Volume 27 - Número 1

OBJECTIVE: The aim of this study is to evaluate the applicability of GuaragnaSCORE for predicting mortality in patients undergoing heart valve surgery in the Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, PE, Brazil. Methods: Retrospective study involving 491 consecutive patients operated between May/2007 and December/2010. The registers contained all the information used to calculate the score. The outcome of interest was death. Association of model factors with death (univariate analysis and multivariate logistic regression analysis), association of risk score classes with death and accuracy of the model by the area under the ROC (receiver operating characteristic) curve were calculated.
RESULTS: The incidence of death was 15.1%. The nine variables of the score were predictive of perioperative death in both univariate and multivariate analysis. We observed that the higher the risk class of the patient (low, medium, high, very high, extremely high), the greater is the incidence of postoperative AF (0%; 7.2%; 25.5%; 38.5%; 52.4%), showing that the model seems to be a good predictor of risk of postoperative death, in a statistically significant association (P <0.001). The score presented a good accuracy, since the discrimination power of the model in this study according to the ROC curve was 78.1%.
CONCLUSIONS: The Brazilian score proved to be a simple and objective index, revealing a satisfactory predictor of perioperative mortality in patients undergoing heart valve surgery at our institution.

INTRODUCTION: Limited information is available about preoperative fasting abbreviation with administration of liquid enriched with carboidrates (CHO) in cardiovascular surgeries.
OBJECTIVES: To assess 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 400ml (6h before) and 200ml (2h before) of maltodextrin at 12.5% (Group I, n=20) or only water (Group II, n=20) before anesthetic induction. Perioperative clinical variables were assessed. Insulin resistance (IR) was assessed 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 AMI 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.

OBJECTIVE: Corticosteroids decrease side effects after noncardiac elective surgery. A randomized, double blinded, placebo-controlled study was plan to test the hypothesis that standard doses of dexamethasone (6X2) would decrease the incidence of atrial fibrillation (AF) following cardiac surgery.
METHODS: A total of 185 patients undergoing coronary revascularization surgery were enrolled in this clinical study. The anesthetic management was standardized in all patients. Dexamethasone (6 mg/ml) or saline (1 ml) was administered after the induction of anesthesia and a second dose of the same study drug was given on the morning after surgery. The incidence of AF was determined by analyzing the first 72 hours of continuously recorded electrocardiogram records after cardiac surgery, to determine the incidence and severity of postoperative side effects.
RESULTS: The incidence of 48 hours postoperative AF was significantly lower in the Dexamethasone group (21/ 92[37.5%]) than in the placebo group (35/92 [62.5%], adjusted hazard ratio, 2.07; 95% confidence interval, 1.09-3.95 (P<0.05). Compared with placebo, patients receiving dexamethasone did not have higher rates of superficial or deep wound infections, or other major complications.
CONCLUSIONS: Prophylactic short-term dexamethasone administration in patients undergoing coronary artery bypasses grafting significantly reduced postoperative atrial fibrillation.

INTRODUÇÃO: A cirurgia cardíaca minimamente invasiva e videoassistida (CCVA) tem aumentado em popularidade nos últimos 15 anos. As pequenas incisões têm sido associadas a um bom efeito estético e menor trauma cirúrgico, consequentemente, menor dor e rápida recuperação pós-operatória.
OBJETIVOS: Apresentar nossa casuística com CCVA, após 6 anos de uso do método.
MÉTODOS: Cento e trinta e seis pacientes foram submetidos à CCVA, após consentimento escrito, entre setembro de 2005 e outubro de 2011, sendo 50% do sexo masculino, com idade de 47,8 ± 15,4 anos, divididos em dois grupos: com circulação extracorpórea (CEC) (GcCEC=105 pacientes): valvopatia mitral (47/105), valvopatia aórtica (39/105) e cardiopatia congênita (19/105) e sem CEC (GsCEC=31 pacientes): ressincronização cardíaca (18/31), tumor cardíaco (4/31) e revascularização miocárdica minimamente invasiva (6/31). No GcCEC, foi realizada minitoracotomia direita (3 a 5 cm) e acesso femoral para canulação periférica.
RESULTADOS: No GcCEC, a média de dias em UTI (DUTI) e de internação hospitalar (DH) foi, respectivamente, 2,4 ± 4,5 dias e 5,0 ± 6,8 dias. Doze pacientes apresentaram complicações no pós-operatório e cinco (4,8%) foram a óbito. Noventa e três (88,6%) pacientes evoluíram sem intercorrências, foram extubados no centro cirúrgico, permanecendo 1,8 ± 0,9 DUTI e 3,6 ± 1,3 DH. No GsCEC, foram 1,3 ± 0,7 DUTI e 2,9 ± 1,4 DH, sem intercorrências ou óbitos.
CONCLUSÃO: Os resultados encontrados nesta casuística são comparáveis aos da literatura mundial e confirmam o método como opção à técnica convencional.

