137 (93.84%) on days 60 and 90, respectively, remained not smoking after surgery. Conclusion: Coronary artery bypass graft surgery is an important determinant of smoking cessation.
Keywords: Myocardial revascularization. Risk factors. Smoking.
Ellen Hettwer Magedanz; Luiz Carlos Bodanese; João Carlos Vieira da Costa Guaragna; Luciano Cabral Albuquerque; Valério Martins; Silvia Daniela Minossi; Jacqueline da Costa Escobar Piccoli; Marco Antônio Goldani
Rev Bras Cir Cardiovasc 2010;25(2):154-159
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Introduction: The mediastinitis is a serious postoperative complication of cardiac surgery, with an incidence of 0.4 to 5% and mortality between 14 and 47%. Several models were proposed to assess risk of mediastinitis after cardiac surgery. However, most of these models do not evaluate the postoperative morbidity. Objective: This study aims to develop a score risk model to predict the risk of mediastinitis for patients undergoing coronary artery bypass grafting. Methods: The study sample included data from 2,809 adult patients undergoing coronary artery bypass grafting between January 1996 and December 2007 at Hospital São Lucas - PUCRS. Logistic regression was used to examine the relationship between risk factors and the development of mediastinitis. Data from 1,889 patients were used to develop the model and its performance was evaluated in the remaining data (n=920). The definitive model was created with the data analisys of 2,809 patients. Results: The rate of mediastinitis was 3.3%, with mortality of 26.6%. In the multivariate analysis, five variables remained independent predictors of the outcome: chronic obstructive pulmonary disease, obesity, surgical reintervention, blood transfusion and stable angina class IV or unstable. The area under the ROC curve was 0.72 (95% CI, 0.67-0.78) and P=0.61. Conclusion: The risk score was constructed for use in daily practice to calculate the rate of mediastinitis after coronary artery bypass grafting. The score includes routinely collected variables and is simple to use.
Keywords: Mediastinitis. Risk factors. Myocardial revascularization.
Rogério Gomes da Silva; Gustavo Glotz de Lima; Nelma Guerra; André Vicente Bigolin; Lucas Celia Petersen
Rev Bras Cir Cardiovasc 2010;25(2):183-189
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Objective: Atrial fibrillation (AF) is a common complication following cardiac surgery and is associated with an increased patient morbidity and mortality. The objective of this study was to develop a risk index proposal to predict AF after cardiac surgery. Methods: A prospective observational study in that 452 patients were selected to assess the incidence and risk factors associated with postoperative AF. Only patients following cardiac surgery were selected. Continuous cardiac monitor and daily electrocardiogram were assessed. The most associated in a multivariable logistic model were selected for the risk index. Results: The average incidence of AF was 22.1%. The most associated factors with AF were: patients older than 75 years of age, mitral valve disease, no use of a beta blocker, withdrawal of a beta-blocker and a positive fluid balance. The absence risk factor determined 4.6% chance to postoperative AF, and for one, two and three or more risk factors, the chance was 16.6%, 25.9% and 46.3%, respectively. Conclusion: In a multivariable logistic model was possible to develop a risk index proposal to predict postoperative AF with a major risk of 46.3% in the presence of three or more risk factors.
Keywords: Atrial fibrillation. Thoracic surgery. Risk factors. Risk assessment.
Márcio Roberto Moraes de Carvalho; Nelson Albuquerque de Souza e Silva; Carlos Henrique Klein; Gláucia Maria Moraes de Oliveira
Rev Bras Cir Cardiovasc 2010;25(2):209-217
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Background: Risk stratification models are used to assess the risk of death in surgery. Objective: To conduct a critical analysis of the EuroSCORE logistic model (ES) application in 2,692 patients undergoing Coronary Artery Bypass Grafting (CABG) in four public hospitals in the Rio de Janeiro Municipality, from 1999 through to December 2003. Methods: Random samples of 150 medical records for surviving and deceased patients were selected at four public hospitals in the City of Rio de Janeiro. The ES was applied, using the logistical model. The observed lethality rate and that forecast by the model were compared. The measurement of the discriminatory power was estimated by the area under the ROC curve. Results: 546 of the 600 selected medical records were located. A significant difference was noted between the prevalence rates for the risk factors in the Brazilian and European populations. The forecast lethality rate was 3.62% (CI-95%: 3.47-3.78) while the estimated observed rate was 12.22% (CI-95%- 10.99-13.46). In all risk ranges, the predicted lethality rate is under-estimated, with notable differences between the predicted and observed rates. The area under the ROC curve was estimated at 0.62. Conclusion: The differences in the prevalence rates for the risk factors constituting the ES, associated with its low power of discrimination, hamper any recommendation of the use of this model in Brazil, without the necessary adjustments.
Keywords: Myocardial revascularization. Risk factors. Risk assessment. Coronary diseases.
Michel Pereira Cadore; João Carlos Vieira da Costa Guaragna; Justino Fermin Amonte Anacker; Luciano Cabral Albuquerque; Luiz Carlos Bodanese; Jacqueline da Costa Escobar Piccoli; João Batista Petraco; Marco Antônio Goldani
Rev Bras Cir Cardiovasc 2010;25(4):447-456
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Introduction: Scores to predict surgical risk in patients submitted to myocardial revascularization surgery are broadly used. Objective: To develop a score capable to predict mortality in patients submitted to myocardial revascularization surgery. Methods: From January 1996 to December 2007, data were collected from 2809 patients submitted to myocardial revascularization surgery at PUC-RS São Lucas Hospital. In 2/3 of the sample (n=1875), the score was developed, after uni and mutivariated analyses. In the remaining 1/3 (n =934) the score was validated. The final score was developed with the total sample, using the same variables (n=2809). The accuracy of the model was tested using the area under the ROC curve. Results: The mean age was 61.3 ±10.1 years and 34% were women. The risk factors identified as independent predictors of surgical mortality and used for score development (parentheses) were: age > 60 years (2), female (2), extracardiac vasculopathy (2), heart failure functional class III and IV (3), ejection fraction<45% (2), atrial fibrillation (2), chronic obstructive pulmonary disease (3), aortic stenosis (3), creatinine 1.5-2.4 (2), creatinine > 2.5 or dialysis (4), emergency/urgency surgery (16). The area obtained under the ROC curve was 0.86 (CI 0.81-0.9). Conclusion: The score developed, using clinical variables easy to obtain (age, sex, extracardiac vasculopathy, functional class, ejection fraction, atrial fibrillation, chronic obstructive pulmonary disease, aortic stenosis, creatinine and emergency/urgency surgery) showed capability to predict mortality in patients submitted to myocardial revascularization surgery in our Hospital.
Keywords: Myocardial revascularization. Risk factors. Mortality. Risk assessment/methods.
CONFERENCE
Domingo M Braile
Rev Bras Cir Cardiovasc 2000;15(2):83-88
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ORIGINAL ARTICLE
Carlos Manuel de Almeida Brandão; Pablo Maria Alberto Pomerantzeff; Luciano Rapold Souza; Flávio Tarasoutchi; Max Grimberg; Sérgio Almeida de Oliveira
Rev Bras Cir Cardiovasc 2002;17(3):236-241
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Carlos Manuel de Almeida Brandão; Pablo Maria Alberto Pomerantzeff; Luciano Rapold Souza; Flávio Tarasoutchi; Max Grimberg; Sérgio Almeida de Oliveira
Rev Bras Cir Cardiovasc 2002;17(4):345-351
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OBJECTIVE: Analyze the risk factors for hospital mortality in valvar reoperations.
METHOD: A prospective analysis was performed of 194 patients that underwent valvar reoperations between July 1995 and June 1999. The following variables were analyzed: gender, age, functional class, number and type of previous operations, cardiac rhythm, urgency at operation, creatinine level, left ventricular ejection fraction, left ventricular systolic and diastolic diameters, right ventricular systolic pressure, prothrombin activity, activated partial thromboplastin time relation, platelet count, cardiopulmonary bypass time, aortic cross-clamp time, number and position of valves, type of procedure, associated procedures and intraoperative bleeding volume. Univariate and multivariate statistical analyses were performed to determine the risk factors for hospital mortality.
RESULTS: The overall hospital mortality was 8.8% (17 patients). Univariate analysis showed that the following variables were associated with higher mortality rates: advanced New York Heart Association functional class, decreased left ventricular ejection fraction, decreased prothrombin activity, increased creatinine level, longer aortic cross-clamping time, prolonged cardiopulmonary bypass time, concomitant associated procedures, and higher intraoperative bleeding volume. Logistic multivariate analysis identified advanced New York Heart Association functional class, creatinine level higher than 1.5 mg/dl, and cardiopulmonary bypass time longer than 120 minutes as independent predictors of hospital mortality.
CONCLUSIONS: The variables functional class IV, creatinine level > 1.5 mg/dl and cardiopulmonary bypass time > 120 min were independent predictors of hospital mortality in valvar reoperations.
Keywords: Heart valves, surgery, risk factors.
Anderson Benício; Luiz Felipe P. Moreira; Fernando Bacal; Noedir A.G. Stolf; Sérgio A. Oliveira
Rev Bras Cir Cardiovasc 2003;18(2):163-171
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PURPOSE: To retrospectively evaluate the survival rate of patients that underwent dynamic cardiomyoplasty, determining the influence of pre-, intra- and post-operative factors and the evolution of left ventricle ejection fraction according to the stimulation mode.
METHOD: Forty-three patients that underwent dynamic cardiomyoplasty between May 1988 and September 1997 were analyzed. Functional class III was predominant (81.4%). The mean left ventricle ejection fraction was 19.37 ± 3.48%. Hospital death was 2.2% and 39 patients who completed the conditioning period had a mean follow up of 46 ± 26 months. Twenty-eight patients were predominantly maintained under stimulation mode 1:1 and 11 under 1:2 stimulation mode.
RESULTS: Survival rate at nine years of follow up was 9%. The causes of death were progression of the heart failure and sudden cardiac death. Functional class, the pulmonary vascular-resistance index and stimulation mode were identified as risk factors. The maintenance of the increase of the left ventricle ejection fraction when compared to the preoperative values was more consistent during the studied period when the graft was stimulated in the 1:2 mode.
CONCLUSION: Late results of dynamic cardiomyoplasty are limited by the high incidence of deaths by progression of the heart failure and sudden cardiac death. Survival rate is influenced by the preoperative clinical condition and by the stimulation mode. Muscle graft performance is higher at late follow up with the 1:2 stimulation mode.
Keywords: Cardiomyopathy. Cardiomyoplasty, risk factors, prognosis. Heart failure, surgery.
Leonardo Augusto Miana; Fernando Antibas Atik; Luiz Felipe P Moreira; Alexandre Ciappina Hueb; Fabio Biscegli Jatene; José Otávio Auler Junior; Sérgio Almeida de Oliveira
Rev Bras Cir Cardiovasc 2004;19(3):280-286
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OBJECTIVE: To determine predictors of postoperative bleeding after cardiac surgery, in order to focus on preventive measures for high-risk populations.
METHODS: From October 2001 to March 2002, 411 consecutive adult cardiac surgery patients were prospectively studied, with the exception of those submitted to heart transplantation. In order to determine risk factors for postoperative bleeding, 20 preoperative, 17 operative and six postoperative variables were analyzed using univariate methods and multiple linear regression.
RESULTS: Operative procedures included coronary artery bypass grafting in 227 (55.2%) patients, valvar operations in 198 (48.2%), aortic surgery in 25 (6.1%) and combined procedures in 60 (14.6%). Cardiopulmonary bypass was used in 335 (81.5%) patients and anti-fibrinolysis agents in 148 (36%). The thirty-day mortality was 5.6% (23 patients). Mean 24-hour postoperative blood loss was 610 ± 500 ml (range 10-4900). Re-exploration for bleeding was required in 15 (3.7%) patients. Independent predictors of postoperative bleeding were emergency operations (p=0.049), postoperative metabolic acidosis (p=0.001), preoperative thrombocytopenia (p=0.034) and prolonged cardiopulmonary bypass (p=0.021).
CCONCLUSIONS: When possible, preoperative stabilization and correction of coagulation disturbances should be achieved in patients requiring urgent or emergent surgery and in those with thrombocytopenias. The duration of cardiopulmonary bypass should be minimized as long as this is practical. Postoperative metabolic acidosis must be actively corrected, especially the main determining cause.
Keywords: Hemorrhage. Blood loss, surgical. Blood coagulation disorders. Risk factors. Cardiac surgical procedures. Postoperative complications. Multivariate analysis.
Roberto Costa; Martino Martinelli Filho; Wagner Tetsuji Tamaki; Kátia Regina da Silva; Luiz Felipe Pinho Moreira; Sérgio Almeida de Oliveira
Rev Bras Cir Cardiovasc 2005;20(2):123-128
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Objective: Permanent cardiac pacing improves survival of children with congenital or acquired bradycardia, although mortality after pacing remains relatively high. The aim of this study was to evaluate the long-term outcomes of children who undergo permanent endocardial cardiac pacing via the femoral vein, including the identification of associated risk factors for mortality.
Method: From 1981 to 2000, 99 patients ranging in ages from one day to 13 years (4.1 ± 3.6 and median = 3 years) underwent permanent transfemoral pacemaker implantation due to congenital (39.4%), postsurgical (54.5%), or non-surgically acquired bradycardia (6.1%).
Results: By the end of 7.1 ± 5.3 years (708.3 patient-years) of prospective follow-up, 18 (18.2%) patients had died. The actuarial survival rates were 85%, 79.5%, and 74.2%, at 5, 10, and 15 years, respectively. Independent predictors of mortality identified by Cox proportional hazards analysis were younger age at implantation (p = 0.028), the presence of untreated cardiac anomalies or intracardiac prostheses (p = 0.0001), and radiographic evidence of cardiomegaly (p = 0.035).
Conclusions: Permanent endocardial pacing via the femoral vein presented survival expectance comparable to other techniques with a low rate of pacing complications. Long-term survival was limited by lower ages and cardiac dilatation at the time of implantation as well as by the presence of untreated cardiac defects or valve prostheses.
Keywords: Cardiac pacing, artificial. Pediatrics. Heart block, mortality. Risk factors.
Sthefano Atique Gabriel; Pedro Henrique Serafim; Carlos Eduardo Moreira de Freitas; Cristiane Knopp Tristão; Rodrigo Seiji Taniguchi; Camila Baumann Beteli; Edmo Atique Gabriel; José Francisco Moron Morad
Rev Bras Cir Cardiovasc 2007;22(1):49-59
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Objective: To evaluate the prevalence of peripheral arterial disease (PAD) in patients with coronary arterial disease. To evaluate the relation between ankle-brachial index (ABI) and coronary arterial disease, and its correlation with cardiovascular risk factors.
Method: ABI investigated with Doppler ultrasonic device. Clinical characteristics researched: age, gender, diabetes, hypertension, alcoholism, smoking and obesity. Population: 113 patients who had coronary angiography. First analyses: 2 groups - absence and presence of coronary arterial disease. Second analyses: 3 groups - Group 1 - absence of coronary lesion; Group 2 - stenosis <70%; and Group 3 - stenosis ³70%. Third analyses: 2 groups - absence and presence of PAD.
Results: 90.76% of patients with coronary arterial disease presented PAD. There were significant difference including age (p<0.001), hypertension (p<0.001). smoking (p<0.001), body mass index (BMI) (p<0.001), systolic blood pressure (SBP) (p<0.001), diastolic blood pressure (DBP) (p<0.001) and pulse pressure (PP) (p<0.001) and ABI (p<0.001) between patients with and without coronary lesion. There were significant difference including age (p<0.001), diabetes (p=0.030), hypertension (p<0.001), smoking (p<0.001), BMI (p<0.001), SBP (p<0.001), DBP (p<0.001) and PP (p<0.001) and ABI (p<0.001) between patients divided as severity of coronary arterial disease. There were significant difference including age (p<0.001), hypertension (p<0.001), smoking (p<0.001), BMI (p<0.001), SBP (p<0.001), DBP (p<0.001) and PP (p<0.001) between patients with and without PAD. By Logistic Regression Analysis, old obese patients with ABI<0.90 have a risk of coronary lesion of 98.93%.
Conclusion: ITB<0.90 might be a marker of coronary arterial disease in patients at risk of cardiovascular diseases.
Keywords: Ankle, blood supply. Brachial artery. Atherosclerosis. Peripheral vascular diseases. Risk factors.
Gustavo de Bacco; Mateus W. de Bacco; João Ricardo Michelin Sant'anna; Marisa F Santos; Roberto T. Sant'anna; Paulo Roberto Prates; Renato A.K. Kalil; Ivo A Nesralla
Rev Bras Cir Cardiovasc 2008;23(3):336-343
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Objetives: This study aims to verify the applicability of Ambler's risk score to patients who have undergone implantation of bovine pericardial bioprosthesis at the Instituto de Cardiologia do RGS/FCU. This study also aims to quantify the risk factors.
Methods: Retrospective study with 703 patients who had undergone implantation of bovine pericardial bioprosthesis between 1991 and 2005 at the Instituto de Cardiologia do RS. Aortic implant occurred in 392 patients, mitral in 250 and combined in 61. Primary outcome was hospital mortality. Characteristics used to estimate risk were: gender, age, body mass index (BMI), NYHA functional class, left ventricular ejection fraction, valvular lesions, systemic arterial hypertension, diabetes mellitus, renal function, cardiac rhythm, previous cardiac operations, and surgical priority. Univariate and multivariate logistic regression was used to quantify preponderant risk factors by the odds-ratio (OR).
Results: The mortality rate was 14.3%, which was higher than the estimated mortality rate (3%, according to Ambler's mean score of 6, (p<0.01)). Patients who died presented a mean score of 8.26, which was higher than the survivors' average score of 5.68. Characteristics of increased risk were emergency surgery (OR=10.87), dialysis (OR=6.10), and age higher than 80 years (OR=6.10). Our sample indicates an area under the ROC curve of 72.9% (accepted value > 70%).
Conclusion: The mortality predicted in Ambler's score was not reproduced in the observed results. However, the ROC curve provides evidence that this model is applicable. Preponderant risk factors were individualizated.
Keywords: Heart valve prosthesis implantation/mortality. Heart valve prosthesis implantation/adverse effects. Bioprosthesis. Heart valves/surgery. Hospital mortality. Cardiac surgical procedures/mortality. Prognosis. Risk assessment/methods. Risk factors.
Lafaiete Alves Júnior; Alfredo José Rodrigues; Paulo Roberto Barbosa Évora; Solange Basseto; Adilson Scorzoni Filho; Paula Menezes Luciano; Karina Simonelly Pinheiro; Walter Villela Andrade Vicente
Rev Bras Cir Cardiovasc 2008;23(4):550-555
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Objectives: Septuagenarians or older patients needing heart surgery has increased in whole world. The objective of study is to know the characteristics of this group of patients and determine the risk factors for operative morbidity.
Methods: We revised the medical records of 783 patients undergone heart valve surgery, myocardial revascularization or both between 2002 and 2007. The patients were divided in "control group" (<70 years) "septuagenarian group" (70 years old or more).
Results: One hundred ninety seven patients were at least 70 years old (mean age 74.1±3.9) and 61% were male. In the control group the mean age was 52.1±11.7 and 54% were male. In the septuagenarians group it was significantly higher the proportion of patients suffering from peripheral vascular disease (9% versus 5%, P=0.019), carotid artery obstruction (5% versus 2%, P=0.026), unstable angina (17% versus 9%, P=0.018). In both groups coronary artery bypass surgery prevailed. In the septuagenarian group 41% of the patients had a least one morbid event, versus 22% of the patients in the control group (P<0.001). Postoperative bleeding, pulmonary complications, mediastinitis, need of vasopressors, renal dysfunction and strokes were significantly higher in the septuagenarian group. The mortality was higher in the septuagenarian (19% versus 8.5%, P<0.001). The logistic regression revealed that COPD (OR: 8.6), EF < 35% (OR: 7,1), non-elective operation (OR: 17,2) and cardiopulmonary bypass time >120 min (OR: 3,4) were predictive of hospital mortality in septuagenarian or older patients.
Conclusions: The hospital mortality of septuagenarians or elderly is significantly higher than younger patients.
Keywords: Aged. Cardiac surgical procedures. Myocardial revascularization. Heart valves/surgery. Risk factors.
Omar Asdrúbal Vilca Mejía; Luiz A Ferreira Lisboa; Luiz Boro Puig; Ricardo Ribeiro Dias; Luís A. Dallan; Pablo M Pomerantzeff; Noedir A.G Stolf
Rev Bras Cir Cardiovasc 2011;26(1):1-6
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Objective: To evaluate the performance of 2000 Bernstein-Parsonnet (2000BP) and additive EuroSCORE (ES) for predicting surgical mortality at the Heart Institute, University of São Paulo.
Methods: A prospective observational design. Seven hundred and seventy four patients were operated for coronary artery bypass graft, valve or combined procedure between May and October, 2007, were analyzed. The mortality was estimated with the 2000BP and ES. The correlation between expected mortality and observed mortality was validated through calibration and discrimination test.
Results: The patients were stratified into five groups for the 2000BP and three for the ES. The Hosmer-Lemeshow test for 2000BP (
P = 0.70) and for ES (
P = 0.39) indicate a good calibration. The ROC curve for the 2000BP = 0.84 and for the ES = 0.81 confirms that the models are good predictors (
P<0.001).
Conclusion: Both models are similar and adequate in predicting surgical mortality at the InCor-USP.
Keywords: Risk Factors. Cardiac Surgical Procedures. Hospital Mortality.
Alexander John Pessoa Grant Anderson; Francisco Xavier do Rêgo Barros Neto; Marcelo de Almeida Costa; Luciano Domingues Dantas; Alexandre Ciappina Hueb; Marcelo Fernandes Prata
Rev Bras Cir Cardiovasc 2011;26(1):69-75
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Objective: To identify risk factors in septuagenarians and octogenarians submitted to cardiovascular surgery with cardiopulmonary bypass (CPB).
Methods: Per-operative variables of 265 patients over 70 years of age were analyzed. 248 (93.6%) were septuagenarians and 17 (6.4%) octogenarians.
Results: Overall mortality did not differ between the groups, nor did the type of procedure (CABG or valvular) (
P=0.545). Pre-operative variables did not increase the death risk, nor did the use of arterial or venous grafts (
P=0.261), or the number of grafts per patient (
P=0.131). CPB and cross-clamp time are associated with higher mortality. The survivors? group had an average CPB time of 70 ± 27 minutes while the non-survivors group 88.8 ± 25.4 minutes (
P<0.001). Cross-clamp time in the survivors was 55.5 ± 20 minutes, while 64.9 ± 16 minutes in the non-survivors (
P=0.014). Using multivariate logistic regression, CPB time is associated with death (Pearson?s chi square= 0.0056). CPB time over 75 minutes presents an increased risk of death of 3.2 times (CI 95%: 1.3-7.9) over those with CPB time
< 75 minutes. Post-operative variables associated with increased death rates: mechanical ventilation
> 12 hours (
P<0.001); ICU stay (P=0.033); re-exploration (
P=0.001); inotropic support > 48 hours (
P<0.001); use of blood components (
P<0.001).
Conclusion: Overall mortality justifies the interventions. CPB time greater than 75 minutes, mechanical ventilation over 12 hours, length of ICU stay, need for reoperation, inotropic drug support over 48 hours, and use of blood components are associated with a higher mortality rate.
Keywords: Aged. Cardiac Surgical Procedures. Myocardial Revascularization. Heart Valves. Risk Factors.
Mathias Alexandre Volkmann; Paulo Eduardo Ballvé Behr; Jayme Eduardo Burmeister; Paulo Roberto Consoni; Renato Abdala Karam Kalil; Paulo Roberto Prates; Ivo Abraão Nesralla; João Ricardo Michelin Sant'anna
Rev Bras Cir Cardiovasc 2011;26(3):319-325
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INTRODUCTION AND OBJECTIVES: Preoperative chronic renal dysfunction is an independent predictor of mortality in cardiac surgery. As normal range serum creatinine is not representative of normal renal function, we compared mortality rates, total hospital stay and post-surgical hospital stay for patients who underwent isolated coronary artery bypass surgery with serum creatinine
< 1.5mg/dL as to their estimated creatinine clearance, normal or impaired.
METHODS: In 4,765 patients submitted to coronary artery bypass surgery between January/1996 and June/2004, the creatinine clearance was estimated by the Cockroft-Gault equation. Impaired renal function was considered as a creatinine clearance <60 mL/min/1.73m
2 (chronic renal disease stage 3 - National Kidney Foundation-USA). In hospital mortality, total hospital stay, and post-surgical hospital stay were compared.
RESULTS: 4,688 patients had the required data, and 4,403 presented serum creatinine
< 1.5mg/dL - 3,177 with creatinine clearance
> 60mL/min (Group A), and 1,226 with <60mL/min (Group B). Group B patients had significantly higher total hospital stay and post-surgical hospital stay than those in Group A (respectively 2.85 and 1.79 more days -
P<0.0001). Relative risk of in-hospital death was 2.09 to Group B (95%CI:1.54-2.84) when compared to Group A.
CONCLUSIONS: More than one quarter of the patients with serum creatinine
<1.5mg/dL had creatinine clearance <60 mL/min. This expressive number of patients, that would not have their renal dysfunction detected by the serum creatinine parameter alone, had double the risk of death, longer total hospital stay and post-surgical hospital stay than the other patients with serum creatinine
< 1.5mg/dL
Keywords: Myocardial Revascularization. Hospital Mortality. Renal Insufficiency, Chronic. Risk Factors. Creatinine.
Michel Pompeu Barros de Oliveira Sá; Evelyn Soares Figueira; Cecília Andrade Santos; Omar Jacobina Figueiredo; Renato Oliveira Albuquerque Lima; Fábio Gonçalves de Rueda; Rodrigo Renda de Escobar; Alexandre Magno Macário Nunes Soares; Ricardo de Carvalho Lima
Rev Bras Cir Cardiovasc 2011;26(3):386-392
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OBJECTIVE: The aim of this study is to evaluate the applicability of a new score for predicting mediastinitis - MagedanzSCORE - in patients undergoing coronary artery bypass graft (CABG) surgery in the Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE.
METHODS: Retrospective study involving 500 patients operated between May/2007 and April/2010. The registers contained all the information used to calculate the MagedanzSCORE. The outcome of interest was mediastinitis. We calculated sensitivity, specificity, positive predictive value, negative predictive value, concordance and accuracy. The accuracy of the model was evaluated by ROC (receiver operating characteristic) curve.
RESULTS: The incidence of mediastinitis was 5.6%, with a lethality rate of 32.1%. In univariate analysis, the five variables of the MagedanzSCORE were predictors of postoperative mediastinitis: chronic obstructive pulmonary disease (OR 6.42; 95.0% CI 2.76-14.96;
P<0.001), obesity (OR 3.06; 95.0% CI 1.32-7.09;
P=0.009), surgical reintervention (OR 82.40; 95.0% CI 30.40-223.30;
P<0.001), multiple transfusion (OR 3.33; 95.0% CI 1.52-7.29;
P=0.003) and stable angina class IV or unstable (OR 2.59; 95.0% CI 1.19-7.64;
P=0.016) according to Canadian Cardiovascular Society. The score had a sensitivity of 96.4%, specificity of 90.0%, positive predictive value of 36.5%, negative predictive value of 99.8% and 90.4% concordance. The accuracy measured by the area under the ROC curve was 96.2% (95.0% CI 94.5%-97.9%).
CONCLUSIONS: The MagedanzSCORE proved to be a simple and objective index, revealing a satisfactory predictor of development of postoperative mediastinitis in patients undergoing CABG surgery at our institution
Keywords: Risk factors. Mediastinitis. Coronary artery bypass. Myocardial revascularization.
Pedro Silvio Farsky; Humberto Graner; Pedro Duccini; Eliana da Cassia Zandonadi; Vivian Lerner Amato; Jaime Anger; Antonio Flavio de Almeida Sanches; Cely Saad Abboud
Rev Bras Cir Cardiovasc 2011;26(4):624-629
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BACKGROUND: Sternal wound infection (SWI) after coronary artery bypass graft (CABG) surgery is a major complication. Identifying patients at risk of SWI is essential for the application of preventive measures.
OBJECTIVE: To identify the pre- and intra-operative risk factors, apply the STS risk score and determine the correlation between the risk score and microorganisms isolated from surgical wounds in a Brazilian hospital.
METHODS: This is a retrospective analysis of a database of all CABG surgeries performed in a single institution from 2006 to 2008. Chi-square analysis was used for categorical variables and Student's t-test was used for quantitative variables. Multivariate logistic regression model was used to identify independent risk factors for SWI. P <0.05 was considered significant.
RESULTS: The infection rate was 7.2% (143/1975). The multiple regression analysis found the following risk factors: female gender (OR 2.06; 95%CI 1.40-3.03; P<0.001), BMI>40 kg/m2 (OR 6.27, 95%CI 2.53-15.48; P<0.001), diabetes (OR 2.33; 95%CI 1.56-3.49; P<0.001), number of affected coronary arteries (OR 7.78; 95%CI 1.04-57.79; P<0.001) and use of bilateral internal thoracic artery (OR 3.85; 95%CI 2.10-7.07; P<0.001). Infected patients had a mean score of 9, whereas non-infected patients had a mean score of 7 (P<0.001). There was no correlation between microorganisms, scores and risk factors.
CONCLUSION: Female gender, diabetes, BMI>40 kg/m2, number of affected coronary arteries and use of bilateral internal thoracic artery were associated with a higher risk of infection. The STS risk score can be successfully used and there was no correlation between microorganisms, the score and risk factors at our institution.
Keywords: Infection. Risk factors. Mediastinitis. Myocardial revascularization.
Omar Asdrúbal Vilca Mejía; Luiz A Ferreira Lisboa; Marcos Gradim Tiveron; José Augusto Duncan Santiago; Rafael Angelo Tineli; Luis Alberto Oliveira Dallan; Fabio Biscegli Jatene; Noedir Antonio Groppo Stolf
Rev Bras Cir Cardiovasc 2012;27(1):66-74
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OBJECTIVE: Coronary artery bypass grafting (CABG) during the acute phase of infarction (AMI) is associated with increased operative risk. The aim of this study was to determine predictors of in-hospital mortality in patients undergoing CABG in AMI.
METHODS: During three years, all patients undergoing CABG in AMI were retrospectively analyzed of the institutional database. Sixty variables per patient were evaluated: 49 preoperative variables from the 2000 Bernstein-Parsonnet and EuroSCORE models, 4 preoperative variables not considered in these models (time between AMI and CABG, maximum CKMB, Troponin maximum and ST-segment elevation) and 7 intraoperative variables [(cardiopulmonary bypass (CPB), CPB time, type of cardioplegia, endarterectomy, number of grafts, use of internal thoracic artery and complete revascularization]. Univariate and multivariate analysis for the outcome of in hospital mortality were performed.
RESULTS: The mean time between AMI and CABG was 3.8 ± 3 days. The overall mortality was 19%. In the multivariate analysis: age > 65 years OR [16.5 (CI 1.8 to 152), P= 0.013]; CPB > 108 minutes [OR 40 (CI 2.7 to 578), P= 0.007], creatinine> 2 mg/dl [OR 35.5 (CI 1.7 to 740), P= 0.021] and systolic pulmonary pressure > 60 mmHg [OR 31 (CI 1.6 to 591), P= 0.022] were predictors of in-hospital mortality.
CONCLUSION: Conventional preoperative variables such as age > 65 years, creatinine > 2 mg/dl and systolic pulmonary pressure > 60 mmHg were predictive of inhospital mortality in patients underwent CABG in AMI.
Keywords: Risk factors. Myocardial infarction. Revascularização miocárdica. Coronary artery bypass.
Michel Pompeu Barros de Oliveira Sá; Débora Oliveira Silva; Érika Nibbering de Souza Lima; Ricardo de Carvalho Lima; Frederico Pires Vasconcelos Silva; Fábio Gonçalves de Rueda; Rodrigo Renda de Escobar; Paulo Ernando Ferraz Cavalcanti
Rev Bras Cir Cardiovasc 2010;25(1):19-24
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OBJECTIVE: To report the incidence of mediastinitis in cardiovascular surgery postoperation. METHODS: The records of all 1038 patients who underwent cardiovascular surgical procedures between May/2007 and June/2009 were reviewed. All operations were performed in Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE. RESULTS: The complication occurred within, on average, 13 days after operation, in total of 25 (2.4%), eight (32%) deaths occurred. Several risk factors mediastinitis were identified: 56% diabetes, 56% smokers, 20% obeses, 16% with chronic obstructive pulmonary disease and 8% of chronic renal failure. Mediastinitis were reported in 21 (84%) cases of patients submitted to coronary artery bypass grafting, being associated to major risk of infection development (IC 3.448.30, P=0.0001). High rates of complications were observed: respiratory insufficiency (44%), stroke (16%), cardiogenic shock (12%), acute renal failure (28%), pulmonary infection (36%), multiple organs failure (16%) and esternal deiscence (48%). Bacterial cultures of exudates were positive in 84% of patients; Staphylococcus aureus was the most responsible pathogen (28.8%). CONCLUSION: Mediastinitis stays a serious surgical complication and difficult management in cardiovascular surgery postoperation. The disease stays with low incidence, but still with high lethality. Coronary bypass was associated to major risk of infection development
Keywords: Infection. Mediastinitis. Cardiac surgical procedures.
Michel Pompeu Barros de Oliveira Sá; Evelyn Figueira Soares; Cecília Andrade Santos; Omar Jacobina Figueiredo; Renato Oliveira Albuquerque Lima; Rodrigo Renda Escobar; Fábio Gonçalves de Rueda; Paulo Ernando Ferraz; Ricardo Carvalho Lima
Rev Bras Cir Cardiovasc 2011;26(2):183-189
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BACKGROUND: Mediastinitis is a serious complication of median
sternotomy and is associated to significant morbidity and mortality. Diabetes
is a feared risk factor for mediastinitis and viewed with caution by
cardiovascular surgeons.
OBJECTIVE: To identify risk factors for mediastinitis in diabetics
undergoing CABG surgery with use of unilateral ITA in the Division of
Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE.
METHODS: Retrospective study of 157 diabetics operated between May 2007
and April 2010. Nine preoperative variables, five intraoperative variables and
seven postoperative variables possibly involved in the development of
postoperative mediastinitis were evaluated. Univariate and multivariate
logistic regression analyses were applied.
RESULTS: The incidence of mediastinitis was 7% (n=11), with a lethality
rate of 36.1% (n=4). Variables associated with increased risk of mediastinitis
were: use of pedicled ITA (OR 8.25, 95% CI 2.03 to 66.10, P=0.016),
postoperative renal complications (OR 5.10, 95% CI 1.03 to 25.62, P=0.049)
and re-operation (OR 7.45, 95% CI 1.24 to 42.17, P=0.023). In
multivariate analysis using backward logistic regression, only one variable
remained as independent risk factor: use of pedicled ITA (OR 7.64, 95% CI 1.95
to 61.6, P=0.048), in comparison to skeletonized ITA.
CONCLUSIONS: We suggest that diabetics should be considered for
strategies to minimize risk of infection. In diabetics that undergo unilateral
ITA, the problem seems to be related to how ITA is harvested. Diabetics should
always be considered for use of skeletonized ITA.
Keywords: Mediastinitis. Myocardial revascularization. Diabetes mellitus. Mammary arteries.
Valdir Cesarino de Souza; André Ney Menezes Freire; José Tavares-Neto
Rev Bras Cir Cardiovasc 2002;17(3):266-270
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João Carlos Guaragna; Luciane Maria Facchi; Carolina Guerra Baião; Ivana Beatrice Mânica da Cruz; Luiz Carlos Bodanese; Luciano Albuquerque; João Batista Petracco; Marco Antônio Goldani
Rev Bras Cir Cardiovasc 2004;19(2):165-170
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OBJECTIVE: Mediastinitis is a serious complication of open-heart surgery, with an incidence that varies from 0.4% to 5%, mortality from 10% to 47% and a high morbidity rate.
OBJECTIVE: To identify preoperative and trans-operative risk factors of mediastinitis after open-heart surgery in our hospital.
METHOD: This was a prospective study of 1298 patients submitted to the open-heart surgery in São Lucas hospital in the period from March 1997 to May 2000. Nine potential risk factors associated with mediastinitis were studied (obesity, diabetes mellitus, chronic obstructive pulmonary disease -COPD-, internal mammary artery, cardiopulmonary bypass time, smoking, gender, ejection fraction and previous heart surgery) using univariate analysis, where necessary followed by multivariate logistic regression.
RESULTS: Of the 1298 studied patients, 62.6% were men and 18.3 suffered from diabetes. Thirty-eight patients (2.9%) presented with mediastinitis postoperatively, and six (15.8%) of these died. Four variables identified as risk factors by univariate analysis (p<0.05) and were after analysed by logistic regression. Three variables were identified as independent predictors of mediastinitis: obesity (p=0.008), COPD (p=0.007) and diabetes mellitus (p= 0.009), even when gender and age were analysed. The internal mammary artery graft was observed as risk predictor only when associated to the obesity.
CONCLUSION: In our hospital, mediastinitis occurs most frequently in patients suffering from obesity, diabetes, and/or COPD and in the obese patients in which internal mammary artery was used.
Keywords: Mediastinitis. Mediastinal infection. Cardiac surgery, infection. Surgical infection.
Tatiana Maia Jorge de Ulhôa Barbosa; Ricardo Nilsson Sgarbieri; Francisco F. Moreira Neto; Fabiano Ferreira Vieira; Gilberto de Araújo Pereira; Altino Vieira de Rezende Filho; Herbert Henrique Capuci; Rafael Meirelles
Rev Bras Cir Cardiovasc 2007;22(2):212-217
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Objective: To compare the observed incidence of mediastinitis and strokes versus the expected incidence according to the NNECDSG score (Northern New England Cardiovascular Disease Study Group) in a population submitted to coronary artery bypass graft surgery.
Methods: A retrospective consultation was made of medical records of all patients submitted to isolated CABG from January 1st, 2000 to December 31st, 2004, at the Cardiac Surgery Service of the Triângulo Mineiro Federal University (UFTM). Data regarding the incidences of observed mediastinitis and strokes and those estimated by the NNECDSG score were submitted to the Kolmogorov-Smirnov normality test. A comparison was achieved using the paired Student t test, with the level of significance determined as p=0.05.
Results: A group of 230 patients were analyzed, including 144 (62.60%) men and 86 (37.39%) women. Sixty-one (26.52%) presented with diabetes, 30 (13.04%) with chronic obstructive pulmonary disease (COPD) and 23 (10%) had peripheral vascular disease (PVD). Emergency surgery occurred in 34 (14.78 %) cases. In 37 (16.08%) patients an ejection fraction (EF) of less than 40% was identified. Mediastinitis occurred in 12 (5.21%) patients and despite the greater general incidence in the sample studied, no statistical significance was found. Strokes occurred in 12 patients (5.21%) and in spite of the higher mean percentage incidence of observed strokes for all scores, a level of statistical significance was not found.
Conclusions: Although the incidences of mediastinitis and strokes were greater in the population studied, these values showed no statistical significance, confirming the score recommended by the NNECDSG as a safe and efficient method for predicting postoperative mediastinitis and strokes in patients submitted to myocardial revascularization surgery in the UFTM.
Keywords: Mediastinitis. Cerebrovascular accident. Myocardial revascularization. Risk assessment.
Vinicius José da Silva Nina; Marco Aurélio Salles Assef; Raimundo Reis Rodrigues; Vinícius Giuliano Gonçalves Mendes; Joyce Santos Lages; Ângela Mirella Magalhães Amorim; Natalino Salgado Filho; Rachel Vilela de Abreu Haickel Nina
Rev Bras Cir Cardiovasc 2008;23(4):507-511
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Objective: To demonstrate the experience with the reconstruction of the chest wall utilizing metal brace to reduce the tension in the suture lines of myocutaneous flap in cases of mediastinitis.
Methods: From July 2001 to February 2006, 1389 heart surgeries were performed in our institution of which eight (0.6%) developed mediastinitis. Seven were male and the mean age was 56.7 years. The risk factors for infection were diabetes and obesity in seven and malnutrition in one case. Seven patients had been undergone CABG and one repair of a congenital heart disease. The chest wall reconstruction consisted of percutaneous insertion of Kirshner wires parallel to the edges of the wound for anchoring of sutures to the muscular plane in order to allow the reduction of tension in the free edges of the wound and subsequent closure of the subcutaneous tissue and skin.
Results: There was one death in the immediate postoperative due to arrhythmia and one late death secondary to sepsis. The remaining patients presented satisfactory postoperative course with good healing of the wound after the removal of the metal braces on the 21th postoperative day and in the follow-up of 6 to 54 months.
Conclusion: The reconstruction of the chest wall utilizing temporary metal braces showed to be a safe and effective procedure with good aesthetic and functional outcomes in this group of patients.
Keywords: Mediastinitis. Cardiac surgical procedures, adverse effects. Sternum, surgery. Osteomyelitis.
Michel Pompeu Barros de Oliveira Sá; Cecília Andrade Santos; Omar Jacobina Figueiredo; Renato Oliveira Albuquerque Lima; Paulo Ernando Ferraz; Alexandre Magno Macário Nunes Soares; Pablo César Lustosa Barros Bezerra; Wendell Nunes Martins; Ricardo de Carvalho Lima
Rev Bras Cir Cardiovasc 2011;26(4):617-623
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BACKGROUND AND OBJECTIVES: Mediastinitis is a serious complication of median sternotomy and is associated to significant morbidity and mortality. The aim of this study is to identify which option of harvesting internal thoracic artery (ITA), pedicled or skeletonized, is associated with lower rates of mediastinitis after coronary artery bypass grafting surgery (CABG) in elderly, in the Division of Cardiovascular Surgery of PROCAPE.
METHODS: Retrospective study of 160 elderly who underwent consecutive CABG between May 2007 and June 2011. Eleven preoperative variables, four intraoperative variables and eight postoperative variables possibly involved in the development of postoperative mediastinitis were evaluated between two groups: CABG with skeletonized ITA (n=80) and pedicled ITA (n=80). Univariate and multivariate logistic regression analyses were applied.
RESULTS: The incidence of mediastinitis was 6.8% (n=11), with a lethality rate of 54.5% (n=6). The skeletonized ITA group were more exposed than pedicled ITA group to obesity (n=12 vs. n=4; 15% vs. 5%; P=0.035) and multiple transfusions (n=25 vs. n=11; 31.2% vs. 13.7%; P=0.008). The pedicled ITA group presented a greater risk of mediastinitis after CABG than skeletonized ITA group (n=10 vs. n=1; 12.5% vs. 1.2%; Unadjusted OR 11.3; 95% CI 1.4 - 241.5; P=0.008). In multivariate analysis, this difference maintained statistically significant (Adjusted OR 5.2; 95% CI 1.5-495.8; P=0.012), being considered an independent association.
CONCLUSIONS: We suggest that elderly should be considered for strategies to minimize risk of infection. In elderly that undergo unilateral ITA, the problem seems to be related to how ITA is harvested. Elderly should always be considered for use of skeletonized ITA.
Keywords: Myocardial revascularization. Mediastinitis. Aged.
Priscila Ledur; Lúcia Almeida; Lucia Campos Pellanda; Beatriz D'agord Schaan
Rev Bras Cir Cardiovasc 2011;26(2):190-196
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BACKGROUND: Although coronary artery bypass grafting (CABG) is
a good alternative therapy in severe arterial disease, it may evolve with
complications, especially infections.
OBJECTIVES: To determine the incidence of infection in post-CABG and its
clinical predictors in a cardiology reference center in Brazil.
METHODS: Cohort study. Data were collected from all patients undergoing
CABG between January/2004 and February/2006, excluding emergency surgery,
absent record of glucose blood levels preoperatively and infection prior to
surgery. Statistical analysis: Student's t test, chi square, logistic
regression.
RESULTS: We evaluated 717 patients, 61.9 ± 11 years old, 67.1% were men,
29.6% with diabetes, of whom 137 (19.1%) developed infection (62% respiratory,
25% superficial wound, 9.5% urinary, 3.6% deep wound). Diabetes was more
prevalent in those who developed infection, as well as prolonged time of
indwelling central venous catheter (79.3 ± 40.5 vs. 61.0 ± 19.3 hours, P<0.001).
After multivariate analysis (model adjusted for dyslipidemia, hypertension,
smoking and leukocytes), both diabetes (OR 4.18 [2.60-6.74]),
prolonged central venous line (OR 1.019 [1.00-1.02] and
cardiac catheterism (OR 2.03 [1.14-3.60] remained predictors
of infection. While diabetes is associated with a higher percentage of
infections (P <0.001), preoperative serum glucose was not associated
with increased risk of infection.
CONCLUSIONS: Diabetes and permanence of central venous catheters were
associated with development of infection in post-CABG. The preoperative blood
glucose was not a predictor of risk of infection. It is probably necessary to
study with greater detail glycemic control trans- and post-operatively.
Keywords: Diabetes mellitus. Myocardial revascularization. Infection. Risk.
Cleusa Ema Quilici Belczak; André Luiz Tyszka; Jose Maria Pereira de Godoy; Rubiana Neves Ramos; Sergio Quilici Belczak; Roberto Augusto Caffaro
Rev Bras Cir Cardiovasc 2009;24(1):68-72
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Objective: The aim of this study was to assess clinical complications of limbs undergone harvesting of the great saphenous vein for venous coronary artery bypass graft surgery using bridge technique. Methods: Fourty-four patients who had undergone CABG using the great saphenous vein harvested by the bridge technique over more than 3 months ago were randomly selected. The exclusion criteria were the harvesting of both saphenous veins, prior saphenectomy of the contralateral limb, edema caused by a systemic etiology, such as heart, renal, thyroid or hepatic diseases and venous insufficiency of the lower limbs as characterized by swollen varicose veins both with and without trophic changes. The age, gender, diabetes, time of surgery and occurrence of complications, such as edema, paresthesia, infection, lymphorrhea, erysipelas and deep venous thrombosis, were assessed. The assessment was clinic and diagnosis of the diabetes was performed by the preoperative exams. The chi-square, Fisher and Student's t tests were used for statistical analysis with an alpha error of 5%. Results: The time between surgery and assessment ranged between 3 and 187 months with a mean of 47.3±42.5 months. Infections of the saphenous harvest site were detected in 25% of the cases, edema in 52.3%, paresthesia in 29.5%, erysipelas in 9.1%, lymphorrhea in 4.5% and deep venous thrombosis in 2.3%. There was no association between diabetes and complications. Conclusion: The saphenous vein harvesting using bridge technique for coronary artery bypass grafting does not eliminate clinical complications, such as paresthesia, infection and edema of the saphenous vein harvesting site.
Keywords: Saphenous vein. Myocardial revascularization. Postoperative complications/etiology. Coronary artery bypass/methods.
Roberto Rocha e Silva; Márcio Augusto Truffa; José Ricardo Bueno de Moraes Birolli; Tárcio Figueiredo Silva; Ricardo de Mola; João Bosco de Oliveira
Rev Bras Cir Cardiovasc 2009;24(2):138-142
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OBJECTIVE: Left internal thoracic artery (LITA) grafting has become the gold standard in coronary artery bypass graft procedure (CABG). In order to optimize the use of LITA or other grats, sequential anastomosis has been used. There is no consensus on equivalence of results between isolated and sequential grafts. The aim of this study is to compare the patency of isolated versus sequential grafts. METHODS: From January 2000 to August 2007, a retrospective patency analysis of the grafts used in 88 symptomatic patients who underwent CABG procedure in our Service was performed through cinecoronariography. Statistical analysis was performed through Student's t test. Each distal anastomosis was considered an independent graft. RESULTS: The mean postoperative period was of 53 + 138 months and mean age was 64 + 11 years. LITA isolated grafts presented patency rate significantly higher than the sequential grafts, respectively 92% (46/50) and 77% (30/39) P = 0.02. However, in injured coronary arteries of > 70%, isolated LITA patency rate was similar to sequential grafts, (95%; 37/39) and (93%; 26/28) respectively; P = 0.37. Mean radial artery patency rate was similar to isolated 71% (5/7) and sequential 90% (19/21) grafts; P = 0.10. Saphenous vein patency rates were similar for isolated 72% (31/43) and sequential 81% (73/90) grafts; P = 0.12. There was no difference between radial artery and saphenous vein patency rates. CONCLUSION: In symptomatic patients, isolated LITA patency is superior than sequential LITA. However, in coronary injuries of > 70%, the isolated and sequential patency rates are similar. Sequential grafts from radial artery and saphenous vein are similar to their respective isolated grafts.
Keywords: Radial artery. Mammary arteries. Saphenous vein. Coronary disease/surgery. Myocardial revascularization.
Katiane Tremarin Morsch; Camila Pereira Leguisamo; Marcelo Dias Camargo; Christian Correa Coronel; Waldo Mattos; Leila D.N Ortiz; Gustavo Glotz de Lima
Rev Bras Cir Cardiovasc 2009;24(2):180-187
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Objective: To assess the ventilatory, radiological and clinical profile of patients undergoing elective CABG in a cardiology reference hospital in South Brazil. Methods: This study included 108 patients undergoing elective CABG surgery, in the period between April 2006 and February 2007 at the Cardiology Institute of Rio Grande do Sul (IC-FUC). The surgical procedure involved median sternotomy, and the saphenous vein and/or internal mammary artery were used for grafting. Lung volume and capacity, as well as the possible existence of ventilatory changes, were assessed by spirometry, and the ventilatory muscle strength was assessed using a vaccum manometer. All evaluations were performed on the preoperative period and on the sixth postoperative day. Results: Preoperative levels of FEV1 and FVC were significantly reduced on the 6th postoperative day (P<0.001) when compared to the preoperative levels. A significant decrease of ventilatory muscle strength, expressed as maximum inspiratory and expiratory pressures (MIP and MEP), was also observed from the pre- to the sixth postoperative day (P<0.001). Pulmonary events were more frequent on the 6th postoperative day (78%) than on the 1st postoperative day (40%). Conclusions: Patients undergone CABG surgery present important reduction in pulmonary volume and capacity, as well as on the ventilatory muscle strength during the postoperative period.
Keywords: Myocardial revascularization. Spirometry.
Ricardo Migliorini Mustafa; José Vladimir Hernan Quiroga Verazain; Margaret Assad Cavalcante; Fabiano Carazzai Pacheco; Henrique Issa Artoni Ebaid; Paulo Henrique Jorge; Orlando Henrique de Melo Sobrinho; Ureliano Cintra e Reis
Rev Bras Cir Cardiovasc 2009;24(2):200-204
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OBJECTIVE: The aim of this study was to assess the coronary vascular resistance (CVR) and to analyze the flow differences through grafts in coronary artery bypass graft surgery. METHODS:Between 17 June and 15 July 2005, we assessed the coronary vascular resistance profile in 10 patients undergoing coronary artery bypass graft surgery by grafting a section of saphenous vein and checking CVR direct (preoperative) and indirect arterial pressure and blood flow during blood cardioplegic infusion. RESULTS: Significant differences between segments of coronary grafts with flow changes ranging from 36.52 to 100 ml/min were verified. CONCLUSION: Despite various factors that contribute to success or unsuccess of coronary grafts, the CVR preoperative assessment can be a possible method to estimate blood flow through the coronary graft implant during surgical procedure.
Keywords: Vascular resistance. Graft occlusion, vascular. Myocardial revascularization.
João Roberto Breda; Danilo Bortoloto Gurian; Ana Silvia Castaldi Ragognetti Breda; Adriano Meneghine; Andréa Cristina de Oliveira Freitas; Leandro Mattos Luongo; Luiz Carlos de Abreu; Adilson Casemiro Pires
Rev Bras Cir Cardiovasc 2009;24(3):341-345
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Objective: Antifibrinolytic agents reduce bleeding after cardiac surgery, but there are adverse effects after their systemic use. These effects are avoided by topical application of antifibrinolytic agents in pericardial cavity. We compared the effects of topically applied epsilon-aminocaproic acid (EACA) and placebo on postoperative bleeding and transfusion requirements after coronary artery bypass surgery. Methods: In this single center prospective, randomized, double-blind trial, 53 patients were randomized into two groups to receive EACA (24 g in 250 ml of saline solution) or placebo (250 ml of saline solution) before sternal closure. Groups were comparable with respect to all preoperative and intraoperative variables. Postoperative bleeding, transfusion requirements and hematologic parameters were evaluated. Results: Postoperative bleeding within first 24 hours (h) period (EACA group 154.66±74.64 x Placebo group 220.21±136.42 ml; P=0.031) showed statistically significant inter-group difference, within 48 h (EACA group 259.14±420.07 x Placebo group 141.67±142.58 ml; P=0.614), as well as cumulative blood loss (EACA group 832.07±576.86 x Placebo group 827.50±434.12 ml; P=0.975), not showed statistically inter-group differences. Inter-group difference of blood product requirements was statistically significant (EACA group 185.90±342.07 x Placebo group 439.42±349.07 ml; P=0.016). Laboratory analyses showed no differences between the two groups postoperative (hematologic characteristics: hemoglobin (g/dl)- EACA group 9.18±0.92 x Placebo group 8.85±1.48 g/dL; P=0.11; hematocrit (%)-EACA group 28.15±3.35 x Placebo group 26.67±4.15%; P=0.06). Conclusion: Topical use of epsilon aminocaproic acid reduces postoperative bleeding in the first 24 hours and requirements of blood transfusion after coronary artery bypass graft surgery.
Keywords: Coronary artery bypass. Antifibrinolytic agents. Hemorrhage.
Aline Garbossa; Emília Maldaner; Daiana Moreira Mortari; Janaína Biasi; Camila Pereira Leguisamo
Rev Bras Cir Cardiovasc 2009;24(3):359-366
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INTRODUCTION: The coronary artery bypass graft surgery is an option of treatment for cardiovascular diseases, and the patients who underwent such procedure can suffer from preoperative anxiety. OBJECTIVE: The aim of this study is to verify the effects of physiotherapeutic instructions at the anxiety level on patients undergone coronary artery bypass graft surgery. METHODS: Randomized clinical trial, with the sample composed by 51 individuals, 27 on the control group and 24 on the intervention; on which it was assessed the anxiety (Beck Scale for Anxiety) and pain (Visual Analog Scale) levels on the pre- and postoperative period and only the second group received instructions about the surgery procedures and ventilatory exercises. For statistical analysis the Wilcoxon, Mann-Whitney and Spearman tests were used. RESULTS: The lower anxiety levels were observed in patients that received the intervention on the period before surgery (9.6 ± 7.2 versus 13.4 ± 5.9, P=0.02). On the control group, the difference among the anxiety levels before and after the surgery was statistically significant (P= 0.003). The female individuals presented more anxious before the surgery compared to the male ones (P=0.058). It was also verified a relationship between lenght of stay at hospital and postoperative anxiety (P=0.05), where the more anxious individuals remained more time at the hospital. CONCLUSION: Patients oriented and instructed about physiotherapeutic ventilatory exercises and hospital routine, presented their levels of anxiety reduced on the preoperative compared to the control group. However, at the postoperative, both groups presented their anxiety levels reduced without significant difference between them
Keywords: Anxiety. Myocardial revascularization. Physical therapy (Specialty).
Rui M. S Almeida
Rev Bras Cir Cardiovasc 2009;24(4):470-477
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EMC
OBJECTIVE: To present the Instituto de Cirurgia Cardiovascular do Oeste do Paraná' (ICCOP) surgical experience, on the treatment of left ventricle aneurysms, by endoventriculoplasty, with septal exclusion (EVSE), and a 111 months follow-up. METHODS: Between April 1999 and April 2006, 28 patients were submitted to EVSE, by the author. Pre, trans and late post clinical and echocardiographic variables were analyzed retrospectively. Mean age was 59.0 ± 9.5 years, being 23 male patients. Seventeen patients were in NYHA functional class IV and the mean EuroScore was 8.2 ± 2.3. The mean pre-operative values for ejection fraction, end systolic and diastolic left ventricular volumes were 32.3 ± 9.2%, 113.9 ± 36.0 ml e 179.2 ± 48.4 ml, respectively. The BraziliAnVErsion of the SF36 quality of life questionnaire was applied in the late follow up period. RESULTS: Four patients died in the immediate post-operative period, being the major cause of morbidity low cardiac output syndrome and arrhythmias. The mean follow-up period was 5.6 ± 3.2 years. Left ventricle's ejection fraction and aortic cross clamping time were the significant factors for hospital and late mortality with P = 0.0222 and P = 0.0123, respectively. Actuarial survival curve showed a survival of 82.1 ± 7.2%, and 54.7 ± 22.9%, pre and post 107 months, of follow-up. CONCLUSION: EVSE' surgery is an effective option to treat this group of patients, with improvement of left ventricular function (from 32.3 to 46.4%) and patients' quality of life.
Keywords: Heart aneurysm, surgery. Cardiac surgical procedures. Myocardial revascularization. Heart failure.