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. Of these, 92 underwent off-pump CABG and 85 on-pump CABG. We evaluated the demographics, preoperative risk factors, preoperative functional class, and risk assessment by the EuroSCORE. A comparison between both groups regarding the postoperative evolution was carried out as well.
RESULTS: The mean number of grafts per patient was 2.48 ± 0.43 in the off-pump group versus 2.90 ± 0.59 in the on pump group. In the off-pump group, 97.8% of patients received an internal thoracic artery graft, while in the onpump group, the percentage was 94.1% (P = 0.03). The rate of complete revascularization was similar in both groups. In the off-pump group, the circumflex artery (circumflex branch of the left coronary artery) was revascularized in 48.9% of the patients versus 68.2% of the patients in the onpump group (P = 0.01). Hospital mortality was 4.3% for offpump CABG and 4.7% for on-pump CABG (P = 0.92). The 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.

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 assigned into two groups: G1 (age > 70 years old) and G2 (age <70 years old). The endpoints were in-hospital mortality, acute myocardial infarction (AMI), stroke, re-exploration for bleeding, intraaortic balloon pump for circulatory shock, respiratory complications, acute renal failure, mediastinitis, sepsis, atrial fibrillation, and complete atrioventricular block (CAVB).
RESULTS: A total of 1,033 were included in the study: G1 comprised 257 (24.8%) patients G2 776 (75.2%). Patients in G1 were more likely to have in-hospital mortality than in 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) in G2. More patients in G1 had re-exploration for bleeding (12.1% vs. 6.1%; P=0.003). Compared to G2, G1 had more incidences 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). There was no significant difference in the use of the intraaortic balloon pump. In the forward stepwise multivariate logistic regression analysis, age > 70 years was an independent predictive factor for higher in-hospital mortality (P=0.004), re-exploration 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 of age > 70 years were at increased risk of death and other complications in the CABG's postoperative period in comparison to younger patients.

OBJECTIVE: To describe the demographic and clinical characteristics of patients undergoing coronary artery bypass graft surgery (CABG) and to test their relation to mortality.
METHODS: This study was a retrospective medical record review of 655 consecutive patients undergoing CABG from May 2002 to April 2010.
RESULTS: Of the 655 patients, 12.1% died during the hospital stay. Mortality was significantly (p<0.05) higher in females (17.3%), aged < 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 < three days (16.3%), undergoing longer cardiopulmonary bypass (CPB), and with more comorbidities (15.4%). Predictor variables of death identified with logistical 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 readmission to the ICU (OR=4.33).
CONCLUSION: Variables such as female sex, increased age, type of surgery, readmission to the ICU, ICU stay, comorbidities, and duration of CPB influence the outcome death in patients undergoing CABG. Thus, such aspects should be considered to reduce hospital mortality in patients undergoing such surgery.

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.

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].
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.

OBJECTIVES: To evaluate the effects of transcutaneous electric nerve stimulation (TENS) on pain and pulmonary function during the postoperative period after thoracic surgery by performing a systematic review and meta-analysis of randomized trials.
METHODS: The search strategy included MEDLINE, PEDro, Cochrane CENTRAL, EMBASE and LILACS, in addition to a manual search, from inception to August, 2011. Randomized trials were included, comparing TENS associated or not with pharmacological analgesia vs. placebo TENS associated or not with pharmacological analgesia or vs. pharmacological analgesia alone to assess pain (visual analog scale - VAS) and/or pulmonary function represented by forced vital capacity (FVC) in postoperative thoracic surgery patients (pulmonary or cardiac with approach by thoracotomy or sternotomy).
RESULTS: Of the 2.489 articles identified, 11 studies were included. In the approach by thoracotomy, TENS associated with pharmacological analgesia reduced pain compared to the placebo TENS associated with pharmacological analgesia (VAS -1.29; 95%CI: -1.94 to - 0.65). In the approach by sternotomy, TENS associated with pharmacological analgesia also reduced pain compared to the placebo TENS associated with pharmacological analgesia (VAS -1.33; 95%CI: -1.89 to -0.77) and compared to pharmacological analgesia alone (VAS -1.23; 95%CI: -1.79 to -0.67). There was no significant improvement in FVC (0.12 L; 95%CI: 0.27 to 0.51).
CONCLUSION: TENS associated with pharmacological analgesia provides pain relief compared to the placebo TENS in postoperative thoracic surgery patients both approached by thoracotomy and sternotomy. In sternotomy it also provides more effective pain relief compared to pharmacological analgesia alone, but it has no significant effect on pulmonary function.