Andréia Cristina Passaroni; Marcos Augusto de Moraes Silva; Antônio Sérgio Martins; Ana Cláudia Kochi
Rev Bras Cir Cardiovasc 2010;25(1):32-37
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EMC
Objective: The objective of this work was to evaluate the influence of the use of nifedipine on the outcome of renal function in patients undergoing myocardial revascularization with extracorporeal circulation. Methods: The casuistics and variables related to extracorporeal circulation were studied. Serum creatinine levels were measured preoperatively, 24, 48 hours and on 7th day postoperatively. Renal failure was defined as an increase in 30% of serum creatinine levels at 24 or 48 hours postoperatively compared to those at baseline. Patients were assigned to four groups: G1 (patients who received nifedipine preoperatively); G2 (patients who received nifedipine postoperatively); G3 (patients who received nifedipine pre and postoperatively) and G4 (patients who did not receive nifedipine). Results: The mean serum creatinine levels postoperatively presented greater rise in G4 (G4>G1=G2=G3), and G4 also presented a higher percentage of patients with acute renal failure (G4>G1 and G4>G3, P<0.05; G1=G3 and G2=G4, P>0.05). Conclusion: The evaluation of serum creatinine values and incidence of acute kidney injury postoperatively suggest a possible nefro-potective effect of nifedipine in patients undergoing myocardial revascularization with extracorporeal circulation.
Keywords: Extracorporeal circulation. Acute renal Insufficiency. Myocardial revascularization.
Anali Galluce Torina; Orlando Petrucci; Pedro Paulo Martins de Oliveira; Elaine Soraya Barbosa de Oliveira Severino; Karlos Alexandre de Souza Vilarinho; Carlos Fernando Ramos Lavagnoli; Maria Heloisa Blotta; Reinaldo Wilson Vieira
Rev Bras Cir Cardiovasc 2010;25(1):59-65
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EMC
Objective: The inflammatory response after cardiac surgery increases vascular permeability leading to higher mortality and morbidity in the post operative time. The modified ultrafiltration (MUF) had shown benefits on respiratory, and hemodynamic in pediatric patients. This approach in adults is not well established yet. We hypothesize that modified ultrafiltration may improve respiratory, hemodynamic and coagulation function in adults after cardiac surgeries. Methods: A prospective randomized study was carried out with 37 patients who underwent coronary artery bypass graft surgery (CABG) were randomized either to MUF (n=20) at the end of bypass or to control (no MUF) (n=17). The anesthesia and ICU team were blinded for the group selection. The MUF were carried out for 15 minutes after the end of bypass. The patients data were taken at beginning of anesthesia, ending of bypass, ending MUF, 24 hours, and 48 hours after surgery. For clinical outcome the pulmonary, hemodynamic and coagulation function were evaluated. Results: We observed lower drain loss in the MUF group compared to control group after 48 hours (598 ± 123 ml vs. 848 ± 455 ml; P=0.04) and required less red blood cells units transfusion compared to control group (0.6 ± 0.6 units/patient vs.1.6 ± 1.1 units/patient; P=0.03). The MUF group showed lower airway resistance (9.3 ± 0.4 cmH2O.L-1s-1 vs. 12.1 ± 0.8 cmH2O.L-1s-1; P=0.04). There were no deaths in both groups. Conclusion: The MUF reduces post operatory bleeding and red blood cells units transfusion, but with no differences on clinical outcome were observed. The routinely MUF employment was not associated with hemodynamic instability.
Keywords: Ultrafiltration. Coronary artery bypass. Myocardial revascularization. Hemorrhage.
Rosane Maria Nery; Juarez Neuhaus Barbisan
Rev Bras Cir Cardiovasc 2010;25(1):73-78
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Objective: The objective of this study was to evaluate the effect of leisure-time physical activity (LTPA) in the early outcome of coronary artery bypass graft surgery (CABG). Methods: This prospective cohort study analyzed 202 patients submitted to CABG. The patients were assigned to two groups, active or sedentary, according to the practice of LTPA in the preoperative period. The independent variable LTPA practiced by the patients in the previous year of the surgery was evaluated. The occurrence of the major adverse cardiac events as death, acute myocardial infarction, reoperation and the hospital stay after surgery were planned to be evaluated. Results: The mean age of patients was 62 ± 10 years, and 134 (66%) were men. Sixty-six (33%) patients practiced LTPA and were classified as active, and 136 (67%) were sedentary. The active group showed 78% less probability (OR= 0.22; CI 95%: 0.09-0.51) to suffer a MACE P<0.001 and a reduction of 33% in length of hospital stay as compared for sedentary patients (HR= 0.67; IC 95%: 0.49 - 0.93). P= 0.018. Conclusion: LTPA is an important predictor of major adverse cardiac events and hospital stay.
Keywords: Exercise. Myocardial revascularization. Cardiovascular surgical procedures.
CASE REPORT
José Glauco Lobo Filho; Heraldo Guedis Lobo Filho; Francisco José Cabral Mesquita; Jaime Paula Pessoa Linhares Filho
Rev Bras Cir Cardiovasc 2010;25(1):118-121
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The use of a composite graft with left internal thoracic artery (LITA) and arterial or saphenous vein (SV) grafts can allow the complete revascularization of the left coronary system (LCS) without cardiopulmonary bypass (CPB) and without ascending aorta manipulation (AAM), in order to reduce some complications in the immediate postoperative. This study shows 8-year angiographic follow-up results of two patients underwent no-touch aorta off-pump coronary artery bypass grafting (CABG) using LITA and SV as a composite graft to supply LCS.
Keywords: Myocardial revascularization. Coronary angiography. Saphenous vein. Mammary arteries.
ORIGINAL ARTICLE
Emad Mohamed Hijazi
Rev Bras Cir Cardiovasc 2010;25(2):197-201
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Objective: Saphenous vein harvesting can be associated with wound complications, incision pain, infection, and poor cosmetic outcome. The objective of our study to determine the difference in wound complication and infection rates between two saphenous vein harvesting techniques, long incision versus multiple short interrupted incisions (tunneling) for coronary artery bypass grafting at King Abdullah University Hospital - Jordan. Methods: Retrospectively we analyzed data from 1.050 consecutive elective coronary artery bypass procedures performed from May 5, 2003, to December 31, 2007, in our institution. Saphenectomy using traditional Long incision vein harvesting (Group 1) performed in six hundred and fifty patients (n=650), while saphenectomy using multiple incisions with small skin bridges - tunneling (Group 2) performed in four hundred patients (n=400). Saphenectomy performed by cardiac surgery registrar or cardiac surgeon. Inflammation, dehiscence, cellulites, lymphangitis, drainage, necrosis, or abscess necessitating dressing, antibiotics or debridement before complete healing without eschar were defined as wound complications. There was no statistical difference in preoperative risk factors in both groups. Test results were considered significant when P <0.05. Results: Leg wound complications observed more in traditional long incision vein harvesting technique (P=0.0005). Female sex, obesity, diabetes are associated with an increased incidence of wound problems (P<0.05). Conclusions: Saphenous vein harvested using saphenous vein tunneling was associated with fewer wound complications than the traditional longitudinal method.
Keywords: Cardiac surgical procedures. Myocardial revascularization. Saphenous vein/surgery. Coronary artery bypass. Surgical wound infection.
Herbert Coelho Hortmann; Homero Geraldo de Oliveira; Renato Rocha Rabello; Eduardo Augusto Victor Rocha; Sérgio Caporali de Oliveira
Rev Bras Cir Cardiovasc 2010;25(2):218-223
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OBJECTIVE: To compare the radial artery and saphenous vein's patency in patients with recurrence of symptoms in a coronary artery bypass grafting (CABG). METHODS: Retrospective study. From January 1998 to December 2005, 469 CABGs were performed using the radial artery as a graft, in Vera Cruz Hospital in Belo Horizonte/ MG. Among the patients who underwent those surgeries, 94 presented ischemic changes in early or late postoperative period, which led them to be re-evaluated by coronary angiography. The grafts were divided in three groups: internal thoracic artery (ITA), radial artery (RA) and saphenous vein (SV), and they were stratified according to the severity of injury: uninjured or patent (< 70%), severe obstruction (70 to 99%) and occlusion. RESULTS: For the 94 patients in the study, 86 grafts of ITA, 94 of RA and 111 of SV were used. For the 86 ITA grafts, 73 (84.88%) were found patent. For the 94 RA grafts, 55 (58.51%) were found patent, and for the 111 SV grafts, 73 (65.76%) were uninjured. A statistically significant difference (P= 0.001) was found between RA and SV grafts, with a higher patency found for VS graft. For the RA grafts, women presented a worse result concerning the RA patency (65.7% and 40.7%), with P = 0.006. Concerning coronary revascularization, a statistically significant difference was found only for the grafts used for the right coronary, with a better result for the SV (P = 0.036). CONCLUSION: Radial artery (RA) presented worse results when compared to Saphenous vein (SV) as a second graft in a CABG, especially in women who were anastomosed in the right coronary artery.
Keywords: Myocardial revascularization. Radial artery. Mammary arteries. Saphenous vein.
Rosane Maria Nery; Marcio Roberto Martini; Cristiane da Rocha Vidor; Mahmud Ismail Mahmud; Maurice Zanini; Aderson Loureiro; Juarez Neuhaus Barbisan
Rev Bras Cir Cardiovasc 2010;25(2):224-228
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Objective: To check changes in the functional capacity of patients undergoing coronary artery bypass grafting (CABG) by testing six-minute walk test (6MWT) following two years. Methods: A prospective cohort study where 215 patients were enrolled who underwent CABG, 13 did not meet the criteria for inclusion. 202 patients were evaluated preoperatively, 13 died during hospitalization and 6 in the follow up of two years. Four patients were considered lost follow up. This study followed 179 patients for two years classified into active and sedentary, according to physical activity in leisure time and to the 6MWT preoperatively and 2 years later. Results: One hundred and twenty patients were evaluated in the day before CABGS, being 67% male with an average age of 63 (±9.75) years. Before surgery and 2 years later, 52 were active and the 6MWT distances performed had been 359m (±164.47) and 439m (±171.34), respectively; P= 0.016. Forty five patients were classified as sedentary before and 2 years after surgery. The 6MWT distances walked before and after surgery had been 255m (±172.15) and 376m (±210.92), respectively; P< 0.001. Eighty two patients transited between these two groups, 71 passed from sedentary to active and had walked before and after surgery 289m (±157.15) and 380m (±125.44), respectively; P= 0.001. The 11 patients who were active and passed to the sedentary group walked 221m (±191.91) and 384m (±63.73), respectively; P= 0.007. Conclusion: The functional capacity of the patients submitted to CABGS had a significant improvement in a medium period of follow-up.
Keywords: Myocardial revascularization. Functional residual capacity. Total lung capacity. Walking.
Marcio Roberto Martini; Juarez Neuhaus Barbisan
Rev Bras Cir Cardiovasc 2010;25(3):359-364
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Objective: To investigate the effect of physical activity in leisure time (LTPA) on the prognosis of patients two years after coronary artery bypass grafting (CABG). Methods: Cohort study with 202 elective CABG patients, mean age of patients was 62 ± 10 years, 134 (66%) men divided into sedentary and active according their LTPA. Followed for two years after CAGB where the occurrence of major adverse cardiac events (MACES) were found, and changes in physical activity. Results: Thirty-eight had MACES. Twenty-nine were sedentary, nine active (P=0.18). Active: three (4.5%) readmissions, three (4.5%) deaths and two (3%) stroke. Sedentary: seven (5.1%) acute myocardial infarction (AMI), seven (5.1%) readmissions, 16 (11.6%) deaths and one (0.7%) stroke. LTPA decreased from preoperative to the postoperative period. Sedentary: 2.09 (±0.58) and 2.08 (±0.57); active: 2.53 (±0.73) and 2.33 (±0.71). The leisure and locomotion activities in the preoperative and postoperative: Sedentary increased 2.08 (±1.09) and 2.13 (±0.78); active reduction 2.53 (±0.73) and 2.27 (±1.12). The 6-minute walk test increased pre and postoperative. Sedentary: 255m (±167.06m) and 377m (±190.63m); active: 337m (±172.42m) and 405m (±148.93 m). The veterans specific activity questionnaire increased the pre and postoperative. Sedentary: 4.39 (±1.80) and 6.99 (±3.08); active: 4.44 (±1.82) and 8.50 (±3.16). Conclusion: The results indicate that LTPA does not modify the late prognostic of CABG patients, but CABG itself promotes physical activity and improves long-term functional capacity.
Keywords: Exercise. Physical education and training. Myocardial revascularization.
REVIEW ARTICLE
Emad Mohamed Hijazi
Rev Bras Cir Cardiovasc 2010;25(3):393-402
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Avoiding the morbidity of cardiopulmonary bypass should theoretically reduce the incidence of organ dysfunction and lead to improved patient outcomes. Recently, cardiac mechanical stabilization techniques were developed, facilitating on-pump CABG (OPCAB). The use of CPB may influence the economic outcome, while maintaining quality of care and patient satisfaction. MEDLINE, EMBASE, Cochrane Controlled Trials Register (CCTR), Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE), Science Citation Index (SCI), Current Contents, NHS Economic Evaluation Database (NEED), and International Network of Agencies for Health Technology Assessment (INAHTA) databases were searched from the date of their inception to the end of March 2008, using the search terms off-pump, minimally invasive, beating heart, coronary artery bypass, and their variants. Off-pump revascularization offers a safe, cost-effective alternative to conventional coronary revascularization with cardiopulmonary bypass (CABG) and cardioplegic arrest.
Keywords: Extracorporeal circulation. Cardiac surgical procedures. Coronary artery bypass. Myocardial revascularization. Coronary artery bypass, off-pump.
CASE REPORT
João Carlos Leal; Victor Rodrigues Ribeiro Ferreira; Luis Ernesto Avanci; Domingo Marcolino Braile
Rev Bras Cir Cardiovasc 2010;25(3):403-405
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Surgical treatment of aortic dissection is a challenge for the cardiac surgeon, especially in patients undergoing cardiac operations. Our objective in this case report is to demonstrate how we treat the chronic type A aortic dissection in patients revascularized using percutaneous arterial and venous cannulae.
Keywords: Extracorporeal circulation. Myocardial revascularization. Systemic inflammatory response syndrome. Aortic aneurysm/surgery.
Joaquim David Carneiro Neto; José Antonio de Lima Neto; Rosa Maria da Costa Simões; Noedir Antonio Groppo Stolf
Rev Bras Cir Cardiovasc 2010;25(3):410-414
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Coronary artery spasm in perioperative of coronary artery bypass graft surgery is a serious complication, with high rate mortality. Patient 51 years-old submitted to coronary artery bypass graft surgery without Extracorporeal Circulation. The patient evolved in 1st post operative (PO) day with enzymatic alteration and ST-elevation, developing soon afterwards in ventricular fibrillation, defibrillation with success. Cardiac catheterization showed important spasm of all coronary arteries and anastomosis between the left internal thoracic artery and the left anterior interventricular artery. Intracoronary Vasodilators and intra-graft, with re-establishment of their usual and immediate calibers to improve clinic and Hemodynamic stability was used. Satisfactory evolution, discharged at 13rd PO day.
Keywords: Myocardial revascularization. Coronary artery bypass. Coronary vasospasm. Heart catheterization.
ORIGINAL ARTICLE
Michel Pompeu Barros de Oliveira Sá; Evelyn Figueira Soares; Cecília Andrade Santos; Omar Jacobina Figueredo; Renato Oliveira Albuquerque Lima; Rodrigo Renda Escobar; Frederico Pires Vasconcelos Silva; Ricardo de Carvalho Lima
Rev Bras Cir Cardiovasc 2010;25(4):474-482
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Objective: The aim of this study is to evaluate the applicability of EuroSCORE in patients undergoing coronary artery bypass graft (CABG) surgery at the Division of Cardiovascular Surgery of Pernambuco Cardiologic Emergency Medical Services - PROCAPE. Methods: A retrospective study involving 500 patients operated between May 2007 and April 2010. The registers contained all the information used to calculate the EuroSCORE. The outcome of interest was death. Univariate analysis and multivariate analysis by backward logistic regression were applied to assess the association between each variable in the EuroSCORE and deaths. The following parameters were calculated: sensitivity, specificity, positive predictive value, and negative predictive value. The power of concordance between the predicted mortality by the EuroSCORE and the observed mortality was measured using the Kappa coefficient. The accuracy of the model was evaluated by the ROC (receiver operating characteristic) curve. Results: The incidence of death was 13%. In multivariate analysis, nine variables remained independent predictors of death: chronic obstructive pulmonary disease, creatinine >2,3mg/dL, active endocarditis, preoperative critical state, unstable angina, ejection fraction 30% to 50%, acute myocardial infarction < 90 days, emergency surgery and additional surgery. The score had a sensitivity of 88.4%, specificity of 79.3%, positive predictive value of 40.7%, negative predictive value of 97.7% and 80.6% concordance. The accuracy measured by the area under the ROC curve was 0.892 (95% CI 0.862-0.922). Conclusions: The EuroSCORE proved to be a simple and objective index, revealing a satisfactory discriminator of postoperative evolution in patients undergoing CABG surgery at our institution.
Keywords: Myocardial revascularization. Risk. Mortality. Risk assessment/methods.
Graziella Ferreira Barros; Cláudia da Silva Santos; Fernanda Boromello Granado; Patrícia Tatiane Costa; Renán Prado Límaco; Giulliano Gardenghi
Rev Bras Cir Cardiovasc 2010;25(4):483-490
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Objectives: 1) To demonstrate the impaired ventilatory capacity during the post operatory period, in patients submitted to coronary arterial bypass graft surgery (CABG). 2) To test the hypothesis that the respiratory muscle training (RMT), performed after the surgery, may increase the ventilatory capacity in this population. Methods: Thirty-eight patients (age: 65±7 years, 29 male), whose underwent CABG with extra-corporeal circulation. Patients were randomized in two groups: 23 patients in the RMT group and 15 in the control group (CO). RMT group received conventional physiotherapy plus RMT. The CO group received the conventional physiotherapy. Evaluated parameters: maximum inspiratory and expiratory pressures (MIP) (MEP), dyspnea (Borg), peak expiratory flow (PEF), pain, tidal volume and hospitalization days. Measures were performed at pre, first post operatory day and also at the patients discharge from the hospital). Results: MIP and MEP in the RMT group were higher when compared with CO at the patients discharge (MIP: 90±26 vs. 55±38 cmH2O, P=0.01) (MEP: 99±30 vs. 53±26 cmH2O, P=0.02). The PEF was higher after hospitalization in the RMT group (237±93 vs. 157±102 lpm, P=0.02). Tidal volume was also higher in the RMT group at discharge (0.71±0.21 vs. 0.44±0.12 liters, P=0,00). No differences were observed among the groups in the aspects: admission days, dyspnea and pain. Conclusions: Patients submitted to CABG presents an impaired respiratory muscle strength in their post operatory. RMT performed in this phase was effective to restore the ventilatory capacity in the following parameters: MIP, MEP, PEF and tidal volume, in this group of patients.
Keywords: Myocardial revascularization. Breathing exercises. Treatment outcome.
Mauro Paes Leme; Antônio de Pádua Jazbik; Henrique Murad; Eduardo Sérgio Bastos; João de Deus e Brito; Rubens Giambroni Filho; José Augusto de Azevedo; Leoncio Feitosa
Rev Bras Cir Cardiovasc 1997;12(2):169-175
Abstract
This study presents the results in a group of fifteen patients submitted to cardiac surgery, using continuous atrial retrograde warm blood cardioplegia for myocardial protection. Eleven patients were submitted to myocardial revascularization and four were submitted to valvular transplantation. There was no need for inotropic drugs or intraaortic balloon pump support during or after the procedure, and no myocardial infarction was detected in this group. When the heart was arrested, the cardioplegia line was switched to the atrial cannula. The aortic root was vented throughout the cross-clamp period, and retrograde perfusion was assured by noting the engorged exygenated cardiac veins as well as the return of dark blood through the vent in the aortic root. The patients presented good clinical and laboratory course. No right ventricular dysfunction was detected. Two patients were in atrial fibrillation before the surgery, one of them returned to this cardiac rhythm three days after the procedure.
Keywords: Heart arrest, methods. Myocardial revascularization. Aortic valve, surgery. Mitral valve, surgery. Extracorporeal circulation.
Ricardo Ribeiro Dias; Fabio B Jatene; Adib D Jatene
Rev Bras Cir Cardiovasc 1997;12(3):244-247
Abstract
We present here the initial results of patients submitted to myocardial revascularization with the employment of minimally invasive technique of saphenous vein graft dissection. We utilized small incisions (3 to 4 cm) over the skin of the inferior limb, repeated at intervals of 8 to 14 cm to obtain the vein graft, with the aid of an adequate ilumination and special retractors. This method provided veins of 30 to 65 cm of length, through 2 to 4 small skin incisions. We operated on 8 patients who received 25 saphenous vein grafts plus the arterial ones. All patients improved well, without complications of the inferior limb and with a very good stetic effect.
Keywords: Surgery, minimally invasive. Saphenous vein, dissection. Saphenous vein, surgery. Myocardial revascularization.
CASE REPORT
José Carlos R Iglézias; Luís Alberto Dallan; J. L. Oliveira Júnior; Artur Lourenção Júnior; Noedir A. G Stolf; Sérgio Almeida de Oliveira; Geraldo Verginelli; Adib D Jatene
Rev Bras Cir Cardiovasc 1997;12(3):292-295
Abstract
An intracavitary location of a coronary artery is rare in our surgical experience with revascularization. This variant has occured in the right coronary artery (0.01%) and in left anterior descending coronary artery (0.2%). The location of the lesion and the pathological condition, length and size of the coronary may dictate exposure of an intracavitary coronary artery for proper revascularization; more commonly surgeons are anaware of the intracavitary position and during intramyocardial dissection of an artery will open a cardiac chamber where the vessel traverses the cavity. Problems that arise are introducion of air, dificulty in exposure due to blood and depth of position and obstruction of the coronary artery during closure of the myotomy. Three patients are presented who required revascularization of intracavitary vessels (three right coronary arteries). The location and lenght of the intracavitary portion of the artery determined the surgical management the methods used to close the cavity varied. The techniques employed were simple closure moving the artery into an aerial position with cavitary closure using bovine pericardium; anastomosis in the intracavitary position with closure of the myotomy, or selection of an alternate distal site for anastomosis.
Keywords: Coronary vessels, surgery. Myocardial revascularization.
ORIGINAL ARTICLE
José Carlos R Iglézias; José de Lima Oliveira Júnior; Klaus Werner Fels; Luís Alberto Dallan; Noedir A. G Stolf; Sérgio Almeida de Oliveira; Geraldo Verginelli; Adib D Jatene
Rev Bras Cir Cardiovasc 1997;12(4):325-334
Abstract
The trend in Brazil of erroneously delaying myocardial revascularization in the elderly determined this study. Three hundred consecutive elderly patients (mean age: 73,92, standard deviation: 3.32). Between October 1992 and July 1995, 361 consecutive patients underwent isolated coronary artery bypass grafting, of whom 111 (30,7%) were females and 250 (69,35) males. There were 128 (35,5%) diabetic patients and 128 (36,7%) were in NYHA III/IV. Univariate analysis per-operatory of 19 factors followed by multivariate logistic regression analysis of the significant variables (p 0.005) were done. Major complication ocurred in 178 (49.3%) and were independent predictors of operative morbidity: Diabetes mellitus, NYHA funcional classification, urgent cases and DP2. There were 33 (9,1%) in hospital deaths, and diabetes mellitus, NYHA functional classification, unstable pre-operative angina and cerebral vascular acidents, renal failure, infection and insufficiency respiratory failure were independent predictors of operative mortality. We concluded that coronary artery bypass grafting is possible in elderly patients with a favorable outcome, especially when done in patients with normal to moderately depressed left ventricular function.
Keywords: Myocardial revascularization. Coronary disease, surgery. Myocardial revascularization, prognosis. Myocardial revascularization, aged.
CASE REPORT
Adilson Casemiro Pires; Wladmir Faustino Saporito; Roberto Álvaro Ramos Filho; Hélio José Castelo Jr.; Dirceu Rodrigues de Almeida
Rev Bras Cir Cardiovasc 1997;12(4):387-391
Abstract
The Bentall and DeBono procedure is the surgery of choice for the repair of annulo-aortic ectasia. The association of such degenerative disease with coronary atherosclerosis is unusual. We report the case of a 57-year old patient with such association who underwent a Bentall and DeBono procedure and concurrent coronary artery by-pass graft (CABG). With the support of extracorporeal circulation and myocardial protection through retrograde cold blood cardioplegia, the following procedure was performed: composite replacement of the aortic valve and the ascending aorta for a valvular bovine pericardium tube graft, and CABG, using the anastomosis of the internal thoracic artery to the left interventricular artery and a segment of the saphenous vein connecting the internal thoracic artery with the marginal branch of the circunflex artery. Both, the surgery and the post operative period, were uneventful.
Keywords: Coronary arteriosclerosis, surgery. Aortic aneurysm, surgery. Aortic valve insufficiency, surgery. Myocardial revascularization.
Hércules Lisboa Bongiovani; Elza Helena F Bongiovani; Lineu João S. Biazotti; William T. Haddad; João Otávio Freitas Júnior; Pércio P. Pandolphi; Sílvio F. C. Rosatti
Rev Bras Cir Cardiovasc 1998;13(1):57-59
Abstract
From the early days of surgical treatment of coronary artery disease by Vineberg until the present time using several types of grafts, we are hoping to improve outcome. Case 1 - A 60 year old man with angina and syncope. An angiographic study has shown a 90% obstruction in A. D., 99% in the right coronary (Fig. 1). An anastomosis between the left Internal thoracic artery and the right coronary artery. A resection of the narrow segment with an end to end anastomosis (Fig. 2). Case 2 - A 40 year old man, with 80% obstruction in the right coronary artery (Fig. 4) and 99% in the descending aorta. A 4 cm segment of ATIE was replaced with a bypass from the right coronary artery (Fig. 3). And a free graft of ATIE from descending anterior artery. The one year follow up of both patients has been good with normal stress test and symptoms.
Keywords: Coronary vessels, surgery. Myocardial revascularization. Thoracic arteries, surgery. Anastomosis, surgical.
ORIGINAL ARTICLE
Serginando Laudenir Ramin; Odilar Paiva Filho; Moacir Fernandes de Godoi; Domingo M Braile
Rev Bras Cir Cardiovasc 1998;13(4):354-356
Abstract
Capnography has been recommended as an anesthetic technique and the end-tidal carbon dioxide tension (PETCO2) is available in the operating room. PETCO2 is governed by metabolism, ventilation and circulation. When the first two parameters are controlled, PETCO2 reflects the lung flow, therefore the cardiac output. Studies have shown that PETCO2 lower than 20 mmHg is invariably associated with a cardiac output less than 2 L/min, even if other hemodynamic parameters are appropriate. Further increases in the preload, reduction of the afterload, establishment of an appropriate atrioventricular synchrony or increasing inotropy is necessary to increase PETCO2 above 25 mmHg. A considerable body of literature describes the use of PETCO2 to assess the adequacy of cardiopulmonary resuscitation after cardiac arrest. Besides, attempts have been made to use PETCO2 as an alternative to the thermodilution technique for determining cardiac output. Little has been reported of its use in cardiac surgery. From June 1996 to June 1997 we have studied 200 patients, submitted to CPB suggesting that PETCO2 around 27 mmHg would indicate a cardiac output good enough to wean the patients on the cardiopulmonary circulation so long as other hemodynamic and metabolic parameters were adequate. None of the patients required CPB giving us the impression that end-tidal carbon dioxide tension generally indicates an appropriate cardiac output.
Keywords: Extracorporeal circulation. Carbon dioxide. Cardiac output. Myocardial revascularization.
CASE REPORT
Giancarlo Grossi Mota; Carlos Heitor Passerino; Maria Alzira Ribeiro Alves Coelho; Dalva Maria S. Machado; Raul Corrêa Rabelo
Rev Bras Cir Cardiovasc 1998;13(4):375-379
Abstract
This report refers to a 69 year old woman, presenting severe stenosis of both carotid arteries, associated with coronary insufficiency. An acute incomplete transitory brain stroke made mandatory the simultaneous surgical approach of bilateral carotid arteries for endarterectomy and myocardial revascularization. The procedure can be performed safely in very selected and unstable cases.
Keywords: Myocardial revascularization. Endarterectomy, carotid. Carotid artery, internal, surgery. Carotid stenosis, surgery. Carotid output, low, surgery.
ORIGINAL ARTICLE
Wellington Araújo Costa; João Marcos de Vasconcellos Santos; Dielson Teixeira Sampaio; Nilcio da Cunha Lobo Jr.; Carlos C. Smith Figueroa
Rev Bras Cir Cardiovasc 1999;14(1):19-26
Abstract
A retrospective study of thirty seven patients with myocardial infarction who underwent myocardial revascularization surgery was accomplished. Two groups of patients were established for the comparative study. The first group consisted of patients operated on within 30 days of the myocardial infarction and the second group was composed of patients operated on after that time. Both groups had similar characteristics: age, sex, affected heart region, coexistence or not of diabetes mellitus or arterial hypertension, and cardiogenic shock. Overall surgical mortality was 13.5% (4 deaths out of 18 patients in group I and 1 death out of 19 patients in group II - p = 0.180). When patients operated on within the first 72 hours of myocardyal infarction were excluded and both groups were compared, overall mortality was 5.9% (one death out of 15 patients in group I; one death out of 19 patients in group II - p = 1.0. Based on previous reports, it is believed that surgery for myocardial revascularization can be safely accomplished especially after the first 72 hours of the ischemic event.
Keywords: Myocardial revascularization. Myocardial infarction, surgery. Myocardial revascularization, mortality.
Maurílio Onofre Deininger; Orlando Gomes de Oliveira; Marcelo Gentil Almeida Guedes; Eugênia Di Giuseppe Deininger; Antônio Carlos Wanderley Cavalcanti; Maria Das Graças Feitosa Wanderley Cavalcanti; Ricardo Wanderley Queiroga; Norland de Souza Lopes
Rev Bras Cir Cardiovasc 1999;14(2):88-97
Abstract
A retrospective analysis involving seventy-year-old patients as well as those over seventy who have undergone CABG as a single procedure, during Jannuary 1992 to December 1997, was carried out with the purpose of assessing their morbidity with mortality. Of the 144 patients, 92 (63.9%) were males, aged 70 to 84 (average age 73.51 and standard deviation 2.82). Most of those, 114 (79.16%), suffered from angina belonging to the functional class III or IV. The occurrence in the pre-operative period of obesity (p = 0.004), heart failure (III/IV class - p = 0.03) and/or acute myocardial infection (less than 21 days - p = 0.01) demonstrated a definite relationship with mortality. There were 120 (83.34%) patients with lesions in three or more vessels (average 3.48 anastomoses/patients).The pediculate internal mammary artery was employed in 126 patients (87.5%) and that rate increased to 98.9% in the last two years. The main complications in the post-operation period leading to death were either infections (p < 0.0001), prolonged ventilatory support (p < 0.0001), renal failure with dialysis (p < 0.0001) and/or low cardiac output (p = 0.003). As to statistical analysis the Student T test, the Chi-square test and Fisher's exact test were used. Surgical mortality totalling 5.5% (8/144) in the first thirty post-operative days decreased to 1.53% (1/65) in the last two years. Coronary artery bypass graft in the elderly can be a procedure with low morbidity and mortality if their body systems are carefully evaluated.
Keywords: Myocardial revascularization. Myocardial revascularization, aged. Myocardial revascularization, mortality. Retrospective studies.
Luiz Antonio Brasil; Walter José Gomes; Reinaldo Salomão; Prof. Dr. José Honório Palma da Fonseca; João Nelson Rodrigues Branco; Enio Buffolo
Rev Bras Cir Cardiovasc 1999;14(3):254-268
Abstract
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Cardiopulmonary bypass (CPB) induces the development of a systemic inflammatory response syndrome, with the release of cytokines that are responsible for many clinical manifestations.
Purpose: The purpose of the study was to observe the release of the cytokines - tumor necrosis factor alpha (TNFa) and Interleukine-6 (IL-6), and to verify the clinical alterations produced in patients undergoing myocardial revascularization with CPB, with or without corticoids.
Material and Methods: Thirty patients were studied - 15 used corticoid (methylprednisolone, 30 mg/kg -Group I) and 15 did not (Group II). Serial blood samples were collected and the TNFa and IL-6 release were analyzed, as well as the leukocyte count, erythrocyte sedimentation rate and glycemia. The blood pressure, cardiac rate, temperature, postoperative bleeding, orotracheal tubing time and inotropic drug requirement were also compared. Statistical significance was assumed when p £ 0.05.
Results: In Group I TNFa was not detected and IL-6 was detected in 13 patients, with levels ranging from 8.6 to 101.8 pg/ml. In Group II TNFa was detected in 13 patients, with levels between 5.4 and 231.0 pg/ml. The IL-6 in this group was detected in 15 patients, with higher levels than those in Group I, varying between 5.5 and 2569.0 pg/ml. The Group I patients had higher medium blood pressure (7.9 ± 0.5 vs 7.3 ± 0.4 mmHg) and lower inotropic drug requirement (5 vs 11). They evolved with less tachycardia (105.6 ± 5.9 vs 109.3 ± 7.2 bpm), lower temperature (36.5 ± 0.2 vs 37.3 ± 0.2°C), lower postoperative bleeding, (576.6 ± 119.5 vs 810.0 ± 176.2 ml), shorter orotracheal tubing time (11.0 ± 2.0 vs 14.6 ± 2.9 hs) and lower leukocytosis. The glycemia level was just significant (Group I > Grupo II) in the immediate postoperative and in the first postoperative samples. The erythrocyte sedimentation rate did not present significant statistical difference between the two groups.
Conclusion: The methylprednisolone significantly inhibited the release of inflammatory cytokines mainly the TNFa. The systemic adverse effects caused by the inflammatory response after CPB were minimized by corticoid use.
Keywords: Myocardial revascularization. Extracorporeal circulation,adverse effect. Corticoids, farmacology. Sepsis syndrome, etiology. IL6, antagonists & inhibitors. TNF-alpha, antagonists & inhibitors.
Fanilda Souto Barros; Sandra Maria Pontes; Melchior Luiz Lima; José Silva Henrique; Márcio Luiz Roldi; Fábio Reis; José Carone Jr.; Schariff Moisés
Rev Bras Cir Cardiovasc 1999;14(4):303-307
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INTRODUCTION: The vascular echocolor Doppler, has made possible the observation of the greater saphenous vein (GSV) state without additional risk to the patient or to vascular lesions. The objective of the study was, working with a group of cardiovascular surgeons, to show the utility of the mapping of the GSV before coronary artery bypass graft (CABG) surgery.
METHOD: During the period from March 1995 to May 1998, 208 extremities of 104 patients selected for CABG were studied. The criteria used for the selection of the GSV was the patency and a diameter larger than or equal to 3.0 mm, using the the ultra-sound equipment ATL - HDI 3000 and Acuson-Sequóia 512.
RESULTS: Within the 208 extremities studied, 186 (89.4%) were appropriate for CABG in accordance with the description from the echocolor Doppler, seventeen (8.2%) did not fulfill the criteria, and five (2.4%) showed GSV stripping. Two of the seventeen inappropriate GSV were surgically explored, confirming the echoultrasound findings.
CONCLUSIONS: The authors conclude that the echocolor Doppler can be effective in the mapping of GSV in the preoperative examination of the greater saphenous vein and its selection for CABG. Due to it´s capacity to correctly identify and select veins for by - pass surgery, the echocolor Doppler saves time in the search for veins and permits the surgeon to better plan the surgery.
Keywords: Myocardial revascularization. Echocardiography, Doppler color. Saphenous vein, ultrasonography. Preoperative care, methods.
Luiz Antônio Brasil; João Batista Mariano; Fernando Martins Dos Santos; André Luiz Silveira; Nilo de Melo; Nivaldo Gomes de Oliveira; Rômulo Sales Andrade; Delzirene Pinheiro Botelho; Antônio Calzada
Rev Bras Cir Cardiovasc 2000;15(1):6-15
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BACKGROUND: Myocardial revascularization without cardiopulmonary bypass (CPB) has been used as an alternative for treatment of coronary insufficiency.
OBJECTIVE: To present our experience with this procedure describing the technique used and our initial results.
MATERIAL AND METHODS: Twenty-three patients were submitted to myocardial revascularization without CPB. The patients selected for this study had lesions in the coronary arteries of the anterodiaphragmatic cardiac region. The main surgical indication was chronic coronary insufficiency (78.3%). 65% of the patients were male, with age between 44-80 (mean - 59.6 years). The surgical approach in all patients was through median sternotomy. He grafts used were internal thoracic arteries, saphenous vein and radial artery.
RESULTS: Mean surgical time was 3:15 hours. There were no intra-operative occurences.
The number of grafts was 1 to 3 in each patient (mean 1.56 graft/patient) out of a total of 36 grafts. The left internal thoracic artery was the most used graft (41.7%). The most frequently revascularized coronary arteries were the anterior interventricular branch (52.8%) and the right coronary (30.5%). Hospital mortality and post-operative infarct were 4.3%. There were no neurological, pulmonary, renal, hemorragic or infectious complications. The mean hospital stay was 7 days.
CONCLUSION: Myocardial revascularization without cardiopulmonary bypass is an effective and safe technique that can be utilized in selected cases with low morbidity and mortality, reducing costs and hospital stay.
Keywords: Myocardial revascularization. Extracorporeal circulation. Heart disease, surgery.
Paulo M Pêgo-Fernandes; Fabio B Jatene; Fabricio Ferreira Coelho; André Felix Gentil; Karina L. Kawasnicka; Noedir A. G Stolf; Sérgio A Oliveira
Rev Bras Cir Cardiovasc 2000;15(3):212-218
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OBJECTIVE: The aim of this study is to evaluate immediate hemodynamics evolution in myocardial revascularization with intermittent aortic cross-clamping, using or not a preconditioning protocol.
MATERIAL AND METHODS: Thirty-five patients underwent myocardial revascularization, they were randomized in two groups: the control group (18) with intermittent aortic-clamping, and the preconditioning group (17) with two short aortic-clamping before the onset of conventional intermittent clamping. In both groups the patients' mean arterial pressure (mAP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), left ventricular stroke work index (LVSWI) were monitored before the onset of the cardiopulmonary bypass (moment 1) and the sternal suture (moment 2), and, postoperatively at six/twelve/eighteen/twenty-four hours (moments 3, 4, 5 and 6, respectively). Also the patients' left ventricular ejection fraction (LVEF) was controlled through echocardiogram, in moments 1 and 2.
RESULTS: None statistical differences was seen between groups, however occurred a growth in CI and LVEF after revascularization. All patients presented good clinical evolution.
CONCLUSION: The hemodynamic evolution was similar between the groups.
Keywords: Myocardial revascularization. Myocardial revascularization, methods. Hemodynamics, physiology. Extracorporeal circulation. Aortic clamping. Myocardial protection. Myocardial revascularization, comparative study. Myocardial revascularization, hemodynamics.
Claudio G. Sobrosa; Eva Jansson; Lennart Kaijser; Vollmer Bomfim
Rev Bras Cir Cardiovasc 2000;15(3):219-226
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MATERIAL AND METHODS: An metabolic analyse of hypothermic retrograde continuous blood cardioplegia was done in a prospective study of 15 patients scheduled for elective CABG. Inclusions criteria were double or triple vessel coronary artery disease and preserved left ventricular function (ejection fraction > 40%). Exclusions criteria were unstable angina, insulin-treated diabetes mellitus and associated peroperative procedures. Three patients were excluded of the study (associated procedure and coronary sinus catether dislocation). Arterial and coronary sinus blood samples were simultaneouslly taken: before ECC (extracorporeal circulation), when the aortic clamp was takem off and 10, 30 and 60 minutes after reperfusion for analysing of oxygen content and lactate concentration. Four transmural left ventricular biopsies samples were obtained: before aortic clamping, immediately after the inicial cardioplegia bolus, immediately before aortic declamping and 30 minutes after reperfusion for analysing of the levels of ATP, ADP, AMP and lactate in the myocardial. The CK-MB isoenzyme was analysed in venous blood samples.
RESULTS: There was no mortality in the group. There was a decrease in the arterial-venous extraction of oxygen and lactate in the heart during reperfusion, occurring a parcial recuperation only at 60 minutes of reperfusion. The ATP and the others nucleotides had their levels in the myocardium maintened during aortic clamping, but these levels decreased during the first 30 minutes of reperfusion. The lactate was accumulated in the heart muscle during aortic clamping and his levels also decreased during reperfusion. The CK-MB levels were elevated specially between the third and sixth post-operative hour.
CONCLUSIONS: In the metabolic point of view the method could not avoid an anaerobic metabolism during cross-clamping and only after 60 minutes of reperfusion there was a parcial metabolic recuperation. These alterations were probably a reflexion of cellular ischemic injury occurred during cross-clamping and they were of transitory effect.
Keywords: Myocardium, metabolism. Heart arrest induced, methods. Hypothermia induced, methods. Myocardium, drug effects. Myocardium reperfusion. Heart physiology. Myocardial revascularization.
André Luiz Tyszka; Leila Satomi Fucuda; Eloisa de Brida Tormena; Antonio Carlos L. Campos
Rev Bras Cir Cardiovasc 2001;16(2):105-113
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Objective: The aim of this study was to evaluate the possibility of excision of the greater saphenous vein through the minimal invasive technique, assessing its morphologic quality and the early complications in the leg wound.
Material And Methods: From July to November/1999, 46 patients received aortocoronary saphenous vein bypass graft. A miniincision was made, the vein was identified and gently dissected out with a special retractor, with a long and narrow blade. The samples of the vein were sent to histological analysis. Taking into accounts the presence or absence of the risk factors (female sex, anemia, obesity, peripheral vascular disease and diabetes mellitus) the patients were divided into two groups. The wounds were inspected, looking for majors and minor wound complications.
Results: The average number of incisions was 2.3, the average length was 3.5 cm, and the average of all incision length was 7.3 cm. The average length of vein harvested was 34.1 cm. The mean duration of the procedure was 28.7 minutes. Minor leg wound complications occurred in 5 (10.8%) patients and the most common problem was local hematoma (6.5%). There were no major complications. The macroscopically evaluation showed two tears but the correction was possible. Histological study showed that vascular integrity was maintained and there was no significant endothelial damage.
Conclusions: It was possible to harvesting satisfactory length of the vein through minimally invasive technique. This technique does not compromise the morphological quality of the vein graft. A low incidence of leg wound complications was observed, independently of the risk factors. These initial results suggest that this technique can be satisfactorily used for harvesting the greater saphenous vein. However, the long-term results still remain to be determined.
Keywords: Myocardial revascularization. Cardiac surgical procedures, methods. Saphenous vein, surgery, methods. Surgical procedures minimally invasive. Saphenous vein, transplantation.
Melchior Luis Lima; Fábio José Dos Reis; Francisco Otávio Gaburro Teixeira; Fanilda Souto Barros
Rev Bras Cir Cardiovasc 2002;17(1):19-23
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INTRODUCTION: With the growing use of the radial artery as a coronary artery bypass graft, becomes necessary to revalue the criteria used for the selection of that vessel in the preoperative of the surgery of coronary artery bypass graft (CABG). The objective of this study was to correlate the evaluation of the viability of the vessel for the heart surgeon at surgery with the study of selection of the radial artery for the methods non invasivos, as EchocolorDoppler(ECD) and the digital photoplethysmography(PPG).
METHODS: Between July of 1998 and January of 2000, 78 radial arteries and 78 arteries ulnares of 39 patients selected for CABG, were studied. The study was carried out bilaterally, using duplex ultrasound ATL - HDI 5000 and Acuson - Sequoia 512, and for the photoplethysmography an apparel Parks Vascular Mini - Lab Model 1052-C. The radial artery was considered susceptible to be used as coronary artery graft bypass, when it filled out the following criteria: ateromatose absence or occlusion of the radial artery and ulnar ipsilateral, internal diameter of the larger radial artery or equal to 2.5mm, appraised for ECD, and presence of pulse wave in two or more digits during the radial compression, appraised for the PPG.
RESULTS: Among the 78 studied radial arteries, 64 (82%) were considered appropriate for use as coronary artery graft bypass and 12 (18.7%), not appropriate. Of the 39 selected patients, 24 (61.5%) they were submitted to CABG with use of the radial artery and the correlation between the viability of the appraised radial artery for the surgeon at surgery with the evaluation preoperative for ECD and for the PPG for selection of the radial artery was of 100%. The contraindication of the harvest of 12 (18.7%) radial arteries took to the alteration of the surgical planning of two patients, owing to the bilateral compromising. In three patients that, for different reasons, they were not submitted to the study by ECD and for the PPG, the clinical evaluation of the patency of the radial artery using Allen's maneuver was not enough to move away the presence of calcification of the arterial wall found in the operative act, disabling the use of that artery as graft.
CONCLUSION: The selection of the radial artery for use as graft coronary artery bypass, appraised by non invasive tests, as ECD and the PPG, it is effective, because the association of those methods presents excellent correlation with the evaluation at surgery and it allows us, cardiovascular surgeons, besides the safety, a better surgical planning for each patient.
Keywords: Radial artery, ultrasonography. Echocardiography, Doppler color, utilization. Photoplethysmography, utilization. Myocardial revascularization.
CASE REPORT
George Ronald Soncini da Rosa; Viviane Guzzo Lemke; Walmor Lemke; João Madeira Neto; Américo Álvaro Farinha Martins; Luiz Fernando Kubrusly
Rev Bras Cir Cardiovasc 2002;17(4):359-361
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This is a report of an unusual case of a patient, with dextrocardia and a "situs inversus totalis". She presented angina pectoris during an ECG stress test. The coronary arteriography revealed severe obstruction in the main left coronary artery. The patient underwent coronary artery bypass grafting surgery. We did not find a similar case in the national medical literature. The myocardial revascularization performed utilizing the right mammary artery for anterior descending artery and saphenous vein grafts for first diagonal branch and first marginal branch.
Keywords: Dextrocardia, surgery. Situs inversus. Myocardial revascularization.
ORIGINAL ARTICLE
Siderval Ferreira Alves; Dolores Cristina M. Albuquerque; Eraldo Antonio Pelloso; Wesley Ferraz Silveira; Christinano Roberto Barros; Rubens T Barros; Antonio C. Penna
Rev Bras Cir Cardiovasc 2003;18(1):32-39
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OBJECTIVE: To evaluate the late patency of the radial artery used as a conduit in coronary artery bypass grafting through a selective catheterization.
METHOD:A group of 109 patients operated on for coronary artery bypass grafting used radial artery as grafts, from September 1995 to October 1996, were re-studied in the immediate post-operative period. Among these patients, 91 (83.5%) were contacted either by phone or through outpatient follow-ups, and 34 underwent a late angiographic study. Twenty-two patients were male (65%). The average age of the patients was 57.4 years old (37-70). The average time of the restudy was of 51.2 months (41-63). Thirty-eight distal anastomoses were performed using the radial artery, with an average of 1.12 distal anastomoses per patient. The analysis of these data is the basis for the present study.
RESULTS: The radial artery was patent in 30 patients (34 distal anastomoses - 89.5%), and had a lesion in only one patient along with the proximal anastomosis in the aorta. Out of the four patients who presented total graft obstruction, two were male. We observed inadequate indications in two patients, and no justifiable occlusions in the others. From the 91 re-studied patients in the immediate post-operative period, there was late mortality in 6 patients (6.6%), one adenocarcinoma of the lung, and the others by cardiac causes. The only patient who presented a lesion at the radial artery underwent angioplasty with a stent implantation and had a satisfactory outcome.
CONCLUSIONS: The radial artery, used as a conduit for coronary artery bypass grafting, shows satisfactory angiographic aspects and also a satisfactory patency, similar to those of the left internal thoracic artery, when evaluated in this time of follow-up.
Keywords: Radial artery, surgery. Radial artery, anatomy and histology. Myocardial revascularization.
João C. Leal; Moacir F. Godoy; Domingo M. Braile; Enio Buffolo
Rev Bras Cir Cardiovasc 2003;18(2):133-136
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OBJECTIVE: Our aim is to demonstrate the possibility of applying the alternative tactic of off-pump coronary artery bypass surgery to left main coronary artery disease and to assess the long-term results over a 5-year follow-up period.
METHODS: Among 210 subjects submitted to off-pump coronary artery bypass, 119 (56.7%) were male. Their ages ranged from 32 to 81 years with a mean age of 59.7. A left coronary artery branch lesion of at least 70% was demonstrated in 48 (22.8%) of the individuals and a right coronary lesion was associated in 10 (20.8%) of the cases.
RESULTS: A breakdown of the number of grafts per patient was: 2 for 52.1%, 3 for 43.5% and 4 for 4.4% of the surgeries. All of the patients were extubated in the intensive care unit after a 6-hour stay. No left ventricular dysfunction was evidenced after a seven-day total hospitalization period. One death, due to cardiac problems, occurred after one month. Follow-up with clinical cardiac evaluation was total until 60 months with a survival rate at 5 years of 96.0% ± 3.9%.
CONCLUSION: In left main coronary artery disease, which is feared by cardiac surgeons, we believe that the technique of off-pump coronary artery bypass could be very useful. If the patients are hemodynamically stable and undergo an elective operation, the operative period can be passed in a safe and tranquil manner.
Keywords: Myocardial revascularization. Coronary disease. Left main coronary artery.
Fábio P. Taniguchi; Paulo M Pêgo-Fernandes; Fabio B Jatene; Karina L. Kwasnicka; Célia M. C. Strumz; Sérgio A Oliveira
Rev Bras Cir Cardiovasc 2003;18(3):210-216
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OBJECTIVES: To evaluate the prognostic implications of myocardial creatine kinase and troponin I (cTn I) in blood samples from the coronary sinus of patients submitted to coronary artery bypass surgery both with and without ischemic preconditioning.
METHODS: From October 1998 to May 1999, 35 patients with coronary artery disease who were submitted to coronary artery bypass surgery were studied. Samples containing creatine kinase and cTn I were obtained from the great cardiac vein during surgery at the onset of cardiopulmonary bypass, at the end of the first anastomosis, and at the end of cardiopulmonary bypass. In May 2002, 29 patients were evaluated in regards to the angina functional class, congestive heart failure, number of hospitalizations, myocardial infarction and death. There were 15 patients in the Preconditioned group and 14 in the Control group. Each group was subdivided into patients with and without cardiovascular symptoms.
RESULTS: The Control and Preconditioned groups were not significantly different in relation to frequency of cardiovascular symptoms. There were progressive increases of the creatine kinase and cTn I levels at different Interval s of the study. The cTn I in the Preconditioned group was 1.21 ± 0.64 ng/mL and 3.19 ± 3.21 ng/mL in the Control group (p<0.05). The Control group with symptoms had the highest level for cTn I of 5.07 ± 3.69 ng/mL, significantly higher than all other groups (p<0.05).
CONCLUSIONS: The Preconditioned group had the lowest level of cTn I. The cTn I may be a marker for late evolution in patients submitted to coronary artery bypass surgery.
Keywords: Myocardial revascularization. Myocardial ischemic preconditioning. Myocardial ischemia, physiology. Troponin.
Diego Felipe Gaia; Rafael Saviolo Moreira; Magaly Arrais; Nivia Cristina Tot Vinhola; Enio Buffolo; Ricardo Luiz Smith
Rev Bras Cir Cardiovasc 2003;18(3):221-226
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OBJECTIVE: Inflammatory response and metabolic disturbances in coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) and without (OFF-PUMP) have been researched. Apoptosis in ischemic reperfusion and chronic disease models has been shown in recent studies. The objective of this study is to compare the apoptosis intensity detected in cardiac myocytes before and after CABG with and without cardiopulmonary bypass.
METHOD: Eighteen patients undergoing elective CABG were divided in two groups: the first group underwent cardiopulmonary bypasses and the second group did not. Auricle myocardial samples were obtained at the beginning and at the end of the surgery. Specimens were examined for apoptosis using the TUNEL method.
RESULTS: There was no significant difference between the two groups in the surgical, demographic and postoperative data. The number of grafts was statistically different. There was no significant difference between the numbers of cells undergoing apoptosis in the two groups at the beginning of the procedure. There was no significant difference in the number of cells undergoing apoptosis from the beginning to the end of CABG in the OFF-PUMP group. There was a significant difference between the number of cells undergoing apoptosis at the beginning and the end of the CABG in the CPB group (p<0.01).
CONCLUSION: The smaller number of cells undergoing apoptosis in the OFF-PUMP group is in accordance with published data that suggest CPB is capable of promoting cell lesion. Having shown that, another favorable argument can be added to the indication of the CABG without CPB.
Keywords: Apoptosis. Cardiopulmonary bypass. Coronary artery bypass grafting.
Ricardo de Carvalho Lima; Mozart Augusto Soares de Escobar; José Glauco Lobo Filho; Roberto Diniz; Antonio Saraiva; Antonio Césio; Mário Gesteira; Frederico Vasconcelos
Rev Bras Cir Cardiovasc 2003;18(3):261-267
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OBJECTIVES: Over the past few years, great strides have been made in off-pump coronary surgery. This progress is due to a combination of the advances in surgical techniques and the development of instruments that make it possible to perform this procedure in the most varied situations. This is a retrospective study, the purpose of which is to assess our experience with this procedure over the last eleven and a half years. The authors underscore the rapid progress of the method in recent years and report on its indications, contraindications and results.
METHODS: In the period from August 1991 to December 2003, 3,410 consecutively patients suffering from angina pectoris were submitted to off-pump coronary surgery. Ages ranged from 13 to 93 years, with a mean of 63 ± 12.0 years. Males accounted for 58% of the cases. The angina was rated according to the criteria of the Canadian Cardiovascular Society, 6.1% of the patients being in Class I, 6.8% in Class II, 46.3% in Class III and 40.8% in Class IV.
RESULTS: Intraoperative mortality was low (0.4%). Hospital mortality (30 postoperative days) was 2.5%. Mortality and morbidity among the octogenarian patients were extremely low compared with patients operated on with cardiopulmonary bypass (CPB) (2.2% versus 12.6%) (p<0.001). Postoperative complications regarded as nonfatal occurred in 7.6%. In the final year no difference was observed between the number of conduits in the patients operated on with and without CPB [with CPB 2.8 ± 1.2 and without 2.8 ± 0.8 (NS)]. Acute myocardial infarction was the most frequent complication, occurring in 2.7% of the patients. The mean time in the intensive care unit was 22.3 hours.
CONCLUSIONS: Off-pump coronary surgery, employed as a revascularization technique in patients requiring multiple grafts, is a reproducible procedure, the results of which are similar to those obtained from conventional surgery with CPB. In the present series it was possible to perform coronary artery bypass grafting without CPB in 95% of the patients, thus making all patients with indication for grafting potential candidates for the procedure without CPB.
Keywords: coronary disease, coronary artery bypass grafting. off-pump coronary surgery.
José Glauco Lobo Filho; Maria Cláudia de Azevedo Leitão; Heraldo Guedis Lobo Filho; André Albuquerque da Silva; João José Aquino Machado; Antonio Jorge de Vasconcelos Forte; Mauro Paes Leme de Sá; Eduardo Sérgio Bastos; Henrique Murad
Rev Bras Cir Cardiovasc 2004;19(1):1-8
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OBJECTIVE: To assess the left internal thoracic artery (LITA) flow pattern, when it was used to supply the left anterior descending artery (LADA) and another branch from the left coronary artery system (LCAS).
METHODS: In the following study, the left internal thoracic artery flow was investigated by echocardiography Doppler, at rest and under dobutamine stress, in two twenty-patient groups. Group A consisted of patients who received only a pedicled LITA graft to the LADA. Group B consisted of patients who received a pedicled LITA graft associated with a vein graft to supply the LADA and another artery from the LCAS. The angiographic study showed graft patency in all patients from both groups. The following parameters were used: systolic flow (SF), diastolic flow, total flow, total flow in stress/total flow at rest ratio (TFS/TFR), systolic peak velocities (SPV), diastolic peak velocities and systolic peak velocity/diastolic peak velocity ratio.
RESULTS: All analysed parameters were considered statistically significant, except SF, TFS/TFR and SPV.
CONCLUSIONS: We concluded that in the same conditions and methodology, the LITA flow in the composite graft (group B) is higher than in the free graft (group A), which shows the great flow adaptability of LITA to respond to flow demand.
Keywords: Myocardial revascularization. Internal mammary-coronary artery anastomosis. Echocardiography, Doppler. Echocardiography, stress. Blood flow velocity.
Luiz Augusto F. Lisboa; Luís Alberto O. Dallan; Luiz Boro Puig; Carlos Abreu Filho; Ricardo Cerquinho Leca; Luís Augusto P. Dallan; Sérgio Almeida de Oliveira
Rev Bras Cir Cardiovasc 2004;19(1):9-16
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OBJECTIVE: To evaluate the midterm benefits of exclusive use of arterial grafts in patients with triple vessel coronary arteriosclerotic disease who underwent complete myocardial revascularization.
METHOD: Between July 1995 and July 1997, 137 consecutive patients with triple vessel coronary atherosclerotic disease underwent complete myocardial revascularization exclusively using arterial grafts. Of these patients, 112 (81.7%) were male and the ages ranged from 36 to 78 years old (mean 56.5 years). Three hundred and sixty-three arterial grafts were used to perform 442 coronary anastomoses; an average of 3.2 coronary anastomoses per patient. Arterial grafts used were left internal thoracic artery (99.3%), right internal thoracic artery (56.2%), radial artery (94.9%), right gastroepiploic artery (13.9%) and inferior epigastric artery (0.7%). In 80 (58.4%) patients, arterial composite "Y" grafts were constructed with the left internal thoracic artery and another arterial graft.
RESULTS: No operative deaths occurred. Four (2.9%) deaths occurred in the post-operative period and only one (0.7%) patient needed reoperation in the early follow-up. The 7 year actuarial survival was 94.0% and the event free probability (myocardial infarction, angioplasty, reoperation or death) was 87.0%.
CONCLUSIONS: Good early and midterm clinical follow-ups can be achieved by exclusively using arterial grafts in the complete myocardial revascularization of patients with triple vessel coronary arteriosclerotic disease. A long-term follow-up will be necessary to show the influence of exclusive use of arterial grafts in the surgical treatment of coronary insufficiency.
Keywords: Myocardial revascularization. Mammary arteries. Arteriosclerosis.
Nilzo Augusto Mendes Ribeiro; Noedir Antônio Groppo Stolf; Augusto Ferreira da Silva Junior; Valcellos José da Cruz Viana; Eduardo Novaes de Carvalho; Rodrigo Athanázio; Mitermayer Galvão Reis; Sérgio Almeida de Oliveira
Rev Bras Cir Cardiovasc 2004;19(1):17-23
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OBJECTIVE: To assess the effects of methylene blue infusion on on-pump coronary artery bypass patients in relation to hemodynamic, laboratorial and systemic inflammatory response.
METHOD: Sixty patients were randomized in two groups. Methylene blue was infused in one group. Blood samples were collected before the anesthesia and, 3, 6, 24 and 48 hours after the end of the extracoporeal circulation to determine the IL-1b, IL-6, IL-8, IL-10, IL-12p40, TNFa and nitric oxide levels and perform gasometry and other routine tests.
RESULTS: In the methylene group we observed at different stages, higher systemic vascular resistance, lower TNFa concentrations, fewer leukocytes and neutrophils as well as lower level of nitric oxide. No adverse effects were evidenced.
CONCLUSIONS: Methylene blue infusion showed less tendency of systemic inflammatory responses, lower levels of nitric oxide and a better hemodynamic performance.
Keywords: Myocardial revascularization. Cytokines. Nitric oxide. Methylene blue.
Solange Guizilini; Walter J Gomes; Sonia M. Faresin; Antonio Carlos C. Carvalho; Jaime I. Jaramillo; Francisco A. Alves; Roberto Catani; Enio Buffolo
Rev Bras Cir Cardiovasc 2004;19(1):47-54
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OBJECTIVE: To analyze the pulmonary function changes and pain in patients undergoing off-pump coronary artery bypass grafting utilizing a left internal thoracic artery graft, comparing the pleural drain insertion through the intercostal space and subxyphoid approach.
METHODS: Twenty eight patients (mean age 57.4 ± 8.4 years) were divided into two groups, according to the pleural drain site. Group IL (n=15) had the pleural drain inserted through the sixth left intercostal space at the mid-axillary line and in the IM group (n=13) the drain was placed through the subxyphoid region. All the patients underwent pre- and post-operative evaluation of pulmonary function tests as well as arterial blood gas analysis. Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were recorded in the preoperative period, and in the first, third and fifth postoperative days. The pain sensation was evaluated using a standard score from 0 to 10.
RESULTS: In both groups falls in FVC and FEV1 were noted, up to the fifth postoperative day (P<0.001). However, the decrease was higher in the IL group, when compared to the IM group (p<0.05). Also arterial blood gas analysis showed a decline of the partial oxygen pressure in both groups on the fist postoperative day, but more significantly in the IL group (p=0.021). The pain sensation was higher in the IL group (p=0.002).
CONCLUSION: Off-pump coronary artery bypass grafting with using of left internal thoracic artery, disregarding the pleural drain site, leads to a significant decrease of postoperative pulmonary function. However, the subxyphoid technique of drain insertion has shown a better preservation of the lung function when compared to the intercostal drain site.
Keywords: Coronary artery bypass surgery. Pleural drain. Pulmonary function.
Luís Alberto O. Dallan; Ayumi A. Miyakawa; Luiz Augusto F. Lisboa; Carlos Alberto Abreu Filho; Luciene Campos; Thaiz Borin; José Eduardo Krieger; Sérgio Almeida de Oliveira
Rev Bras Cir Cardiovasc 2004;19(2):126-135
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OBJECTIVE: The saphenous vein (SV) used in coronary artery bypass grafting is submitted to elevated and continuous shear stress. Occlusion of the grafts can occur in response to the new hemodynamic conditions. The aim of this study is to compare the precocious structural and molecular (cDNA) changes in saphenous veins grafts submitted to low pressure hemodynamic conditions versus systemic hemodynamic conditions.
METHOD: Forty sections of SV were cultivated "ex-vivo" under venous hemodynamic conditions (VHC) (without pressure, flow: 5 mL/min) and under arterial hemodynamic conditions (AHC) (pressure: 80 mmHg, flow: 50 mL/min). The following variables were analyzed: cellular viability (MTT assay) cellular density (hoeschst 33258 staining) and apoptosis (TUNEL assay), before and 1, 2 and 4 days after the procedure. "cDNA microarray" analysis of the SV sections was used to determine the precociously changed molecular targets in the veins cultivated under arterial conditions. The identification of these targets was achieved using a RNA homogenized pool of these vein sections, interacting on slides with 16,000 pre-determined human genes (Agilent Technologies slide). The genes with changed expressions were verified by real time PCR in the veins of 16 patients.
RESULTS: There was a gradual reduction in the cellular density and in the tissue viability in the saphenous veins cultivated under AHC, whereas no alterations were observed in the saphenous veins cultivated under VHC of up to 4 days. In the AHC group there were signs of a cellular apoptotic process (positive - TUNEL) from the first day after cultivation. In the VHC group these alterations were not observed. Although the cellular density was the same in the veins submitted to arterial conditions, after 24 hours of cultivation, many cells already showed signs of the apoptotic process. The Oncogene 3 and the Interleucin 1ß were the most common sites with alterations identified in this research. The Oncogene 3 expression was elevated in 11 (68.7%) of the veins cultivated under AHC, and the Interleucin 1ß expression was elevated in 9 (56.2%) of these vein sections (p<0.05).
CONCLUSION: The "ex vivo" study model was able to mimic events that occur "in vivo" by SVs utilized in the coronary artery bypass grafting. In the AHC group precocious loss of cellular viability (apoptosis) and significant elevation in the Oncogene 3 and Interleucin 1ß genic expressions were observed. The long-term follow up of these patients is important to determine the real effect of these immediate changes in the patency of the vein grafts.
Keywords: Myocardial revascularization. Saphenous Vein. Gene Expression.
Antônio S. Martins; Rubens R. Andrade; Marcos A. Moraes Silva; Reinaldo A. Oliveira; Nelson L. K. L Campos; Ricardo de Mola; Ademar R. Souza; Júlio Vidotto; Carlos Padovani
Rev Bras Cir Cardiovasc 2004;19(2):152-156
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OBJECTIVE: To comparatively analyze minimally invasive procurement of saphenous veins using Mini-Harvest® system and a technique using adapted traditional instruments.
METHOD: From June 1996 to January 1999, 63 patients who were submitted to Coronary Artery Bypass Grafting Surgery had their saphenous veins resected using minimally invasive techniques. In the first 30 patients of the series, a direct visualization method employing two Langenbeck's retractors was utilized and for the 33 remaining patients the Mini-Harvest® technique was utilized.
RESULTS: The mean age of the patients was 61 ± 8.75 years old. Fifty-two patients were male and 11 female. Forty-five patients were diabetics, 45 were overweight or obese, 25 were smokers and 32 presented history of myocardial infarction. The mean time to resect the saphenous vein using the Langenbeck's retractors was 34.2 ± 8.14 minutes and using the Mini-Harvest® it was 39.20 ± 9.12 minutes. The lenghts of the extracted veins were similar in both groups, varying between 10 and 30 cm. There was one case of superficial dehiscence in the Langenbeck group. With two patients in the Mini-Harvest® group and one in Langenbeck's group it was necessary to revert to the traditional method of procurement. The incidence of tran-soperative infarction was 4.5% (three patients) in Langenbeck's group and 3.1% (two patients) in the Mini-Harvest® group.
CONCLUSIONS: We can conclude that the minimally invasive procurement methods of the saphenous vein by direct visualization are effective and safe, both when employing adapted traditional instruments and using purpose-made retractors. We stress, however, that the Mini-Harvest® method does not require an assistant.
Keywords: Myocardial revascularization. Cardiac surgical procedures, methods. Saphenous vein, surgery, methods. Surgical procedures, minimally invasive.
Walter J Gomes; Jaime I. Jaramillo; Fernando Asanuma; Francisco A. Alves
Rev Bras Cir Cardiovasc 2004;19(4):353-357
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BACKGROUND: The outcome of patients with heart failure, as well as after left ventricular reconstruction, is related to the size of the left ventricular cavity. Also the use of synthetic materials in the ventricular reconstruction could induce a chronic myocardial inflammatory reaction. We report on a modification of the ventricular reconstruction technique that eliminates the need of intraventricular patches and the use of synthetic material.
METHOD: Eleven consecutive patients presenting with left ventricular aneurysms, evolving to functional class III and IV of the New York Heart Association, underwent direct left ventricular reconstruction surgery without the use of intraventricular patches or prosthetic strips.
RESULTS: There was no operative mortality or need of mechanical circulatory support. The postoperative hospital stay ranged from 4 to 7 days (average 5.3 ± 1.1 days). The serial echocardiogram control showed reduction of the left ventricular diastolic diameter (from 69.0± 7.5 mm preoperatively to 62.6 ± 5.1 mm postoperatively). The left ventricular ejection fraction increased from 47.3% ± 6.6% to 56.3% ±10.5%. One-year follow-up revealed eight patients in functional class I and three in class II.
CONCLUSION: This technique, with elimination of prosthetic materials, could contribute to an improvement of the clinical results in patients who undergo left ventricular reconstruction, providing virtual elimination of left ventricular akinetic areas and potentially attenuating the long-term myocardial chronic inflammatory reaction.
Keywords: Heart aneurysm, surgery. Heart ventricles, surgery. Left ventricular dysfunction. Myocardial revascularization.
Walter J Gomes; George B. Tavares; Jaime I. Jaramillo; Francisco A. Alves; José Miguel G. Torrijos; Roberto Catani; Enio Buffolo
Rev Bras Cir Cardiovasc 2005;20(1):33-38
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Objective: Off-pump coronary artery bypass surgery (OPCAB) has been demonstrated to provide a reduction of cardiovascular events and mortality. Also, the bilateral use of the internal thoracic arteries (ITAs) can offer additional benefits, improving survival. We present the technique of OPCAB using both pedicled ATI grafts, with the right ITA (RITA) routed retro-aortic through the transverse sinus, to revascularize the branches of the circumflex artery (Cx).
Method: Twenty-six patients, who underwent OPCAB with bilateral ATI grafts, were studied, where the left ATI (LITA) was used to revascularize the left anterior descending artery (LAD) and the pedicled RITA, routed through the transverse sinus and anastomosed to the branches of the Cx. Twenty-one patients were male and five female, the age ranging between 42 and 74 years. The morbidities observed in this cohort were previous myocardial infarction in 18 (69%) patients, diabetes mellitus in 10 (38%), renal failure in four (7.7%) and AIDS in one (3.8%) patient.
Results: No patient presented ECG changes or enzymatic increases in the postoperative period. The grafts per patient varied from two to four (average 3.0 grafts/patient). No cases of sternal infection or dehiscence were observed. One patient had a stroke on the 4º postoperative day and died. The postoperative hospital stay varied between 3 to 12 days (average 5.8±2.0 days). No late deaths or cardiovascular events were recorded.
Conclusions: This technique makes off-pump grafting of the circumflex artery branches using the pedicled RITA possible and potentially enhances the benefits of coronary artery bypass surgery.
Keywords: Myocardial revascularization. Internal mammary-coronary artery anastomosis. Mammary arteries. Extracorporeal circulation.
Daniel Navia; Mariano Vrancic; Guillermo Nuncio Vaccarino; Fernando Piccinini; Eduardo Iparraguirre; Marcelo Casas; Jorge Thierer
Rev Bras Cir Cardiovasc 2005;20(1):39-45
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Objective: To analyze intra-hospital results in patients undergoing elective off-pump total arterial revascularization and identify morbidity and mortality predictors using this surgical strategy.
Method: From May 1999 to February 2004, 203 myocardial revascularization procedures with total arterial revascularization without cardiopulmonary bypass (off-pump) were carried out in patients with multivessel disease (three vessels 81.7 %, one vessel disease was excluded). We report pre-surgical variables and co-morbidities: average age 63.9 ± 9.13 years, men 182 (89.5%), hypertension 132 (65%), smokers 125 (61%), hypercholesterolemia 152 (74.8%), previous myocardial infarction (> 30 days) 73 (35%), moderate to severe ventricular dysfunction 31 (15%), redo five (2.5%). Total arterial revascularization included T-grafts and sequential grafts with left internal mammary (100%), right internal mammary (56.6%) and radial (63%) arteries. The total number of distal anastomosis was 576 (mean of three grafts/patient), all carried out with external mechanical stabilizers. There were no proximal aortic anastomoses. Conversion to on-pump surgery occurred in three (1.5%) patients; 90% of the patients was extubated in the operating room. The multiple logistic regression test was used for statistical analysis.
Results: The postoperative incidence of atrial fibrillation was 12.8% (26), oligoanuric renal failure 3% (six), dialysis 0.49% (one), postoperative myocardial infarction 1.47% (three), low cardiac output 4% (eight), Redo for bleeding 1.47% (three), mediastinitis 1.47% (three), stroke 1.47% (three). Intra-hospital mortality was 2.45% (five). The only independent 30 day morbidity predictor was age (p=0.033; OR 1.04; IC 95%: 1-1.08).
Conclusion: Off-pump myocardial revascularization with arterial conduits for multiple vessel disease is feasible with a low 30-day morbidity and mortality.
Keywords: Myocardial revascularization. Mammary arteries. Extracorporeal circulation.
Luís A.O. Dallan; Ayumi A. Miyakawa; Luiz A. Lisboa; Thaiz F. Borin; Carlos A.C. Abreu Filho; Luciene C. Campos; José E. Krieger; Sérgio A Oliveira
Rev Bras Cir Cardiovasc 2005;20(2):111-116
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Objective: The saphenous vein (SV) is an effective graft used in coronary artery bypass grafting, although, its patency can be affected by the development of atherosclerosis. We have developed an experimental study demonstrating the development of apoptosis in SV grafts cultivated under arterial hemodynamic conditions (AHC). The Interleukin - 1ß expression was also elevated in these veins slices. The aim of this study is to evaluate the influence of the interleukin - 1ß in the precocious proliferation of the cultures of primary smooth muscle cells (PSMC).
Method: PSMC of six different human SVs were cultivated in Dulbecco's Modified Eagle Method associated with bovine fetal serum. The control group was not treated with Interleukin - 1ß but treated groups were. Cellular proliferation (CP) was evaluated by measuring triple thymidine [3H], incorporated into the proliferated cells.
Results: The treatment with Interleukin - 1ß decreases cellular proliferation. The control group presented 100 ± 4.5% of CP. In the treated groups the quantity of Interleukin - 1ß administered and the respective levels of CP observed were: 0.1 ng/ml - 112 ± 0.7%; 1 ng/mL - 83 ± 4.7%; 10 ng/mL - 69.1 ± 3.8% and 100 ng/mL - 76.3 ± 10.9% (p < 0.01).
Conclusion: We can conclude that the administration of increasing quantities of Interleukin - 1ß inhibits the proliferation of PSMC cultivated from human SVs. This suggests that the precocious process of apoptosis observed in the SV grafts exposed to AHC can be related to the action of this interleukin.
Keywords: Cell culture. Saphenous vein. Myocardial revascularization. Gene Expression. Interleukin - 1.
Gustavo Calado de Aguiar Ribeiro; Ana Nunes; Fernando Antoniali; Mauricio Marson Lopes; Cledicyon Eloy da Costa
Rev Bras Cir Cardiovasc 2005;20(2):117-122
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Objectives: To evaluate the integration of both viability and clinical parameters on the improvement in systolic performance, symptoms and prognosis, with post-revascularization reverse remodeling.
Method: One hundred and fifteen patients underwent thallium-201 imaging before myocardial revascularization. Left ventricular ejection fraction, left ventricular end-systolic volume index and left ventricular end-diastolic volume index were determined before and at each 6 months post-revascularization for 3 years.
Results: Patients with ³ 4 viable segments on thallium-201 imaging demonstrated an improvement in left ventricular ejection fraction from 34±6 to 44±4%, p<0.001), left ventricular end-systolic volume decreased from 78.3±11 to 57±17 mL/m2, p<0.001; left end-diastolic volume decreased from 113±31 to 91±22 ml/m2, p<0.001). Patients with < 4 viable segments failed to demonstrate an improvement of the left ventricle ejection fraction, 33.4±4 vs. 35.1±5% (p=0.19), and exhibited ongoing left ventricle end-systolic remodeling, 72±23 vs. 73±12 mL/m2 (p= 0.81), and the left ventricle end-diastolic volume increased from 112±24 to 118±16 mL/m2 (p=0.34), without improvement in NYHA class, and worse long-term prognosis (event; log rank test, p=0.0053). The multivariable analysis demonstrated clinical variables related to the unfavorable evolution showed diabetes, more than one myocardial infarction, and time interval between myocardial infarction and surgery were associated with worse prognosis.
Conclusion: The benefits of myocardium revascularization in patients with viable muscle, as well as an improvement in the left ventricular ejection fraction, provide reverse remodeling, improvement in functional class and favorable long-term prognosis.
Keywords: Myocardial revascularization. Ventricular remodeling. Heart failure, congestive.
Camila Pereira Leguisamo; Renato A.K. Kalil; Ana Paula Furlani
Rev Bras Cir Cardiovasc 2005;20(2):134-141
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Introduction: Postoperative pulmonary complications are a major source of mortality and morbility. Respiratory physiotherapy, which is often used to prevent and treat these complications, can be started preoperatively, in order to assess and guide the patients.
Objective: To establish the effectiveness of a preoperative physiotherapy program for patients submitted to elective coronary artery bypass surgery as regards to the reduction of the hospital stay and prevention of pulmonary complications, changes in pulmonary volumes and inspiratory muscle force.
Method: This was a randomized clinical trial. The study group consisted of 86 patients submitted to elective coronary artery bypass surgery at the Instituto de Cardiologia do Rio Grande do Sul. The intervention group (44 patients) was assessed and received physiotherapeutic guidance with written manuals at least 15 days before surgery. The control group (42 patients), on the other hand, received routine guidance on the day of hospital entry.
Results: A significant reduction in the hospital stay (p<0.05) was observed in the intervention group. No difference were found between the groups in respect to the change of lung volumes, inspiratory muscle force and occurrence of pulmonary complications as seen by X-ray.
Conclusion: Patients who have had preoperative instruction are better prepared to cooperate with postoperative treatment. As these patients understand the purpose of pre- and post-operative physiotherapy, the limitations resulting from the surgical process and the physiotherapeutic technique proposed, they may ultimately have a shorter stay in hospital.
Keywords: Physical therapy. Preoperative care. Myocardial revascularization.
Rui Manoel Sequeira de Almeida
Rev Bras Cir Cardiovasc 2005;20(2):142-148
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Objective: To compare the cost of coronary bypass surgery (CBS) and percutaneous transluminal coronary angioplasty (PTCA) for a one year follow-up.
Method: Eight-six patients were submitted to 87 CBS and 240 patients to 267 PTCA, between October 2003 and April 2004. The mean age of the two groups was 62 years. The CBS group was submitted to a mean of 3.7 bypass/ patient, using 96.5% of arterial conduits. In the PTCA group, a mean of 1.1 angioplasties/procedure were performed. Twenty-one (24.4%) patients had an angioplasty performed before the CBS. Each group was subdivided in, group A and B, in respect to the manner of payment.
Results: The mean cost for CBS was R$ 7.759,78, per procedure; in the PTCA group the cost/angioplasty was R$ 6.307,79. At the end of a year, the end values were R$ 7.875,73 for the CBS and R$ 8.234,96 for the PTCA group. In group B the CBS patients had a mean hospital cost of R$ 11.061,63 and R$ 11.087,29 at the end of a year; in the PTCA group the hospital costs were R$ 11.110,83, and at the end of a year R$ 13.414,59.
Conclusions: The author concludes that: 1) only 26.4% of the 326 patients were submitted to CBS; 2) PTCA group presented 26.7% re-interventions/patient and CBS group only 3.5%; 3) CBS costs were 17.4% less than those of the PTCA after one year, in group B.
Keywords: Myocardial revascularization. Costs and cost analysis. Coronary artery bypass. Angioplasty, transluminal, percutaneous coronary.
José Glauco Lobo Filho; Maria Cláudia Leitão; Roberto Augusto Mesquita Lobo; José Mário de Lima Júnior; João Paulo Aguiar Ribeiro; Fernanda Cavalcante; Glício Rebouças; Allison Borges; Dadson Leandro Sales; Newton Teles Júnior
Rev Bras Cir Cardiovasc 2005;20(3):279-285
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Objective: To evaluate a methodology of anticoagulation during off pump coronary artery bypass surgery (CABS) that promotes safe anticoagulation during the procedure (Activated Coagulation Time ³200 seconds), using an initial dose of 1 mg of sodium heparin/kg weight.
Method: 40 patients (30 men and 10 women), ages ranging from 41 to 85 years, were submitted to off pump CABS, using an initial sodium heparin dose of 1mg/kg of weight. Ten minutes after that drug was administered, if the ACT was ³ 200 seconds, we initiated the revascularization procedure. If not, we administered an additional of 0.5mg/kg heparin. During the surgery, the ACT was measured at 30 intervals. After revascularization, heparin reversal was achieved with a dose of protamine chloride equal do the total heparin dose infused during the procedure (1:1).
Results: The mean ACT at 10 minutes after heparinization was 372.2 (+/-104.31) seconds, without significant statistical difference between gender and age groups (p>0.05). The ACT values at 30 and 60 minutes remained greater than 200 seconds in all patients. The ACT at 30 minutes showed a significant statistical difference between age groups and gender (p<0.05). After heparin reversal using protamine, all patients returned to their initial hemostasis level (ACT < 200s).
Conclusion: The results show the safety and effectiveness of an initial sodium heparin dose of 1mg/kg of weight during off-pump CABS maintaining safe ACT (³ 200s) even after 60 minutes of heparinization, independently of age and gender.
Keywords: Myocardial revascularization. Heparin. Whole blood coagulation time.
Cristiano Pederneiras Jaeger; Renato A.K. Kalil; João Carlos Vieira da Costa Guaragna; João Batista Petracco
Rev Bras Cir Cardiovasc 2005;20(3):291-295
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Objective: To evaluate which preoperative and trans-operative variables are predictors for the occurrence of myocardial infarction in the perioperative period of surgical myocardial revascularization in a general hospital in Porto Alegre, Brazil.
Method: A retrospective cohort study was made of the database of heart surgery in the Hospital São Lucas of the Pontifícia Universidade Católica in Rio Grande do Sul analyzing 1471 consecutive patients who underwent on-pump surgical myocardial revascularization from January 1998 to December 2002.
Results: Fourteen percent of the patients presented with perioperative myocardial infarction. The variables that proved to be independent predictors of perioperative myocardial infarction in surgical myocardial revascularization in this study were: prior surgical myocardial revascularization (OR: 2.070 - p=0.036), left main coronary artery lesion (OR: 1.692 - p=0.006), female (OR: 1.572 - p=0.034), preoperative unstable angina (OR: 1.533 - p=0.011), high number of grafts (OR: 1.336 - p=0.001) and prolonged cardiopulmonary bypass time (OR: 1.013 - p<0.001).
Conclusions: Prior surgical myocardial revascularization, left main coronary artery lesion, female, preoperative unstable angina, high number of grafts and prolonged cardiopulmonary bypass time proved to be independent predictors of perioperative myocardial infarction in surgical myocardial revascularization in this study of patients from a general hospital from Porto Alegre, Brazil.
Keywords: Myocardial infarction. Myocardial revascularization. Risk assessment. Coronary disease.
Rodrigo Milani; Paulo R Brofman; José Augusto M. Souza; Maximiliano Guimarães; Laura Barboza; Alexandre Barbosa; Dalton Précoma; Francisco Maia
Rev Bras Cir Cardiovasc 2005;20(3):296-300
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Objective: The present study reviews our immediate experience of off-pump coronary artery bypass grafting using arterial grafts alone.
Method: Between June 2000 and December 2004, 300 patients were submitted to off-pump myocardial revascularization using only arterial grafts. The left internal mammary artery was the first-choice graft, followed by radial artery and the right mammary artery.
Results: The ages of the patients ranged from 33 to 77 years, with 234 male and 66 female. In respect to risk factors for coronary disease, 77% had hypertension, 66% had history of smoking, 53% had high levels of cholesterol and 21% had diabetes. Eighty-four patients (28%) had a history of myocardial infarction and 77 (25.6%) were using endovenous nitroglycerin in the preoperative period. The ejection fraction was less than 30% in 77 (25.6%) patients. A total of 189 patients had multi-vessel disease. The EuroSCORE ranged from 0 to 12 points with an expected mortality rate of 3.7%. The total numbers of distal anastomoses were 838, with a mean of 2.79±0.97 anastomoses per patient. There were six deaths in this series, one caused by renal failure, one caused by metabolic disorders, two caused by mediastinitis, one caused by pneumonia and one caused by bleeding. Diabetes was the only factor associated with mortality.
Conclusion: The use of arterial grafts in off-pump myocardial revascularization did not increase the immediate mobidity and mortality in this series. The results were similar to the results predicted by EuroSCORE. The use of arterial grafts alone in diabetics patients must be carefully evaluated.
Keywords: Myocardial revascularization. Extracorporeal circulation. Coronary disease, surgery. Internal mammary-coronary artery anastomosis.
Solange Guizilini; Walter J Gomes; Sonia M. Faresin; Douglas W. Bolzan; Francisco A. Alves; Roberto Catani; Enio Buffolo
Rev Bras Cir Cardiovasc 2005;20(3):310-316
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Objective: To evaluate and compare the pulmonary function in patients following on- and off-pump coronary artery bypass grafting (CABG).
Method: Thirty patients (mean age 56.76 ± 10.20 years) were allocated to two groups, according to the use or not of cardiopulmonary bypasses: group A (n=15) off-pump and group B (n=15) on-pump, with all patients undergoing pre- and post-operative evaluation of the pulmonary function as well as arterial blood gases analysis. Forced vital capacity (FVC) and forced expiratory volume at 1 second (FEV1) were recorded in the preoperative period, and on the first, third and fifth postoperative days. Blood gases were evaluated in the preoperative period and on the first postoperative day.
Results: In both groups, significant falls in the FVC and FEV1 were detected up to the fifth postoperative day (p<0.05). When both groups were compared, the decreases in FCV and VEF1 were higher in group B (p<0.05). PaO2 values and the PaO2/FiO2 ratio presented significant drops on the first postoperative day in both groups, however the fall was higher in group B (p<0.05).
Conclusion: Patients who undergo CABG, regardless of the use of CPB, display a significant reduction in the postoperative pulmonary function. However, patients who undergo off-pump CABG have a better preservation of the lung function compared to on-pump CABG.
Keywords: Myocardial revascularization. Extracorporeal circulation. Respiratory function tests.
Flávia Heinz Feier; Roberto Tofani Sant´Anna; Eduardo Garcia; Felipe W de Bacco; Edemar M Pereira; Marisa Fátima Dos Santos; Altamiro Reis da Costa; João Ricardo M Sant`Anna; Ivo A Nesralla
Rev Bras Cir Cardiovasc 2005;20(3):317-322
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Introduction: The improvement in care and management of ischemic heart disease and the dissemination of percutaneous coronary intervention (PCI) changed the indications for coronary artery bypass grafting (CABG), regarding procedures for patientswith multivessel disease in bad clinical conditions.
Objective: To compare surgical and clinical profiles between two groups of CABG patients at a 10 year interval observing the influence on hospital mortality rates.
Method: Retrospective Cohort study, including 307 CABG patients operated on in 1991to 1992 (n=153) and 2001 to 2002 (n=154). Demographic characteristics, heart disease severity, comorbidities and pre-operative events were evaluated and compared between the groups.
Results: Patients operated in 2001 and 2002 were older, more severely ill (in a worse NYHA classand had higher prevalence of heart failure, and multi-vessel involvement) and with more co-morbidities. Patients operated in 1991 and 1992 had more urgent procedures. The observed surgical mortality rates were similar (3.3% and 1.9%, respectively).
Conclusion: Patients submitted to CABG currently are older and in worse clinical conditions than those operated 10 years ago, but hospital mortality has not altered significantly.
Keywords: Myocardial revascularization. Risk assessment. Heart diseases, surgery.
EXPERIÊNCIA DO SERVIÇO
Jose Burgos-Irazabal; Risshi D. Rampersad; Walter J Gomes; Kamal A. Rampersad; Gianni D. Angelini
Rev Bras Cir Cardiovasc 2005;20(3):332-335
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Introduction: The Caribbean is a multi-ethnic society, including Caucasian, Afro-Caribbean, East Indians, Asians, Hispanics, European and natives, which has a broad range of living standards. The incidence and types of heart diseases vary significantly amongst these races. We report the surgical experience (adult and paediatric) of a low volume multiethnic population service based on Trinidad and Tobago.
Methods: The Adult Heart Surgery program started in November 1993. The data on a total of 878 cases (629 male, median age 67, range 18-88 years old) is reported. Of these 39.4% were diabetics and 46.5% hypertensive. The procedures performed include coronary artery bypass grafting, valve repair and replacement, and major aortic surgery including emergency dissection.
The paediatric heart surgery program started in Sept 1998 and a total of 279 operations have been performed (Age range, 2 weeks to 21 years)
Results: Adult - Overall mortality was 3.8%. The majority of procedures were CABG (82.3%) with an overall mortality of 2.8% (0% in 2004). Off pump CABG accounts for 43% of the total procedures (71.2% in 2004). Aortic valve surgery was carried out in 49 patients and mitral valve replacement/ repair in 96 either with or without CABG. Paediatric - The majority of the procedures were VSD 111, ASD 57, TOF 23, and 88 others (including A-V canal, BT shunt, aorta coarctation) with an overall mortality of 1.5%.
Conclusion: Heart surgery in a multiethnic low volume service can be performed with excellent results comparable to international standards for adults and paediatrics.
Keywords: Cardiac surgical procedures. Hospitals, statistics & numerical data. Myocardial revascularization. Extracorporeal circulation.
ORIGINAL ARTICLE
Luis Sérgio de Moura Fragomeni; Roque Paulo Torres Falleiro**; Gustavo Roberto Hoppen; Guilherme Krahl
Rev Bras Cir Cardiovasc 2005;20(4):371-376
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Objective: To observe the surgical characteristics of patients operated on after percutaneous coronary intervention (PCI).
Method: Fifty-six patients (41 M and 15 F), by the time of coronary artery by-pass grafts (CABG), already had undergone coronary stenting procedures. In 101 PCI, 116 stents were implanted. By the time of the first PCI, 32 patients had three or more coronaries with severe stenosis. Six patients were treated with PCI for severe left main stem stenosis. Since the implantation of the first stent, 12 patients developed severe de novo lesions in the left coronary trunk. In six of these, the stenosis was developed in 6 months after the implant of the stent. Diabetes was present in 35.7% of the patients. In 22 patients (39.2%), at the time of CABG, the left ventricular (LV) function was reduced (p<0.001). At surgery, 160 grafts were implanted. Surgical studies included coronary and muscle biopsy.
Results: Surgical observation showed arteritis and inflammatory tissues adjacent to the stent in comparison to other areas. Seventeen patients that could not have antiplatelets drugs withdrawn needed more blood transfusion. There were no hospital deaths.
Conclusion: In patients operated on after stents implantation, facts like loss in LV function or de novo vascular lesions add complexity to surgical cases and may impair long-term results. Due to endothelial dysfunction caused by stents, grafts may close earlier. In addition, the efficiency of clinical therapy may not be the same.
Keywords: Stents. Myocardial revascularization. Coronary arteriosclerosis.
Alexandre Ricardo Pepe Ambrozin; Antônio José Maria Cataneo
Rev Bras Cir Cardiovasc 2005;20(4):408-415
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Objective: To compare the dynamic and static compliance, airway resistance values (Cdyn, Cst and Raw) and to gas exchange index (PaO2/FiO2) postoperative to Coronary Artery Bypass Surgery Graft (CABG) with normality parameters, and to compare the values of these variables between groups with and without preoperative risk factors.
Method: Questioning the patients about previous pulmonary diseases, respiratory symptomology, smoking, and comorbidities. After CABG measures were taken for Cdyn, Cst, Raw and the PaO2/FiO2. Variables were compared with normality and related to pre- and postoperative variables by the Mann-Whitney non-parametric Test and the Test for one proportion (p<0.05).
Result: Seventy patients were evaluated (61% men) aged between 26 and 77 years. With regard to normality, diminution of Cdyn and Cst was presented in 64 and 66 patients, respectively, and increase of Raw in 24. Approximately 50% presented reduction in PaO2/FiO2. There was no significant difference in postoperative variables about previous pulmonary diseases, respiratory symptomology and smoking. In patients with comorbidities was PaO2/FiO2 significantly less and, in men, Cdyn and Cst were greater than in women.
Conclusion: Pulmonary compliance is diminished in more than 90% of patients that undergo CABG; and the airway resistance is increased in one third of them. The gas exchange index is reduced in half of them. The present previous pulmonary diseases, respiratory symtomology and smoking did not influence mechanical variables, but the gas exchange index is influence by the presence of comorbidities.
Keywords: Respiratory mechanics. Thoracic surgery. Respiration, artificial. Postoperative complications. Myocardial revascularization.
CASE REPORT
Marcelo Luiz Peixoto Sobral; Luis Alberto Saraiva Santos; Gilmar Geraldo Dos Santos; Noedir Antonio Groppo Stolf
Rev Bras Cir Cardiovasc 2005;20(4):441-444
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Coronary artery spasms may occur as a serious complication during the trans-operative and immediate postoperative periods of coronary artery bypass surgery (CABS). The small number of cases reported is responsible for making it difficult not only to choose an adequate treatment but also to determine risk factors that might be responsible for its incidence. Coronary artery spasms have a multifactorial character, sudden appearance and must be part of the differential diagnosis of acute myocardial infarction and low output syndrome among patients submitted to heart surgery. We describe a case of a patient submitted to CABS with extracorporeal circulation who presented electrocardiographic alterations suggesting acute myocardial infarction during the immediate postoperative period but was diagnosed as having coronary artery spasms evidenced by a coronary catheterism performed afterwards. The patient was successfully treated with intracoronary vasodilators with good evolution over the short and medium terms.
Keywords: Coronary disease. Spasm. Myocardial revascularization. Coronary vasospasm.
ORIGINAL ARTICLE
Fernando Moraes Neto; Carlos Duarte; Edmílson Cardoso; Euclides Tenório; Virgílio Pereira; Diana Lampreia; João Fernando Wanderley; Carlos R Moraes
Rev Bras Cir Cardiovasc 2006;21(1):29-34
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Objective: To assess the applicability of the European Risk System in Cardiac Operations (EuroSCORE) in patients undergoing myocardial revascularization at the Heart Institute of Pernambuco.
Method: During 2003 and 2004, 759 patients underwent myocardial revascularization. Of these, seven were excluded owing to the lack of information on one aspect or another involved in obtaining a EuroSCORE. In order to assess the applicability of the EuroSCORE, an adjustment was made using a logistic regression model of operative mortality (response variable) on the EuroSCORE (explanatory variable). The calibration of the model was measured by comparing the morbidity observed with that expected, using the Hosmer-Lemeshow Test of Goodness of Fit. The accuracy of the model was evaluated by means of Statistic-c.
Results: The accuracy of the model, estimated at 69.9%, and the calibration (Hosmer-Lemeshow test, p=0.663) were satisfactory. The total predicted mortality was practically identical to that observed - 1.7%. The low-risk group (EuroSCORE: 0-2) comprised 231 patients and two (0.87%) deaths occurred. The medium-risk group (EuroSCORE: 3-5) comprised 268 patients and one (0.37%) death occurred. The high-risk group (EuroSCORE: >6) comprised 253 patients and ten (3.95%) deaths occurred. The discrepancies between the percentages of deaths observed in these groups and those predicted by the model were not statistically significant on the basis of the result of the chi-square test (p=0.624).
Conclusion: The EuroSCORE, a simple and objective index, proved to be a satisfactory predictor of operative mortality in patients submitted to myocardial revascularization in the Heart Institute of Pernambuco.
Keywords: Myocardial revascularization. Epidemiologic methods. Severity of illness index. Risk assessment, methods. Survival analysis. Mortality.
Marcelo Luiz Peixoto Sobral; Gilmar Geraldo Dos Santos; Luis Alberto Saraiva Santos; Victor Luiz Santos Haddad; Silas Fernandes de Avelar Júnior; Noedir Antonio Groppo Stolf
Rev Bras Cir Cardiovasc 2006;21(1):35-41
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Objective: The clinical results of the radial artery when proximally anastomosed to the aorta or to the left internal thoracic artery (LITA) as a composite Y-graft were comparatively evaluated.
Methods: From November 1999 to March 2001, 100 patients who underwent coronary artery bypass grafting using the RA, the LITA and, when required, the saphenous vein, were divided in two groups with 50 patients each in a prospective randomized study. Group I (GI) with radial artery proximally anastomosed to the aorta and Group II (GII) as a composite graft (Y-graft) with the LITA.
Results: Early mortality was 1.0 % (GI 2.0% and GII 0.0%) (p=1.00). A mean of 3.0+0.12 (GI) versus 2.82+0.12 (GII) (p=0.29) coronary vessels were grafted per patient. Patients in composite Y-graft group had shorter bypass time (p=0.0001). There were no differences in terms of perioperative outcomes.
Conclusions: The RA provides similar clinical results as aorto-coronary grafts and ascomposite Y-grafts with the LITA, except in respect to the bypass time.
Keywords: Myocardial revascularization. Radial artery. Anastomosis, surgical, methods.
Fábio Augusto Pinton; Cecília Freire de Carvalho; Maria Cristina de Oliveira Santos Miyazaki; Moacir Fernandes de Godoy
Rev Bras Cir Cardiovasc 2006;21(1):68-74
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Objective: To assess presence of symptoms of depression in the in the preoperative period, immediate postoperative period (IPP) and in the late postoperative period (LPP) in patients with coronary artery disease undergoing bypass surgery and its impact on early and late postoperative morbidity.
Method: Fifty-eight inpatients waiting to undergo an elective bypass surgery completed the Beck Depression Inventory (BDI) before surgery (Period I), after surgery just before hospital discharge (Period II) and three months later (Period III). Patients mean age was 61.2 (34 to 78 years; SD: 10.1), 34 (58.6%) were male, 31 (55.4%) had a history of infarction, 35 (62.5%) had ejection fraction >40% and 19 (33.0%) had diabetes.
Results: Depression symptoms were identified in 12 (20.7%) patients in Period I, 13 (23.6%) in Period II and four (9.8%) in Period III. Eighteen (31.0%) patients had complications in the IPP, 17 (34.0%) in the LPP. IPP complications were more frequent for older patients (more than 65 years; p=0.003), with at least three grafts (p=0.001) and depression in Period I (p=0.011). When those variables were associated with complications on the LPP, there was a significant difference for females (p=0.006) and depression in Period II (p=0.008). Female patients had more depression symptoms while staying in hospital (p=0.04).
Conclusion: More than 65 years, females, three or more grafts and depression symptoms in the postoperative period were associated with more complications after bypass surgery. Patients undergoing bypass surgery should be carefully monitored for depression and treated if necessary since it may be associated with complications after surgery.
Keywords: Coronary disease. Depression. Myocardial revascularization.
João Carlos Vieira da Costa Guaragna; Daniela Cecília Bolsi; Cristiano Pederneiras Jaeger; Raquel Melchior; João Batista Petracco; Luciane Maria Facchi; Luciano Cabral Albuquerque
Rev Bras Cir Cardiovasc 2006;21(2):173-179
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Objective: The aim of this study was to evaluate the incidence and to identify possible predictors of major postoperative neurologic dysfunction (defined as stroke) and to evaluate early clinical outcome in a non-selected cohort.
Method: A total of 1760 consecutive patients who underwent isolated CABG in the San Lucas Hospital -PUCRS, between January 1997 and February 2004, were enrolled. Demographic and laboratory data, informations regarding the procedure and perioperative endpoints were collected prospectively using a standard protocol of data register of the cardiac postoperative unit of our hospital. We considered statistically significant those variables with a p value no greater than 0.05 with a confidence interval of 95%.
Results: In this study, 52 (3%) patients presented with major neurologic dysfunction. On the univariable analysis advanced age, higher prevalence of obstructive pulmonary disease, previous cerebrovascular disease, higher mean value of fibrinogen, occurrence of shock or severe hypotension, presence of supraventricular tachycardia (atrial fibrillation or flutter), occurrence of the systemic inflammatory syndrome and prolonged mechanical ventilation were associated with stroke. On the multivariable analysis previous history of cerebrovascular disease and obstructive pulmonary disease presented as independent predictors for the occurrence of major neurologic dysfunction. Prolonged mechanical ventilation was also independently associated with the endpoint. Furthermore, the occurrence of stroke raised significantly the duration of hospital stay and in-hospital mortality.
Conclusion: Neurological dysfunction is still a significant cause of morbidity after CABG.
Keywords: Cerebrovascular acccident. Cerebrovascular disorders. Cardiac surgical procedures, adverse effects. Myocardial revascularization.
Maximiliano C. Kneubill; Walter J Gomes; Marcelo S. Aquino; Paulo Mazzilli; Guiomar N. Gomes; Maria Flavia L. Ribeiro; Camille D. Benatti; Enio Buffolo
Rev Bras Cir Cardiovasc 2006;21(4):371-376
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Objective: The use of left internal thoracic artery (LITA) in coronary artery bypass surgery is currently recognized as the best option, providing lower incidences of cardiovascular events and superior long-term survival. Now, incremental utilization of these grafts makes a reassessment of its histological structure necessary. Therefore, the purpose of this study was to examine and compare the sequential histological structure of LITA.
Method: Specimens of LITA harvested from 18 cadavers, divided into nine proportional segments, were studied. Cuts of each segment were stained by the Verhoeff-Van Gieson technique. The following parameters were analyzed: perimeter of the arterial lumen, thickness of the intima, thickness of the media layer, amount of elastic fiber in the media layer and the elastic fiber density.
Results: The collected data showed that perimeter of the LITA decreases downstream on its course, the thickness of the intima is increased in the proximal segments, the thickness of the media layer diminishes throughout its extension, the number of elastic fibers is concentrated in the intermediate segments and the density of elastic fibers is reduced in the proximal and distal segments.
Conclusion: Therefore, the findings of the present study validate the heterogeneity of the LITA sequential histological structure.
Keywords: Mammary arteries. Myocardial revascularization. Histology, comparative.
Leonardo Augusto Miana; Diego Silveira Lima; Joseph Fredric Whitaker; Pedro Horácio Cosenza Passos; João Batista Lopes Loures; Antonio Augusto Miana
Rev Bras Cir Cardiovasc 2007;22(1):60-67
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Objective: We sought to compare early clinical outcomes in patients receiving a right internal thoracic artery or a radial artery as the second arterial graft in myocardial revascularization.
Methods: We retrospectively studied 58 consecutive patients who underwent coronary artery bypass surgery and received both a left internal thoracic artery graft and either a right internal thoracic artery (n=20) or a radial artery graft (n=38), between January 2004 and March 2006. Hospital mortality, pleural drainage, operative time and postoperative complications were analyzed.
Results: There were no significant preoperative differences between groups. There was only one (1.7%) in-hospital death which occurred in the Radial Group. Operative times was significantly higher in the Right Internal Thoracic Group (p-value = 0.0018), but were not associated with increased Intensive Care Unit stays, mechanical ventilation or other postoperative complications. We were able to perform significantly more distal anastomosis using the radial artery than the right internal thoracic artery (1.57 versus 1.05: p-value =0.003).
Conclusion: In our group of patients, the use of a right internal thoracic artery as a second arterial graft was associated with a prolonged operative time, but had no interference with the immediate clinical outcomes.
Keywords: Myocardial revascularization. Mammary arteries. Radial artery. Evaluation of results of therapeutic interventions.
REVIEW ARTICLE
Rafael Angelo Tineli; Fernanda Viaro; Marcelo Bellini Dalio; Graziela Saraiva Reis; Solange Basseto; Walter Villela de Andrade Vicente; Alfredo José Rodrigues; Paulo Roberto Barbosa Evora
Rev Bras Cir Cardiovasc 2007;22(1):87-95
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Vascular endothelial cells are exposed to a variety of in vivo mechanical forces, specifically, shear stress for the blood flow, tensile stress from the compliance of the vessel wall and the hydrostatic pressure from containment of blood within inside the vasculature. Many authors studied hemodynamic, functional and morphological human saphenous veins alterations caused by these different forces with conflictant results. This review text was motivated with the specific aim of analyze literature data and some experimental data carried out in our laboratory. The adopted review subjects were: 1) Endothelial responses and gene regulation to shear stress; 2) Effects of the hydrostatic pressure in the endothelial cell morphology, gene expression of the endothelial cellular surface and proliferation of endothelial cells; 3) Effects of the traction on the human saphenous vein endothelium.
Keywords: Endothelium. Saphenous vein. Nitric oxide. Myocardial revascularization.
EXPERIÊNCIA DO SERVIÇO
Rodrigo Milani; Paulo Roberto Slud Brofman; José Augusto Moutinho de Souza; Laura Barboza; Maximiliano Ricardo Guimarães; Alexandre Barbosa; Alexandre Manoel Varela; Marcel Rogers Ravagnelli; Francisco Maia da Silva
Rev Bras Cir Cardiovasc 2007;22(1):104-110
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Objective: To analyze the hospital outcomes of patients, with chronic renal insufficiency in the hemodialysis, submitted to OPCAB.
Method: Fifty-one patients with chronic renal insufficiency were submitted to OPCAB. Hemodialysis was performed on the day before and the day after the operation. Myocardial revascularization was performed using LIMA's suture and suction stabilization.
Results: Fifty-one patients, with an averageof 61.28±11.09 years, were analyzed. Thirty patients (58.8%) were female. The predominant functional class was IV in 21 (41.1%) of the patients. The left ventricle ejection fraction was dire in 21 (41.1%) patients. The mean EUROSCORE of this series was 7.65±3.83 and the mean number of distal anastomosis was 3.1±0.78 per patient. The average time of mechanical ventilation was 3.78±4.35 hours and the mean ICU stay was 41.9±13.8 hours, while the average hospitalization was 6.5±1.31 days. In respect to complications, nine (17.6%) of the patients developed atrial fibrilation, and one (1.9%) patient presented with a case of ischemic stroke but had a good recovery during hospitalization. There were no deaths in this series.
Conclusion: Chronic renal patients submitted to hemodialysis were always a high risk population for myocardial revascularization. In this series, the absence of extracorporeal circulation appeared to be safe and efficient in this special subgroup of patients. The operations were performed with low indices of complications, absence of deaths and relatively low stays in the ICU and in hospital.
Keywords: Myocardial revascularization. Renal insufficiency, chronic. Renal dialysis.
CASE REPORT
Gustavo J. Ventura Couto; Alexandre de O. Deslandes; Paulo César de Souza Santos; Alexandre de Araújo Cruz; Roberto Santos Saraiva
Rev Bras Cir Cardiovasc 2007;22(1):119-122
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The purpose of the paper is to demonstrate the case of a 62-year-old man, with spontaneous coronary dissection of the left circumflex artery, treated surgically by myocardial revascularization. The successfully accomplished surgery demonstrates, in this case, to be the only possible way of a cure.
Keywords: Coronary vessels. Coronary circulation. Coronary arteriosclerosis. Myocardial revascularization.
ORIGINAL ARTICLE
Fernanda Viaro; Carlos Gilberto Carlotti Jr; Alfredo José Rodrigues; Walter Vilella de Andrade Vicente; Solange Bassetto; Graziela Saraiva Reis; Lafaiete Alves Junior; Paulo Roberto Barbosa Evora
Rev Bras Cir Cardiovasc 2007;22(2):169-175
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Objective: To study morphofunctional alterations induced by brief pressure increases in human saphenous veins utilized in coronary artery bypass grafting.
Method: Saphenous veins of 20 patients undergoing coronary artery bypass grafting, were distributed into four experimental groups, control, 100 mmHg, 200 mmHg and 300 mmHg, and submitted to pressure distention over 15 seconds using Krebs solution. The evaluation included CD34 immunohistochemistry and an In vitro vascular reactivity study in organ chambers.
Results: The main experimental findings were 1) From pressures of 200 mmHg there was a tendency to reduce the CD34 expression which became statistically significant at 300 mmHg; 2) There was no impairment of the contraction and relaxation as evidenced by in vitro vascular reactivity tests.
Conclusion: Although vascular reactivity impairment was not demonstrated in vitro, the CD34 expression, measured by imunohistochemistry, shows there is endothelium dysfunction at pressures of 300 mmHg.
Keywords: Endothelium. Saphenous vein. Nitric oxide. Hydrostatic pressure. Myocardial revascularization.
Alexandre Motta de Menezes; Frederico Pires de Vasconcelos; Ricardo de Carvalho Lima; Mário Gesteira Costa; Mozart Augusto Soares de Escobar
Rev Bras Cir Cardiovasc 2007;22(2):206-211
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Objective: To describe the technique and evaluate the immediate results of using an ultrasonic scalpel in the skeletonization of the internal thoracic artery for coronary artery bypass grafting surgery.
Methods: From January 2000 to October 2006, 188 patients were submitted to coronary artery bypass grafting with the internal thoracic artery skeletonized using an ultrasonic scalpel. Seventy-one patients (37.8%) were women. The patients' ages varied from 28 to 81 years old. The entire internal thoracic artery was exposed opening the endothoracic fascia using scissors as close as possible to the arterial adventitia. An ultrasonic scalpel was used to transect and coagulate all the intercostal branches, thereby minimizing the use of metallic clips.
Results: The skeletonized internal thoracic arteries presented with excellent flow, obviating the need for intraluminal manipulation for vasodilatation. In the immediate postoperative period, two patients were found to have temporary left-sided diaphragmatic paralysis. There were no sternal wound infections in this series. The dissection can be performed in approximately 33 minutes however with more experience this time may be reduced.
Conclusion: This technique facilitates and shortens the internal thoracic artery skeletonization procedure and does not cause arterial spasms. Cauterization of the collateral branches with an ultrasonic scalpel is efficient and the use of metallic clips is almost unnecessary. It is a procedure that is easy to reproduce and may be recommended as the first-choice technique for the dissection of the internal thoracic artery.
Keywords: Myocardial revascularization. Coronary artery bypass. Mammary arteries.
Christiano da Silveira de Barcellos; Orlando C. B. Wender; Paulo Cerati de Azambuja
Rev Bras Cir Cardiovasc 2007;22(3):275-284
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Objective: This study was undertaken to determine whether GIK infusion improves hemodynamic performance by reducing the use of inotropic agents, as well as the morbidity of diabetic patients submitted to CABG.
Methods: Patients with type 2 DM referred for CABG were randomized to receive GIK or subcutaneous insulin from anesthetic induction up to 12 hours postoperatively. The primary clinical outcome was the cardiac index (CI) and the secondary clinical outcomes were the remaining hemodynamic parameters; the use of inotropics and vasodilators, the glycemic control (maintenance of plasma glucose levels), and the postoperative morbidity. Hemodynamic and laboratory measurements were performed in the first 24 hours postoperatively, and the patients were followed up for 30 days to detect any surgery-related complications.
Results: Twenty-four patients were randomly included in the study. IC did not show significant difference (mean cardiac index at 24 hours in both GIK group 3.49±0.94 and Control group 3.38±0.75; p=0.74). The GIK group revealed lower blood glucose levels in the infusion period (glucose at 12 hours GIK group 195.6±68.25 versus Control group 269.6±78.48; p=0.02), with a lower incidence of hyperglycemia in the GIK group, two (16%) against eight (64%) in the control group (RR 0.25; 95%CI 0.07-0.94; p=0.03). Postoperative infectious complications were less frequent in the GIK group than in Control group, three (25%) against 10 (80%), respectively (RR 0.30; 95%CI 0.11 - 0.83; p=0.01).
Conclusions: Studies have proven that GIK improves hemodynamic performance of both patients with or without DM submitted to CABG, what was not confirmed in this study. The use of GIK neither improved the CI improvement nor reduced the use of inotropic drugs, but it provided better glucose control. Secondary clinical outcome, including postoperative infections, was more frequent in the control group.
Keywords: Glucose. Insulin. Potassium. Myocardial revascularization. Diabetes mellitus.
Stevan Krieger Martins; Magaly Arrais Dos Santos; Freddy H. Ponce Tirado; Francisco C. E. Martins Jr; Hassan F. Malat; Adib Domingos Jatene; Luiz Carlos Bento de Souza
Rev Bras Cir Cardiovasc 2007;22(3):291-296
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Objective: We sought to describe the use of both internal mammary arteries (IMA) in patients with diabetes mellitus (DM) submitted to coronary artery bypass grafting (CABG).
Method: Between January of 1995 to August of 2005, 4.569 patients received isolated CABG in our institution, of these, 1.298 had DM. Mean sample age was 62 years, and total mortality was 2.18% (100 patients). We have used both IMA's in 700 patients, that here are split in two groups, with DM (group I, 148 patients), and without DM (group II, 552 patients). Patient selection for double IMA grafting was based on coronary artery anatomy and sternal bone quality, the later was evaluated during sternal transsection. When these two factors were considered favorable, we harvested both IMA's, not mattering if the patient had or had not DM. During IMA's harvest, care was taken not to open the pleural spaces.
Results: There was small difference between the two groups in terms of morbidity and mortality.
Conclusion: Our data suggest that patients with DM can benefit of double IMA's grafting, with little increase in risk for complications if its application is carefully indicated.
Keywords: Myocardial revascularization. Mammary arteries. Internal mammary-coronary artery anastomosis. Diabetes mellitus.
Rosane Maria Nery; Juarez Neuhaus Barbisan; Mahmud Ismail Mahmud
Rev Bras Cir Cardiovasc 2007;22(3):297-302
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Objective: To evaluate the modifications of the frequency of physical activities practice of the patients submitted to coronary artery bypass graft surgery (CABG) and the influence of the frequency of physical practice activity of the patients before surgery in the surgical prognostic.
Methods: Cases studies of 55 patients submitted to CABG divided in active and sedentary in relation to physical practice activities.
Results: After CAGB 14 (47%) of the patients classified as sedentary before surgery were practing exercises (p=0.03). Seventeen (59%) sedentary patients in the pre-operatory period presented complications after the surgery comparing to 8 (31%) in those actives (p= 0.4%). The post-operatory period of hospitalization in the sedentary group and in those that were active in the pre-operatory period were respctively 15 (SD=8) and 12 (SD=5) days p=0.03.
Conclusion: This study showed the importance of pre-operatory physical activity practice in the results of coronary artery bypass surgery. The patients physically active had a shorter time of postoperative hospital stay and a smaller number of hospital and one year follow up surgery complications. The cardiac surgery promoted a modification of the habits of the patients increasing the number of physically active patients during the one year follow up.
Keywords: Exercise. Surgery. Post-operative complications. Myocardial revascularization. Risk reduction behavior.
Vicente Avila Neto; Roberto Costa; Kátia Regina da Silva; André Luiz Mendes Martins; Luiz Felipe Pinho Moreira; Letícia Bezerra Santos; Ricardo F. de Azevedo Melo
Rev Bras Cir Cardiovasc 2007;22(3):332-340
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Objective: To evaluated the effects of temporary atrial pacing to prevent the atrial fibrillation after coronary artery bypass graft surgery and the risk factors to the occurrence of this arrhytmia.
Methods: We have studied 160 patients who, at the end of coronary artery bypass graft surgery, were submitted to epicardial electrode implantation in the right atrium lateral wall. They were randomized into two groups: non-pacing (NP) group and right atrial (RA) pacing group. The cardiac rhythm was monitorized over 72 hours following to the end of surgery and the variables studied were as follow: incidence of atrial fibrillation; the risk factors pre-, intra-, and postoperative for its occurrence, and postoperative events.
Results: There were 21 (13.1%) episodes of atrial fibrillation, 20 in NP group and one in RA group. The relative risk (RR) for development of atrial fibrillation was 0.18 (95% CI; 0.05-0.60) for the RA group when compared to the NP group. The logistic regression identified that the study variables, such as younger age; use of beta-blockers in the preoperative, and the presence of right atrial pacing had been associated to a lower Odds ratios (ORs) for the occurrence of atrial fibrillation in the postoperative.
Conclusions: The temporary atrial pacing reduced the incidence of atrial fibrillation after the CABG surgery. Older age and a non-atrial pacing were the independent predictive factors of the occurrence of this arrhythmia.
Keywords: Cardiac pacing, artificial. Atrial fibrillation. Myocardial revascularization. Postoperative complications. Extracorporeal circulation.
EXPERIÊNCIA DO SERVIÇO
Carlos Sérgio Luna Gomes Duarte; Fernando Ribeiro de Moraes Neto; Carlos Roberto Ribeiro de Moraes
Rev Bras Cir Cardiovasc 2007;22(3):341-345
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Objective: To describe patient selection criteria, surgical technique and early outcomes in patients undergoing reoperative coronary artery bypass surgery (RECABG) through a left thoracotomy without cardiopulmonary bypass (CPB).
Methods: Eight patients with patent grafts to the left interventricular coronary artery (four of whom had also patent grafts to the right coronary artery) requiring revascularization of the circumflex coronary system had redo-CABG without CPB through a left posterolateral thoracotomy.
Results: There were no in-hospital mortality or serious postoperative complications. All patients are angina-free.
Conclusions: An off-pump redo-CABG through a left posterolateral thoracotomy may reduce risks attributable to resternotomy in patients who met the selection criteria.
Keywords: Myocardial revascularization. Reoperation. Coronary artery bypass, methods. Thoracotomy.
CASE REPORT
Eduardo Keller Saadi; Luis Henrique Dussin; Alvaro Nicolao; Alcides José Zago
Rev Bras Cir Cardiovasc 2007;22(3):346-348
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Situs inversus totalis is a rare congenital anomaly. We report a 78 year old woman with this condition and ischemic coronary artery disease who underwent myocardial revascularisation. The cardiac catheterism showed severe proximal stenosis with aneurysms in the interventricular, diagonal and right coronary. The procedure was done with the surgeon positioned in the left hand side of the patient, with the righ internal thoracic artery anastomosed to the interventricular artery and two more vein grafts. Very few cases were reported in the world and this is the third case in Brazil and the first in the world with coronary aneurysms.
Keywords: Dextrocardia. Situs inversus. Coronary disease. Myocardial revascularization.
Luiz Carlos de Lima; Silas Fernandes Avelar; Fernando Luiz Westphal; Ingrid Loureiro de Queiroz Lima
Rev Bras Cir Cardiovasc 2007;22(3):359-361
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A 67-year-old male patient underwent exploratory thoracotomy for pulmonary nodule resection. The patient presented a cardiorespiratory arrest during anesthesia due to myocardium infarction. After reanimation the patient was sent to ICU where he remained intubated for 7 days. Subsequently, he developed cervical tracheal stenosis. At first, the patient underwent a myocardium revascularization followed by surgical resection of tracheal stenosis through tracheoplasty.
Keywords: Tracheal stenosis. Myocardial revascularization. Lung neoplasms. Hamartoma.
REVIEW ARTICLE
Adriana Silveira de Almeida; Marcelo Curcio Gib Waldomiro Carlos Manfroi
Rev Bras Cir Cardiovasc 2007;22(4):476-483
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Considering that the world's population average age is increasing and the proportions of those over the age of 80, the fastest growing population worldwide, new approaches to health care and treatment will be necessary. Due to the development of new drugs and by means of transluminal coronary angioplasty or coronary artery bypass graft, many elderly patients had their lives prolonged and their quality of life improved. We carried out a bibliography review to search for evidence to support the best treatment choice according to the clinical manifestation of the patient.
Keywords: Myocardial revascularization. Angioplasty, transluminal, percutaneous coronary. Aged.
EXPERIÊNCIA DO SERVIÇO
José Carlos Dorsa Vieira Pontes; Guilherme Viotto Rodrigues da Silva; Ricardo Adala Benfatti; Natália Pereira Machado; Renato Pontelli; Elenir Rose Jardim Cury Pontes
Rev Bras Cir Cardiovasc 2007;22(4):484-490
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Objectives: To evaluate incidence, mortality, and risk factors related to the development of acute renal failure (ARF) after on-pump coronary artery bypass grafting (CABG), between January 2002 and November 2004.
Methods: Seventy four patients who underwent on-pump CABG were analyzed retrospectively and distributed into two groups according to the development of ARF. Bivariate and multivariate analyses were performed to analyze. P £ 0.05 was considered statistically significant.
Results: During the period analyzed, 18 patients (24.32%) developed acute renal failure (ARF); 1 patient (1.35%), who required dialysis, died. Associated risk factors identified in-between the development of ARF was: the postoperative use of inotropic or vasoconstrictor drugs (p=0.048) and body mass index greater than 25 (p=0.004). The CPB time did not determine the ARF increase (p=0.0668).
Conclusion: The CPB time was not associated with an increased of ARF following on-pump CABG.
Keywords: Myocardial revascularization. Renal insufficiency, acute. Extracorporeal Circulation.
ORIGINAL ARTICLE
Maria Flavia L. Ribeiro; Maximiliano C. Kneubill; Marcelo S. Aquino; Guiomar N. Gomes; Paulo Mazzilli; Enio Buffolo; Camille D. Benatti; Walter J Gomes
Rev Bras Cir Cardiovasc 2008;23(1):1-6
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Objetivo: O uso do enxerto de artéria torácica interna esquerda (ATIE) é atualmente reconhecido como a melhor opção na cirurgia de revascularização miocárdica, proporcionando menor incidência tardia de eventos cardiovasculares e maior sobrevida. Conseqüentemente, houve grande incremento nas últimas décadas do uso bilateral das artérias torácicas internas (ATIs), com demonstração de melhora adicional de sobrevida em longo-termo. O objetivo desse trabalho foi estudar a estrutura histológica das ATIs esquerda e direita (ATID), com a análise histomorfométrica seqüencial e comparativa entre os segmentos das duas artérias.
Métodos: Foram estudados espécimes de ATIs retirados de 18 cadáveres, divididos em nove segmentos proporcionais. Cortes de cada segmento foram corados com técnica de hematoxilina-eosina e Verhoeff-Van Gieson. Foram analisados os seguintes parâmetros: perímetro da luz arterial, espessura da íntima, espessura da camada média e quantidade de fibras elásticas da camada média.
Resultados: O perímetro interno de ambas as ATIs diminuiu ao longo do percurso, dos segmentos mais proximais para os mais distais. Os segmentos proximais da ATID apresentaram perímetro significativamente maiores do que os da ATIE. A análise da espessura da íntima revelou não existir diferença significativa entre ATIE e ATID, exceto no segmento 1. A espessura da camada média diminuiu ao longo da extensão das ATIs, não havendo diferença estatística entre elas, exceto no segmento 9. O número de lâminas elásticas nos segmentos distais da ATIE foi estatisticamente superior ao da ATID.
Conclusão: Portanto, os dados do presente estudo sugerem haver diferenças estruturais entre as ATIs direita e esquerda.
Keywords: Mammary arteries. Myocardial revascularization. Histology, comparative. Humans. Cadaver.
Delawer Reber; Marcus Fritz; Alfred Germing; Peter Marks; Axel Laczkovics
Rev Bras Cir Cardiovasc 2008;23(1):23-28
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Objective: One of the major and devastating complications of the coronary artery bypass grafting (CABG) is the stroke. Avoiding cardiopulmonary bypass (CPB) may reduce this neurological complication. In the past years there was an increased interest in the off-pump coronary artery grafting (OPCAB). The benefit of this method of revascularization in term of stroke and mortality is controversially discussed.
Methods: A retrospective analysis of collected data from 252 patients were operated without cardiopulmonary bypass out of 1516 CABG procedures from January 2004 through May 2006. The mean age of the patient population was 70±11years, within a range of 27-88 years. Forty-eight (19%) patients were older than 80 years and there were 172 (69%) males. Mean graft per patient was 1.78±0.79. The internal mammary artery (IMA) graft was used in 95% of the patients. For eight (3.17%) patients this was the second procedure.
Results: Hospital mortality was 3.17%; Mean EuroSCORE in these patients was 10.36±6.67. No neurological complications occurred, six (2.38%) patients had temporary psycho syndrome. Postoperative myocardial infarction occurred in three (1.19%) patients. Two patients required rethoracotomy as a result of bleeding. Thirty-eight (15%) patients needed postoperative therapy for atrial fibrillation.
Conclusion: CABG with OPCAB technique has the benefit of low mortality and morbidity in terms of stroke. The advantages of this technique depends on the patient's general condition at the time of the operation, the sufficiency of pump function and coronary morphology, as well as on the surgeon's experience.
Keywords: Myocardial revascularization. Coronary artery bypass/adverse effects. Cerebrovascular accident.
Ana Maria Rocha Pinto e Silva; Valquiria Pelisser Campagnucci; Wilson Lopes Pereira; Ronaldo F. Rosa; Roberto A. Franken; Sylvio M. A.Gandra; Luiz A. Rivetti
Rev Bras Cir Cardiovasc 2008;23(1):40-45
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Objective: To analyze the in-hospital outcome of elderly patients aged 70 years and older who underwent off-pump coronary artery bypass graft surgery with an intraluminal shunt in urgent, emergent, and elective coronary revascularizations.
Methods: From July 1989 to July 2005, we analyzed 87 patients ranging in age from 70 to 92 years. Of the 87 patients enrolled, 50 (57.5%) patients had unstable angina, with three (3.4%) acute myocardial infarction; thirty-one (35.6%) patients underwent urgent and emergent surgery; thirteen (14.9%) patients had myocardial infarction in less than 30 days, and 34 (39.1%) in more than 30 days.
Results: The main postoperative complications were: atrial fibrillation (32.2%), heart failure (12.6%), pneumonia (10.3%), septicemia (3.4%), acute myocardial infarction (2.3%), mediastinitis (1.1%) transient ischemic attack (1.1%), and pneumothorax (1.1%). The mean extubation time was 18.50±19.09 hours, the length of stay in the intensive care unit was 2.92±2.03 days, and hospital length of stay was 10.55±7.16 days. Packed red cells were given to nine (10.34%) patients and none of them was operated due to bleeding. The in-hospital mortality was 4,6%.
Conclusions: In patients over 70 years-old, elective and non-elective off-pump coronary artery bypass grafting with intracoronary shunt showed to be safe and effective, associated with low rates of postoperative complications and mortality in relation to the studied population.
Keywords: Myocardial revascularization. Aged. Coronary disease/surgery. Hospital mortality. Postoperative complications.
EXPERIÊNCIA DO SERVIÇO
João Bosco de Oliveira; Roberto Rocha e Silva; Ricardo de Mola; Roger Alain Pantoja Ribera
Rev Bras Cir Cardiovasc 2008;23(1):114-117
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Objective: The various techniques of radial artery (RA) harvesting produce similar results. These techniques use electrocautery, ultrasonic scalpel, or sharp scissors in different combinations, but usually associated with the use of hemostatic clips. We describe a RA harvesting technique with the combination of sharp scissors and electrocautery without the use of hemostatic clips.
Methods: We describe a retrospective study of 107 patients ranging from 28 and 78 years of age (mean ± SD; 53.3 ± 8 yrs). Bleeding, re-operation, infarct, and death were analyzed.
Results: No bleeding was imputable to the RA and no re-operations were required. There were three (2.8%) infarcts possibly related to the RA anastomosis territory. Mortality was 0.9%, but unrelated to cardiac complications.
Conclusion: RA electrocautery harvesting without hemostatic clips presented no bleeding and was an inexpensive procedure, requiring no investments in additional equipment.
Keywords: Radial artery. Myocardial revascularization. Myocardial ischemia. Coronary disease.
ORIGINAL ARTICLE
Eduardo I. Melo; Mariana S. Pereira; Rodrigo S. Cunha; Mauro Paes Leme de Sá; Paulo A. S. Mourão
Rev Bras Cir Cardiovasc 2008;23(2):169-174
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Introduction: The change in the heparin solution trade mark in Brazil that had been commonly used in cardiac surgery has shown increased number in the coagulopathy, re-exploration and other side effects in our Institution and others.
Methods: All four different heparin solutions available in the Brazilian market were studied in the Connective Tissue Lab, HUCFF, UFRJ and compared to the Liquemine (out of the market) and the international control solution. All samples were evaluated by magnetic nuclear resonance as well as their anticoagulant effectiveness.
Results: There were significant differences among them regarding the anticoagulant activity. It was also observed contamination with other dermatan sulfate, samples chemically degraded and with significant change in the molecular weight.
Conclusion: Among the studied samples, none of them can offer security in cardiac surgeries on pump. None of them has demonstrated similar quality to Liquemine, which is not available in the Brazilian market.
Keywords: Heparin. Myocardial revascularization. Extracorporeal circulation.
João Roberto Breda; Ana Silvia Castaldi Ragognetti Breda; Andréa Cristina Oliveira Freitas; Adriano Meneghini; Carlos Mendes Tavares; Luís Carlos de Abreu; Neif Murad; Adilson Casemiro Pires
Rev Bras Cir Cardiovasc 2008;23(2):204-208
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Objective: To evaluate the effect of ventral cardiac denervation in the incidence of atrial fibrillation after coronary artery bypass surgery.
Methods: Between September and November, 50 patients without history or previous diagnosis of atrial arrhythmia from the same institution presenting coronary heart disease with indication for coronary artery graft bypass surgery were enrolled in a prospective and randomized study. The exclusion criteria were: patients older than 75 years of age, previous history of atrial arrhythmia and associated heart surgeries. Denervation was performed before cardiopulmonary bypass and it was achieved by removing the adipose tissues around the superior vena cava, aorta and pulmonary artery. The groups were compared regarding demographic, clinical and operative variables.
Results: There were no hospital mortalities. The additional time for the denervation was 7.64 ± 2.33 minutes, and there were no associated complications. Postoperative atrial fibrillation was present in two (8%) patients of the Control Group and in three (12%) patients who underwent ventral cardiac denervation. The risk of postoperative atrial fibrillation in patients undergoing ventral cardiac denervation was 22% higher than in the Control Group (0.56-2.66,confidence interval); however, this outcome was not statistically significant (p=0.64).
Conclusion: Ventral cardiac denervation, despite being a fast and low-risk procedure, does not significantly reduce the incidence of atrial fibrillation after coronary artery bypass graft surgery.
Keywords: Atrial fibrillation/prevention & control. Denervation. Myocardial revascularization.
REVIEW ARTICLE
José Fernando Vilela Martin; Renan Oliveira Vaz de Melo; Letícia Pinheiro de Sousa
Rev Bras Cir Cardiovasc 2008;23(2):245-255
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Postoperative cognitive dysfunction is frequent in cardiac surgeries leading to major consequences. The physiopathological processes involved in this condition are still not completely elucidated, despite the multifactor character. Besides pre-operative factors such as age and education, some intra-operative factors are also of extreme importance. However, according to a vast literature on the subject, these factors are not capable to clarify the totality of the cases, taking us to a genetic base for this neurological sequel. In this revision, we briefly assess the factors involved in this cognitive dysfunction as well as discuss the pharmacotherapy in the prevention of this event.
Keywords: Myocardial revascularization. Extracorporeal circulation. Cognition. Cognition disorders/etiology. Cardiac surgical procedures/adverse effects.
ORIGINAL ARTICLE
Monir Abbaszadeh; Mk Arabnia; A. Rabbani; Mh. Mandegar; S. Vahedi
Rev Bras Cir Cardiovasc 2008;23(3):317-322
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Objective: Problem of wound healing is commonly observed after coronary artery bypass graft procedures. Our aim is to determine the prevalence and the predictors of saphenous vein harvesting complication after coronary revascularization procedures.
Methods: After institutional ethical committee review and approval, a retrospective review was undertaken of 4029 bypass procedures with saphenous vein graft performed over a period of six years is conducted. Thirteen risk factors for those who developed major leg wound complications were analyzed and compared with the entire cohort of patients, undergoing similar bypass procedures during the same period.
Results: Lower extremity wound complications occurred in 68 patients (1.7%), 43 of them required additional surgical interventions. There were 17 wound debridements, nine skin grafts, one angioplasty, 11 fasciotomies, three vascular procedures, and two free tissue transfers. Of 13 variables evaluated by multivariate analysis, female gender, BMI, use of internal thoracic artery graft, peripheral vascular disease, the use of postoperative intraaortic balloon pump and preexisting hyperlipidemia were identified as significant independent predictors of major leg wound complications (p<0.05).
Conclusions: The causes of major leg wound complications after saphenous vein harvest for coronary artery bypass graft procedures are multifactorial. To minimize these complications, we recommend vascular evaluations before saphenous vein harvest, attention to proper surgical technique, and careful harvest site section.
Keywords: Myocardial Revascularization. Saphenous vein. Coronary artery bypass. Leg. Postoperative complications/etiology.
Virgílio Figueiredo Silva; Márcia Marcelino de Souza Ishigai; Edna Freymüller; João Nelson Rodrigues Branco; Diego Felipe Gaia; Edmo Atique Gabriel; Renata Aparecida Leonel Romão; Enio Buffolo
Rev Bras Cir Cardiovasc 2008;23(3):323-329
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Objective: Saphenous vein grafts (SV) used in coronary artery bypass grafting have a limited life and vein occlusion may be the final adverse effect. Efforts to develop new techniques to harvest the saphenous vein may improve the viability of the graft.
Methods: Twenty patients were randomly divided into two groups with the objective of evaluating the vascular endothelium. The No Touch (NT) technique consists in removing the saphenous vein with perivascular tissue. The conventional technique consists in harvesting with "in situ" removal of the perivascular tissue. The standard saphenous vein harvesting procedure used bridged incisions. Characteristics of the vein were considered. Evaluation of the endothelium was achieved by electron microscopy and histologic analysis using hematoxylin eosin staining. The Picrosirius and Masson Trichrome methods were used to analyze subendothelial collagen.
Results: Electron microscopy demonstrated that the NT Group had larger non-denudated endothelial areas as well as a smaller number of degraded cells. Histological analysis showed the form and integrity of the saphenous vein layers. A larger amount of collagen fibers were identified in the NT Group.
Conclusions: The NT technique better preserves the saphenous vein endothelium suggesting a more viable graft in the long term.
Keywords: Saphenous vein. Myocardial revascularization. Endothelium, vascular. Coronary artery bypass.
Rodrigo Milani; Paulo Roberto Brofman; Maximiliano Guimarães; Laura Barboza; Rodrigo Mezzalira Tchaick; Hugo Meister Filho; Thales Baggio; Francisco Maia
Rev Bras Cir Cardiovasc 2008;23(3):351-357
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Objective: To evaluate the influence of the technique used in the dissection of thoracic arteries in the evolution of diabetic patients submitted to OPCAB.
Methods: Seventy diabetic patients submitted to OPCAB using bilateral thoracic arteries were evaluated. In Group A, thoracic arteries were dissected as a pedicle, while in Group B they were skeletonized.
Results: The mean age of patients in Group A was 52.14 ± 7.35 years old versus 55.71 ± 8.1 years for Group B (p=0.057). In Group A, six patients (17.1%) were insulin dependent against nine (25.7%) in Group B (p = 0.561). The EUROSCORE was 3.97 ± 2.49 for Group A opposed to 4.14 ± 3.06 for Group B (p = 0.879). The number of distal anastomoses in Group A was 3 ± 0.77 versus 3.03 ± 0.89 in Group B (p = 0.981). Three patients (8.57%) from Group A presented with mediastinitis. Insulin dependence was the only significant risk factor (p=0.008) for mediastinitis. In this group the use of skeletonized internal thoracic arteries significantly decreased the incidence of mediastinitis (p = 0.044).
Conclusion: The incidence of mediastinitis was lower in the group for which mammary arteries were dissected using skeletonization. Among insulin-dependent diabetics, 50% of the patients from the group in which the pedicled internal thoracic artery was utilized presented with mediastinitis; the utilization of skeletonized internal thoracic arteries significantly decreases the incidence of mediastinitis.
Keywords: Myocardial revascularization. Mammary arteries. Diabetes mellitus.
EDITORIAL
Walter J Gomes; Domingo M Braile
Rev Bras Cir Cardiovasc 2008;23(4):III-IV
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ORIGINAL ARTICLE
Ahmad Ali Abdouni; Luiz Augusto Ferreira Lisboa; Luiz Boro Puig; Carlos Eduardo Tossuniam; Luís Alberto Oliveira Dallan; Fabio Biscegli Jatene; Sergio Almeida de Oliveira; Noedir Antonio Groppo Stolf
Rev Bras Cir Cardiovasc 2008;23(4):494-500
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Objective: To evaluate the long-term results of the coronary artery bypass grafting with exclusive use of arterial grafts for patients with triple vessel disease.
Methods: We evaluated 136 patients who underwent isolated coronary artery bypass grafting between January 1995 and December 1997. 353 grafts were used for revascularization of 449 arteries (mean: 3.30 per patient). Grafts used were left internal thoracic artery (99.2%), right internal thoracic artery (56.6%), radial artery (87.5%), right gastroepiploic artery (20.5%) and one inferior epigastric artery. 76 (55.8%) patients received composite grafts ("Y" shape) and 66 (48.5%) patients received sequential anastomoses.
Results: Hospital mortality was 4.4%. In the long-term follow-up (9.5 to 12.8 years), 82.1% of the patients were free of cardiac events. 20 (17.9%) patients had hospital readmission due to cardiac events: 15 presented angina and five presented acute myocardial infarction, and three of them presented associated heart failure. Eigth (7.1%) patients needed coronary reintervention: one of them underwent coronary bypass reoperation and the others underwent coronary angioplasty with stent. Estimated probability of cardiac event-free was 98.2%, 95.4% e 84.2% at 1, 5 and 10 years follow-up respectively. There were 16 (14.2%) late deaths and four of them (3.6%) were cardiac-related. Actuarial 12.8-year-survival of all deaths was 85% in this group.
Conclusion: Coronary artery bypass grafting with exclusive use of arterial grafts is a safe procedure for patients with triple vessel coronary disease with good long-term results.
Keywords: Myocardial revascularization. Arteriosclerosis/surgery. Mammary arteries. Radial artery.
Cíntia Reis; Sandra Mari Barbiero; Luciane Ribas
Rev Bras Cir Cardiovasc 2008;23(4):524-529
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Objectives: To evaluate the effect of BMI (body mass index) in the postoperative period of elderly patients undergoing CABG.
Methods: Cross-sectional retrospective study, carried out in academic hospital, with all patients (n=290), aged or above 60 years, undergone CABG, from August 2006 to July 2007. The patients were divided into tertiles of BMI (<22, 22-27,> 27kg/m²). The variables included in the study were collected from medical records of patients and analyzed by logistic regression in association with the categories of BMI.
Results: In the group with malnutrition were found larger percentage of impaired lung, kidney, hospital stay and immediate surgical mortality; but without statistical significance. Among female patients, the group malnutrition and eutrophy, 61.5% had hospital stay for a period longer than seven postoperative days compared to 42.5% male patients (P=0.003). In the group with malnutrition was found association between the CPB time and renal dysfunction with P<0.001 and, in eutrophic group with P=0.04. Obesity obtained protective association for lung dysfunction (RR=0.99), readmissions (RR=0.45) and mortality (RR = 0.77), and risk factor for renal dysfunction (RR=1.12).
Conclusions: In short-term, elderly with lower BMI may have increased the risk for complications. In contrast, obesity can have a protective effect, except for renal dysfunction.
Keywords: Body mass index. Myocardial revascularization. Aged. Postoperative complications.
REVIEW ARTICLE
Julia Alencar Renault; Ricardo Costa-Val; Márcia Braz Rossetti
Rev Bras Cir Cardiovasc 2008;23(4):562-569
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The aim of this work is to make a critical review about the different techniques of respiratory physiotherapy used following cardiac surgery and this effectiveness in reverting pulmonary dysfunction. It has been used as reference publications in English and Portuguese using as key words thoracic surgery, respiratory exercises, physical therapy modalities, postoperative complications and myocardial revascularization, contained in the following databases - BIREME, SciELO Brazil, LILACS, PUBMED, from 1997 to 2007. A secondary search of the reference list of identified articles also was made. It has been selected eleven randomized trials (997 patients). For the articles included incentive spirometry was used in three; deep breathing exercises in six; deep breathing exercises added to positive expiratory pressure in four and positive airway pressure added to inspiratory resistance in two. Three trials used intermittent positive pressure breathing. Continuous positive airway pressure and bi-level positive airway pressure has been used in three and two trials. The protocols used in the studies were varied and the co interventions were present in a big part of these. The different analyzed varieties and the time of postoperatory follow up make a comparative analysis difficult. Pulmonary dysfunction is evident in the postoperatory period of cardiac surgery. The use of non-invasive ventilation has been associated with good results in the first postoperatory days. Despite the known importance of postoperatory respiratory physiotherapy, until now, there is no literary consensus about the superiority of one technique over the others.
Keywords: Thoracic surgery. Breathing exercises. Physical therapy modalities. Postoperative complications. Myocardial revascularization.
ORIGINAL ARTICLE
Fernando Pivatto Júnior; Felipe H. Valle; Edemar M. C Pereira; Fernanda M. Aguiar; Nicoli T. Henn; Paulo E. B. Behr; Ivo A Nesralla; Renato A. K Kalil
Rev Bras Cir Cardiovasc 2011;26(1):21-26
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EMC
Introduction: An increasing number of octogenarian patients is undergoing coronary artery bypass graft surgery (CABG). The short-term results of this procedure have been broadly studied, but there are few national reports on long-term outcomes.
Objectives: To describe hospital mortality and long-term survival of patients aged
> 80 years undergoing isolated CABG.
Methods: Retrospective cohort study with 142 consecutive patients aged
> 80 years undergoing isolated CABG in the period between January/1996 and December/2007 in a Brazilian reference center. Mean age (± SD) was 82.3 ± 2.1 years, and 56.3% were male. The prevalence of hypertension was 73.2%, of previous myocardial infarction 30.3%, of diabetes 26.8%, and of renal dysfunction (creatinine
3 2.0 mg/ml) was 4.9%. The median follow-up was 4.0 years, with a loss of 11.6% of patients. Survival analysis was performed by the Kaplan-Meier method.
Results: Overall hospital mortality was 14.8% (95% CI: 8.8 to 20.8), with a reduction of this rate during the study period (1996-1999: 25.9%, 2000-2003: 15.8%, and 2004-2007: 8.6%). Mean survival was 6.5 years (95% CI: 5.5 to 7.5), and the survival rate at 1, 3 and 5 years was 79.4, 73.4 and 65.2%, respectively.
Conclusion: Results are in agreement with international reports. Mean survival was 6.5 years and the survival rate at 5 years was 65.2%.
Keywords: Myocardial Revascularization. Aged, 80 and over. Survival Analysis.
Taciane Procópio Assunção; Breno César Diniz Pontes; Carlos Américo Veiga Damasceno
Rev Bras Cir Cardiovasc 2011;26(1):43-46
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Objective: To study the prevalence of wound infection on myocardial revascularization surgery stitches as well as the causing microorganisms, predominant sex and age.
Methods: A retrospective and transversal study, with analysis of the files of the 21 patients with infected myocardial revascularization wounds among 357 operated patients between the years of 2007 and 2009. The files were checked on 2009. Results: There was no statistics significance analyzing the sex of the patients. The average of patients were old aged and the prevalence is similar to the index found in literature, but there are variations about the found microorganisms all over the years.
Conclusion: Besides the raise of wound infections along the 3 years, the prevalence kept stable, once the numbers of maid surgeries proportionately raised. Sex is not a significant variable to the occurrence of myocardium revascularizations wound infection. Old aged people are more predictable to this complication and the causing microorganism is variable.
Keywords: Surgical Wound Infection. Myocardial Revascularization. Postoperative Complications. Infection.
Ricardo Manrique; Ricardo Pavanello; Hélio M. de Magalhães
Rev Bras Cir Cardiovasc 1996;11(4):248-258
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Around 5 percent of the patients submitted to heart surgery with extracorporeal circulation present neurological problems. In relation to neuropsicological functions the alteration rate achieve 50 to 70%. An independent variable to stroke is age, the frequency in patients older then 75 years is close to 9%. Taking in account that rate of the elderly population grows very fast and that the coronary patient are frequently older than 65 years, we found very important to search for prophylactic ways to reduce this incidence. New drugs promise to achieve the goal of a prophylaxis of the cerebral injury induced by extracorporeal circulation and nimodipine, a neurovascular specific calcium channel blocker, seems to be a great promise for the prevention of cerebral damage. This is a pilot, double blind, randomized and controlling study with 64 patients, 30 in the nimodipine group and 34 in the placebo branch. Demographics and preoperative data were similar, without any significative difference but the incidence of previous transitory ischaemic attack. The nimodipine group shows a reduction in the number of neurological events in comparation with the placebo group, although a most complicated surgical procedure and inter and post-operative evolution. In the nimodipine group 3 patients presented mental confusion but in the placebo branch we found also 3 cases of mental confusion plus 2 cases of drowsy and one ischaemic stroke with sequels. In summary in the nimodipine group were 3 cases in 30 patients (10%) against 6 in 34 patients (17.64%) in one placebo group. It means a neurological events reduction of 76.4%. Legault reported high mortality in patients using nimodipine in cardiac valve replacement surgery, mainly related to bleeding. We don't found such correlation. The hospital - mortality was similiar in both groups (1 patient in each group) and non statistically significant difference in bleeding (1 severe case in the nimodipine group). In the follow up till 41 months there was a higher mortality in the placebo (4 patients) than in the nimodipine group (1 case).
Keywords: Myocardial revascularization. Cerebral ischemia, prevention and control. Confusion, prevention and control. Nimodipine, therapeutic use. Nimodipine, administration and dosage. Myocardial revacularizatton, mortality. Extracorporeal circulation, adverse effects. Double-blind method.
Graciane Radaelli; Luiz Carlos Bodanese; João Carlos Vieira da Costa Guaragna; Anibal Pires Borges; Marco Antonio Goldani; João Batista Petracco; Jacqueline da Costa Escobar Piccoli; Luciano Cabral Albuquerque
Rev Bras Cir Cardiovasc 2011;26(3):373-379
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BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors reduce the chance of death, myocardial infarction (MI) and cerebrovascular accident (CVA) in patients with coronary disease. However there is no consensus as to its indication in patients undergoing coronary artery bypass grafting (CABG).
OBJECTIVE: To assess the relationship between preoperative use of ACE inhibitors and clinical outcomes after CABG.
METHODS: Retrospective cohort study. We included data from 3,139 consecutive patients undergoing isolated CABG in Brazilian tertiary care hospital between January 1996 and December 2009. Follow-up was until discharge or death. Clinical outcomes after surgery were analyzed between users and nonusers of ACE inhibitors preoperatively.
RESULTS: Fifty-two percent (n=1,635) of patients received ACE inhibitors preoperatively. The use of ACE inhibitors was an independent predictor of need for inotropic support (OR 1.24, 95% CI 1.01 to 1.47,
P = 0.01), acute renal failure (OR 1.23, 95% CI 1.01 to 1.73,
P = 0.04) and progression to atrial fibrillation (OR 1.32, 95% CI 1.02 to 1.7,
P = 0.03) postoperatively. The mortality rate among patients receiving or not preoperative ACE inhibitors was similar (10.3% vs. 9.4%,
P = 0.436), as well as the incidence of myocardial infarction and stroke (15.6% vs. 15.0%,
P = 0.694 and 3.4% vs. 3.5%,
P = 0.963, respectively).
CONCLUSION: The use of preoperative ACE inhibitors was associated with increased need for inotropic support and higher incidence of acute renal failure and postoperative atrial fibrillation, not associated with increased rates of myocardial infarction, stroke or death
Keywords: Angiotensin-converting enzyme inhibitors. Myocardial revascularization. Coronary disease. Coronary artery bypass.
REVIEW ARTICLE
Simone Cavenaghi; Lucas Lima Ferreira; Lais Helena Carvalho Marino; Neuseli Marino Lamari
Rev Bras Cir Cardiovasc 2011;26(3):455-461
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The cardiovascular diseases are among the main death causes in the developed world. They have been increasing epidemically in the developing countries. In spite of several alternatives for the treatment of the coronary artery disease; the surgery of the myocardial revascularization is an option with proper indications of medium and long-term with good results. It provides the remission of the angina symptoms contributing to the increase of the expectation and improvement of the life quality. Most of patients undergoing myocardial revascularization surgery develop postoperative lung dysfunction with important reduction of the lung volumes, damages in the respiratory mechanism, decrease in the lung indulgence and increase of the respiratory work. The reduction of volumes and lung capacities can contribute to alterations in the gas exchanges, resulting in hypoxemia and decrease in the diffusion capacity. Taking this into account, the Physiotherapy has been requested more and more to perform in the pre as well as in the postoperative period of this surgery. This study aimed at updating the knowledge regarding the respiratory physiotherapy performance in the pre and postoperative period of the myocardial revascularization surgery enhancing the prevention of lung complications. The Physiotherapy uses several techniques in the preoperative period; such as: the incentive spirometry, exercises of deep breathing, cough, inspiratory muscle training, earlier ambulation and physiotherapeutic orientations. While in the postoperative period, the objective is the treatment after lung complications took place, performed by means of physiotherapeutic maneuvers and noninvasive respiratory devices, aiming at improving the respiratory mechanism, the lung reexpansion and the bronchial hygiene. Respiratory physiotherapy is an integral part in the care management of the patient with cardiopathy, either in the pre or in the postoperative period, since it contributes significantly to a better prognosis of these patients with the use of specific techniques.
Keywords: Physical Therapy (Specialty). Myocardial Revascularization. Preoperative Care. Postoperative Care.
ORIGINAL ARTICLE
Edmo Atique Gabriel; Rafael Fagionato Locali; Priscila Katsumi Matsuoka; Thiago Cherbo; Enio Buffolo
Rev Bras Cir Cardiovasc 2011;26(4):525-531
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EMC
OBJECTIVE: The authors sought to assess biochemical, hormonal and cellular repercussions from use of cardiopulmonary bypass (CPB) in coronary artery bypass graft (CABG) surgery.
METHODS: Eighteen patients underwent on-pump CABG surgery. Mean time of CPB was 80.3 minutes. Hormonal, biochemical and cellular measurements were taken in some time points - preoperatively, immediately after coming off CPB, 24 and 48 hours postoperatively. Friedman and Wilcoxon tests were applied based on significance level of 5%.
RESULTS: There was activation and significant elevation of total leukocytes and neutrophils count over CPB, remaining this way up to 48 hours postoperatively. Total platelets count, in turn, was marked by relevant reduction immediately after coming off CPB as well as in two postoperative time points. Serum levels of total proteins and albumin, immediately after coming off CPB and also in two postoperative time points, were significantly decreased comparing with preoperative status. There was remarkable reduction of total T3, free T3 and total T4 particularly up to first 24 hours postoperatively.
CONCLUSION: In on-pump CABG surgery, inflammatory effects encompass activation of total leukocytes, neutrophils and platelets, reduction of serum level of total proteins and albumin and decreased thyroid hormones levels, especially within first postoperative 24 hours.
Keywords: Extracorporeal circulation. Myocardial revascularization. Coronary disease.
Walter J Gomes; Raul E. Saavedra; Débora M. Garanhão; Alexandre R. Carvalho; Francisco A. Alves
Rev Bras Cir Cardiovasc 2011;26(4):544-551
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OBJECTIVES: The reconstruction of the left ventricle (LV) is effective in the treatment of ischemic cardiomyopathy with large akinetic or dyskinetic areas. However, late survival outcomes are related to the remnant left ventricular cavity size, thus eliminating intracavitary patch placement provides additional LV reduction. The aim of this study was to analyze the results with left ventricular reconstruction surgery using the concept of maximum ventricular reduction, with systematic patch abolition.
METHODS: Seventy-six consecutive patients with ischemic heart disease (age 30-78 years, mean 57.6 ± 10.1), evolving in functional class III and IV underwent surgical ventricular reconstruction with no use of intracavitary patches or Teflon strips for closing the left ventriculotomy.
RESULTS: The left ventricular end-systolic diameter decreased from 52.3 ± 5.4 in the preoperative period to 45.2 ± 6.9 mm in the postoperative period. LV ejection fraction increased from 34.2% ± 10.4% to 45.5% ± 9.4%. Associated CABG was performed in 75/76 patients with a mean of 2.4 grafts per patient. The 30-day mortality was 3/76 (3.9%). At an average follow up of 39 months, the majority of the patients (91.4%) remain in functional class I and II.
CONCLUSION: The concept of maximizing LV reduction with systematic patchless reconstruction is feasible, safe and effective, the early and late outcomes comparing favorably to previous series reported in the medical literature. Additionally, the concept meets the contemporary pathophysiologic basis of heart failure.
Keywords: Heart Failure. Myocardial Ischemia. Heart Aneurysm. Coronary Artery Bypass. Coronary Disease.
Gibran Roder Feguri; Paulo Ruiz Lúcio Lima; Andréa Mazoni Lopes; Andréa Roledo; Miriam Marchese; Mônica Trevisan; Haitham Ahmad; Bruno Baranhuk de Freitas; José Eduardo de Aguilar-Nascimento
Rev Bras Cir Cardiovasc 2012;27(1):7-17
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INTRODUCTION: Limited information is available about preoperative fasting abbreviation with administration of liquid enriched with carbohydrates (CHO) in cardiovascular surgeries.
OBJECTIVES: To evaluate clinical variables, security of the method and effects on the metabolism of patients undergoing fasting abbreviation in coronary artery bypass graft (CABG) surgery.
METHODS: Forty patients undergoing CABG were randomized to receive 400 ml (6 hours before) and 200 ml (2 hours before) of maltodextrin at 12.5% (Group I, n=20) or just water (Group II, n=20) before anesthetic induction. Perioperative clinical variables were evaluated. Insulin resistance (IR) was evaluated by Homa-IR index and also by the need of exogenous insulin; pancreatic beta-cell excretory function by Homa-Beta index and glycemic control by tests of capillary glucose.
RESULTS: Deaths, bronchoaspiration, mediastinitis, stroke and acute myocardial infarction did not occur. Atrial fibrillation occurred in two patients of each group and infectious complications did not differ among groups (P=0.611). Patients of Group I presented two days less of hospital stay (P=0.025) and one day less in the ICU (P<0.001). The length of time using dobutamine was shorter in Group I (P=0.034). Glycemic control in the first 6h after surgery was worse for Group II (P=0.012). IR was verified and did not differ among groups (P>0.05). A decline in the endogenous production of insulin was observed in both groups (P<0.001).
CONCLUSION: Preoperative fasting abbreviation with the administration of CHO in the CABG was safe. The glycemic control improved in the ICU; there was less time in the use of dobutamine and length of hospital and ICU stay was reduced. However, neither IR nor morbimortality during hospital phase were influenced.
Keywords: Myocardial revascularization. Perioperative care. Insulin resistance. Metabolism. Fasting.
Marcos Antonio Cantero; Rui M. S. Almeida; Roberto Galhardo
Rev Bras Cir Cardiovasc 2012;27(1):38-44
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OBJECTIVE: The objective of this study is to compare the immediate results of patients undergoing on-pump versus off-pump coronary artery bypass graft (CABG) surgery.
METHODS: From January 2007 to January 2009, 177 patients underwent CABG, being 92 off-pump and 85 onpump. We evaluated the demographics, preoperative risk factors, preoperative functional class and risk assessment by the EuroSCORE. The postoperative evolution was compared between groups.
RESULTS: The mean number of grafts per patient was 2.48 ± 0.43 in off-pump group and 2.90 ± 0.59 in on-pump group. In the off-pump group, 97.8% of patients received an internal thoracic artery graft, while on-pump group the percentage was 94.1% (P = 0.03). The rate of complete revascularization was similar in both groups. In off-pump group, the circumflex artery was revascularized in 48.9% and 68.2% in the onpump group (P = 0.01). Hospital mortality was 4.3% and 4.7%, respectively in the off-pump group in the on-pump group (P = 0.92). Off-pump group had fewer complications in relation to perioperative myocardial infarction (P = 0.02) and use of intra-aortic balloon pump (P = 0.01).
CONCLUSION: The off-pump CABG is a safe procedure with hospital mortality similar to that observed in on-pump CABG, with lower rates of complications and less need for intra-aortic balloon.
Keywords: Extracorporeal circulation. Cardiopulmonary bypass. Coronary artery disease. Myocardial revascularization.
Antônio Sérgio Cordeiro da Rocha; Felipe José Monassa Pittella; Andrea Rocha de Lorenzo; Valmir Barzan; Alexandre Siciliano Colafranceschi; José Oscar Reis Brito; Marco Antonio de Mattos; Paulo Roberto Dutra da Silva
Rev Bras Cir Cardiovasc 2012;27(1):45-51
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OBJECTIVE: To analyze the results of isolated on-pump coronary artery bypass graft surgery (CABG) in patients >70 years-old in comparison to patients <70 years-old.
METHODS: Patients undergoing isolated CABG were selected for the study. The patients were grouped in G1 (age > 70 years-old) and G2 (age <70 years-old). The endpoints were in-hospital mortality, acute myocardial infarction (AMI), stroke, reexploration for bleeding, intra-aortic balloon for circulatory shock, respiratory complications, acute renal failure, mediastinitis, sepsis, atrial fibrillation, and complete atrioventricular block (CAVB).
RESULTS: 1,033 patients were included, 257 (24.8%) in G1 and 776 (75.2%) in G2. Patients in G1 were more likely to have in-hospital mortality than G2 (8.9% vs. 3.6%, respectively; P=0.001), while the incidence of AMI was similar (5.8% vs. 5.5%; P=0.87) than G2. More patients in G1 had re-exploration for bleeding (12.1% vs. 6.1%; P=0.003). G1 had more incidence of respiratory complications (21.4% vs. 9.1%; P<0.001), mediastinitis (5.1% vs. 1.9%; P=0.013), stroke (3.9% vs. 1.3%; P=0.016), acute renal failure (7.8% vs. 1.3%; P<0.001), sepsis (3.9% vs. 1.9%;P=0.003), atrial fibrillation (15.6% vs. 9.8%; P=0.016), and CAVB (3.5% vs. 1.2%; P=0.023) than G2. There was no significant difference in the use of intra-aortic balloon. In the forward stepwise multivariate logistic regression analysis age > 70-year-old was an independent predictive factor for higher in-hospital mortality (P=0.004), reexploration for bleeding (P=0.002), sepsis (P=0.002), respiratory complications (P<0.001), mediastinitis (P=0.016), stroke (P=0.029), acute renal failure (P<0.001), atrial fibrillation (P=0.021) and CAVB (P=0.031).
CONCLUSION: This study suggests that patients > 70 years-old were at increased risk of death and other complications in the CABG's postoperative period in comparison to younger patients.
Keywords: Mortalidade hospitalar. Myocardial revascularization. Hospital mortality. Postoperative complications. Aged.
Eduardo Lafaiette de Oliveira; Glauco Adrieno Westphal; Marco Fabio Mastroeni
Rev Bras Cir Cardiovasc 2012;27(1):52-60
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OBJECTIVE: To describe the demographic and clinical characteristics and to test their relation to mortality in patients undergoing to coronary artery bypass graft surgery (CABG).
METHODS: It is a retrospective study developed from the medical records of 655 patients undergoing CABG from May 2002 to April 2010.
RESULTS: Hospital mortality was 12.1%. Mortality was significantly (P<0.05) higher in females (17.3%), aged less than 70 years (22.8%), in emergency surgery (36.4%), in cases of readmission to the intensive care unit (ICU) (33.3%), when the stay in the ICU was less than three days (16.3%), undergoing longer cardiopulmonary bypass (CPB) and with more comorbidities (15.4%). Predictor variables of death identified with logistic regression analysis were: female (OR=2.04), age >70 years (OR=2.69), emergency surgery (OR=15.43) and urgency (OR=3.81), performance of CPB (OR=2.19) and re-admission to the ICU (OR=4.33).
CONCLUSION: Variables such as gender, age, type of surgery, readmission to the ICU, ICU stay, comorbidities and time of CPB influence the outcome death in patients undergoing to CABG. Thus, such aspects should be considered to reduce hospital mortality in patients undergoing such surgery.
Keywords: Myocardial revascularization. Coronary artery bypass. Hospital mortality.
Flora Eli Melek; Liz Andréa Villela Baroncini; João Carlos Domingus Repka; Celso Soares Nascimento; Dalton Bertolim Précoma
Rev Bras Cir Cardiovasc 2012;27(1):61-65
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INTRODUCTION: Thiobarbituric acid-reactive substance is a marker of oxidative stress and has cytotoxic and genotoxic actions. C- reactive protein is used to evaluate the acute phase of inflammatory response.
OBJECTIVES: To assess the thiobarbituric acid-reactive substance and C-reactive protein levels during extracorporeal circulation in patients submitted to cardiopulmonary bypass.
METHODS: Twenty-five consecutive surgical patients (16 men and nine women; mean age 61.2 ± 9.7 years) with severe coronary artery disease diagnosed by angiography scheduled for myocardial revascularization surgery with extracorporeal circulation were selected. Blood samples were collected immediately before initializing extracorporeal circulation, T0; in 10 minutes, T10; and in 30 minutes, T30.
RESULTS: The thiobarbituric acid-reactive substance levels increased after extracorporeal circulation (P=0.001), with average values in T0=1.5 ± 0.07; in T10=5.54 ± 0.35; and in T30=3.36 ± 0.29 mmoles/mg of serum protein. The C-reactive protein levels in T0 were negative in all samples; in T10 average was 0.96 ± 0.7 mg/dl; and in T30 average was 0.99 ± 0.76 mg/dl. There were no significant differences between the dosages in T10 and T30 (P=0.83).
CONCLUSIONS: C-reactive protein and thiobarbituric acid-reactive substance plasma levels progressively increased during extracorporeal circulation, with maximum values of thiobarbituric acid-reactive substance at 10 min and of Creactive protein at 30 min. It suggests that there are an inflammatory response and oxidative stress during extracorporeal circulation.
Keywords: Myocardial revascularization. Coronary artery bypass. Systemic inflammatory response syndrome. Inflammation. Inflammation mediators.
Andreia S. A. Cancio; Solange Guizilini; Douglas W. Bolzan; Renato B. Dauar; José E. Succi; Angelo A. V. de Paola; Antonio C. de Camargo Carvalho; Walter J. Gomes
Rev Bras Cir Cardiovasc 2012;27(1):103-109
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OBJECTIVE: To evaluate respiratory muscle strength, oxygenation and chest pain in patients undergoing off-pump coronary artery bypass (OPCAB) using internal thoracic artery grafts comparing pleural drain insertion site at the subxyphoid region versus the lateral region.
METHODS: Forty patients were randomized into two groups in accordance with the pleural drain site. Group II (n = 19) -pleural drain exteriorized in the intercostal space; group (SI) (n = 21) chest tube exteriorized at the subxyphoid region. All patients underwent assessment of respiratory muscle strength (inspiratory and expiratory) on the pre, 1, 3 and 5 postoperative days (POD). Arterial blood gas analysis was collected on the pre and POD1. The chest pain sensation was measured 1, 3 and 5 POD.
RESULTS: A significant decrease in respiratory muscle strength (inspiratory and expiratory) was seen in both groups until POD5 (P <0.05). When compared, the difference between groups remained significant with greater decrease in the II (P <0.05). The blood arterial oxygenation fell in both groups (P <0.05), but the oxygenation was lower in the II (P <0.05). Referred chest pain was higher 1, 3 and 5 POD in the II group (P <0.05). The orotracheal intubation time and postoperative length of hospital stay were higher in the II group (P <0.05).
CONCLUSION: Patients submitted to subxyphoid pleural drainage showed less decrease in respiratory muscle strength, better preservation of blood oxygenation and reduced thoracic pain compared to patients with intercostal drain on early OPCAB postoperative.
Keywords: Myocardial revascularization. Coronary artery bypass, off-pump. Pulmonary gas exchange. Respiratory function tests. Respiratory mechanics.
CASE REPORT
Claudio Ribeiro da Cunha; Paulo César Santos; Fernando Antibas Atik; Daniel Oliveira de Conti
Rev Bras Cir Cardiovasc 2012;27(1):163-166
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We report the case of a 58-year-old patient, with a three vessel disease with unstable angina. Due to refractory angina, she was referred to urgent coronary artery bypass graft (CABG). In the preoperative evaluation were found severe obstructive lesions in the brachiocephalic trunk origin, left common carotid origin and left internal carotid artery. The patient underwent CABG, supra-aortic trunks revascularization (extra-anatomic bypass) and carotid endarterectomy in the same procedure. She presented an uneventful recovery and was discharged home on the seventh postoperative day. Currently, two years after the procedure, she continues under follow-up, symptomless.
Keywords: Angina, unstable. Myocardial revascularization. Carotid stenosis.
BRIEF COMMUNICATION
Rômulo César Arnal Bonini; Vladimir Quiroga Verazain; Ricardo M. Mustafa; Yuri Neumman; Margaret Assad; Henrique E. Issa; Ureliano Cintra; Jair J. Golghetto
Rev Bras Cir Cardiovasc 2012;27(1):155-159
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Patient 75, years-old, with free wall rupture of the right ventricle, corrected with prolene 3.0 points anchored in bovine pericardium patch, promoting the closure of the rupture. The patient was discharged on the 59th day after surgery in good clinical ans laboratorial conditions.
Keywords: Aneurysm, ruptured. Heart rupture, post-infarction/surgery. Myocardial revascularization. Anterior wall myocardial infarction.
SCHEDULE OF MEETINGS/SYMPOSIA AND MEETINGS
Luiz Antônio Brasil; Walter José Gomes; Reinaldo Salomão; Ênio Buffolo
Rev Bras Cir Cardiovasc 1996;11(3):188-200
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Systemic inflammatory response syndrome induced by cardiopulmonary bypass (CPB) is responsible for organ dysfunctions observed in some patients. The tumor necrosis factor-alpha (TNF-α) has been implicated in many clinical manifestations following cardiac operations with CPB, mainly in the vasoplegic syndrome. The purpose of this study was to verify the TNF-α release and its possible effects in patients with coronary atherosclerosis undergoing coronary artery surgery with and without CPB. Twenty patients were studied, 10 with CPB(Group I) and 10 without CPB(Group II). Serial blood samples were obtained during and until 48 hours after surgery in order to measure circulating TNF-α presence (using enzyme-linked immunosorbent assay-ELISA), leukocyte count and erythrocytes sedimentation rate. Hemodynamic parameters as blood pressure and cardiac rate, body temperature, orotracheal tubing time, postoperative bleeding and inotropic drugs requirements were also compared. Statistical significance was assumed when the p value was less than 0.05. Serum levels of TNF-α (limit detection of the assay = 10 pg/mL) were detected in 6 patients from Group I (60%). This cytokine was detected in Group II. The TNF-α peaked soon after the CPB starting and remained detectable 48 hours postoperatively. The patients of Group I had hypotension in relation to Group II (7.4 ± 1.0 vs 8.5 ± 0.67). They also required more inotropic drugs (8 vs 1), had a higher cardiac rate (114.2 ± 8.0 vs 98 ± 10 bpm), hyperthermia (37.17 ± 0.54 vs 36.67 ± 0.35ºC), more postoperative bleeding (820 ± 120 mL vs 360 ± 84 mL), a longer orotracheal tubing time (13.6 ± 2.2 vs 9.3 ± 1.4 horas) and a more pronounced leucocytosis. We concluded that CPB induces the TNF α release and leads hemodynamic and organic alterations that can be deleterious to patients. It may play a role on the pathophysiology of the alterations observed in this study and the inhibition of the TNFα could contribute to minimize these effects.
Keywords: Tumor necrosis factor, blood, cytokine. Myocardial revascularization. Extracorporeal circulation, adverse effects.
ORIGINAL ARTICLE
Fernando Antoniali; Cledicyon Eloy da Costa; Luciano Dos Santos Tarelho; Maurício Marson Lopes; Ana Paula Nunes de Albuquerque; Gleice Agnes Almeida Reinert; Gustavo Calado de Aguiar Ribeiro
Rev Bras Cir Cardiovasc 2005;20(4):382-391
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Objective: To assess the impact of new preventive measures of surgical site infections after coronary artery bypass graft (CABG) surgery.
Method: A retrospective study of 468 patients who underwent CABG surgery with cardiopulmonary bypass was performed. These patients were distributed into two groups: Group A (n=224) and Group B (n=244), respectively before and after a new protocol. The two groups were compared by statistical analysis to determine differences in risk factors, the incidence of sternotomy surgical site infections (superficial and deep), recurrent infections and hospital readmission.
Results: There was a greater use of internal thoracic artery grafts (p=0.003) and a shorter time of mechanical ventilation (p=0.001) in Group B. Surgical site infections occurred in 44 patients of Group A (19.6%); 33 superficial (14.7%) and 11 deep (4.9%) while in Group B only 13 patients had this complication (5.3%); 10 superficial (4.1%) and three deep (1.2%) surgical site infections. Significant improvements were seen in the total number of surgical site infections (p<0.001), of superficial infections (p<0.001) and of deep infections (p=0.037). There were 36.3% and 7.7% of recurrent infections in Groups A and B, respectively (p=0.102). Hospital readmissions due to surgical site infections were 21 in Group A and three in Group B (p<0.001).
Conclusion: The new preventive measures and treatment for surgical site infections after CABG surgery in this series of patients, significantly reduced the incidence of sternotomy surgical site infections and hospital readmissions related to this complication.
Keywords: Infection. Surgical wound infection. Infection control. Cardiac surgical procedures. Myocardial revascularization.
Luís Alberto Oliveira Dallan; Luís Henrique Gowdak; Luiz Augusto Ferreira Lisboa; Isolmar Schettert; José Eduardo Krieger; Luiz Antonio Machado Cesar; Sérgio Almeida de Oliveira; Noedir Antonio Groppo Stolf
Rev Bras Cir Cardiovasc 2008;23(1):46-52
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Objective: We tested the hypothesis that TMLR combined with intramyocardial injection of BMC is safe, and may help increase the functional capacity of patient with refractory angina.
Methods: Nine patients (eight men), 65±5 years old, with refractory angina for multivessel disease and previous myocardial revascularization procedures (CABG/PCI), not candidates for another procedure due to the extension of the disease were enrolled. TMLR (11±3 laser drills) was performed via a limited thoracotomy using a CO
2 Heart Laser System. BMC were obtained immediately prior to surgery, and the lymphomonocytic fraction separated by density gradient centrifugation. During surgery, 5mL containing approximately 1.9±0.3x108 BMC were delivered by multiple injections in the ischemic myocardium. Before (B) and 6 months (6M) after the procedure, patient underwent clinical evaluation and myocardial perfusion assessment by cardiac magnetic resonance imaging (MRI) during pharmacological stress with dypiridamole.
Results: No major complications or deaths occurred during the procedure. One patient died after 2 years (non cardiac cause).There was a reduction in the ischemic score as assessed by MRI from 1.64±0.10 (B) to 0.88±0.09 (6M) (P=0.01). Clinically, there was a reduction in functional class of angina from 3.7±0.2 (B) to 1.3±0.2 (6M) (P<0.0001).
Conclusions: In this initial experience, the combined strategy of TMLR plus cell therapy appeared to be safe, and may have synergistically acted to reduce myocardial ischemia, with clinically relevant improvement in functional capacity. Provided these data are confirmed in a larger, randomized, controlled trial with longer follow-up, this strategy could be used as a novel therapeutic option for treating pt with refractory angina.
Keywords: Angina pectoris. Myocardial ischemia. Stem cells. Laser surgery. Myocardial revascularization. Coronary disease.
Fábio Biscegli Jatene; Pedro C. P Lemos; Adib D Jatene
Rev Bras Cir Cardiovasc 1986;1(1):49-53
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Evaluation of blood flow in saphenous vein grafts during coronary surgery gives valuable information about myocardial perfusion and long-term by- pass patency as well. However, electronic flowmeter availability is a limiting factor because of costs and maintenance. A system was developed consisting of a connection to the arterial line, with a Y tube; one branch of the Y tube is connected to a manometer and the other one to the vein graft. Since the connection to the arterial line has a know diameter, pressure drop in the system is proportional to the flow in the graft. With previous calibration, a chart was constructed that allows instantaneous evaluation of the flow. Another advantage of the system is the selective perfusion of the area to be treated before the conclusion of the proximal anastomosis. This system is being used in our Service; it is efficient and practical.
Keywords: flowmeter, hidro-dynamic. myocardial revascularization.
ORIGINAL WORKS
Luís Roberto Gerola; Luís Antônio Ribeiro de Moura; Ênio Buffolo; Luis Eduardo Villaça Leão; Henrique Caivano Soares; Costabile Gallucci
Rev Bras Cir Cardiovasc 1987;2(1):64-69
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Coronary artery surgery, specially when performed without cardiopulmonary bypass, needs an "atraumatic" method that allows temporary coronary occlusion with minimal injury to the vessel wall. An experimental study was performed using the right coronary artery of cadaver hearts in order to evaluate the methods of "atraumatic" clamping of arteries with variable degrees of atherosclerosis. The vessels were evaluated histologically both for intensity of the atherosclerotic disease and intensity of injury to the coronary artery wall. Results suggest a relationship between severity of coronary artery disease and degree of injury to the artery wall.
Keywords: coronary occlusion. vascular injury. coronary atherosclerosis. myocardial revascularization.
ORIGINAL ARTICLE
Fernando Moraes; Nader Helena; Dietrich Carlos P; Buffolo Ênio
Rev Bras Cir Cardiovasc 1996;11(3):201-207
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In order to quantify seric levels of heparin, its attenuation as a time function and its residual value after neutralization with protamine sulfate, blood samples were collected, at pre-set intervals, from 27 patients undergoing myocardial revascularization surgery under extracorporeal circulation. After heparinization (400 Ul/Kg), blood samples were collected at 5, 10, 30 and 60 minutes and subsequently every 30 minutes depending upon the extracorporeal circulation lenght. At each hour after heparinization, a new heparin dose (200 Ul/Kg) was administered. The samples were kept at 4ºC prior to the heparin extract process, which was performed by physical/chemical method. The dosages showed that 5 minutes after heparinization the patients show maximal blood concentration of heparin and after 60 minutes it is aproximately 68% of the concentration at 5 minutes. At 90 minutes time, that is, after re-heparinization, the concentration of heparin is 96% of the one showed on the fifth minute and after the protamine sulfate neutralization (1.5:1), a residual value corresponding to 4% of the one initially observed is still found. It was observed that older patients have a tendency to keep longer seric heparin level, and heparin concentration at a given time could be estimated by the Equation Heparin - Concentration = 104.7 + (-12.85 x minutes (In) + 0.25 x age).
Keywords: Heparin, blood. Myocardial revascularization. Extracorporeal circulation.