OBJECTIVE: The aim of this study was to investigate the SDS-based decellularization process as an anticalcification method in glutaraldehyde-preserved bovine pericardium in subcutaneous rat model.
METHODS: Pericardium samples with 0.5 cm² area and divided into four groups: GDA group: 0.5% glutaraldehyde preserved pericardium (GDA); GDA-GL group: GDA + 0.2% glutamic acid (GL); D-GDA group: decellularized (D) pericardium with 0.1% SDS + GDA, and D-GDA-GL group: decellularized pericardium + GDA + 0.2% glutamic acid. Afterwards these samples were implanted in 18 rats in subcutaneous position up to 90 days. Each animal received samples of the four groups. The explants were performed at 45 and 90 days. The explants were subjected to histology in glass slides stained with hematoxilin-eosin and alizarin red, morphometry evaluation and the calcium content was measured by flame atomic absorption spectrometry.
RESULTS: The standard of inflammatory infiltrate was the same in all groups, however more intense in GDA and GDA-GL groups in 45 days, increasing at 90 days. The calcium contents for 45 days were: 32.52 ± 3.19 µg/mg in GDA group; 22.12 ± 3.87 µg/mg in GDA-GL group; 1.06 ± 0.38 µg/mg in D-GDA group and 3.99 ± 5.78 µg/mg in D-GDA-GL (P< 0.001). For 90 days were 65.91 ± 24.67 µg/mg in GDA group; 38.37 ± 13.79 µg/mg in GDA-GL group; 1.24 ± 0.99 µg/mg in D-GDA group and 30.54 ± 8.21 µg/mg in D-GDA-GL (P< 0.001). Only D-GDA did not show increase rates of calcium at 45 to 90 days (P=0.314).
CONCLUSION: SDS-based decellularization process reduced the inflammatory intensity and calcification in bovine pericardium in subcutaneous rat model for 90 days.

OBJECTIVE: To describe our experience with repair of coarctation of the aorta in adults using left heart bypass.
METHODS: From November 2007 to October 2009, eight adult patients with coarctation of the aorta underwent surgical repair under circulatory support using a left atrium to femoral artery bypass circuit, with graft interposition tube through left posterolateral thoracotomy. Five patients were female, with mean age of 31.5 ± 13.1 years. All patients had hypertension and others associated cardiovascular diseases.
RESULTS: There were no deaths or neurological complications. The mean surgical time was 308 minutes with mean left heart bypass and distal aortic clamping time of 73 and 65 minutes respectively. Postoperative bleeding was 696 ml in average. Six patients developed severe hypertension postoperatively requiring intravenous vasodilators. The mean length of stay was 9 days. A significant reduction of gradient blood pressure occurred. Echocardiographic follow-up up to two months postoperatively showed mean aortic / graft gradient of 20.3 mmHg.
CONCLUSION: In this series the use of left heart bypass showed to be a safe option in the surgical correction of coarctation of the aorta in adults, especially in patients with abnormal aortic wall. There was no spinal cord ischemia in the cases studied.

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.

BACKGROUND: There is a growing need to improve myocardial protection, which will lead to better performance of cardiac operations and reduce morbidity and mortality. Therefore, the objective of this study was to compare the efficacy of myocardial protection solution using both intracellular and extracellular crystalloid type regarding the performance of the electrical conduction system, left ventricular contractility and edema, after being subjected to ischemic arrest and reperfusion.
METHODS: Hearts isolated from male Wistar (n=32) rats were prepared using Langendorff method and randomly divided equally into four groups according the cardioprotective solutions used Krebs-Henseleit-Buffer (KHB), Bretschneider-HTK (HTK), St. Thomas-1 (STH-1) and Celsior (CEL). After stabilization with KHB at 37ºC, baseline values (control) were collected for heart rate (HR), left ventricle systolic pressure (LVSP), maximum first derivate of rise left ventricular pressure (+dP/dt), maximum first derivate of fall left ventricular pressure (-dP/dt) and coronary flow (CF). The hearts were then perfused at 10ºC for 5 min and kept for 2 h in static ischemia at 20ºC in each cardioprotective solution. Data evaluation was done using analysis of variance in completely randomized One-Way ANOVA and Tukey's test for multiple comparisons. The level of statistical significance chosen was P<0.05.
RESULTS: HR was restored with all the solutions used. The evaluation of left ventricular contractility (LVSP, +dP/ dt and -dP/dt) showed that treatment with CEL solution was better compared to other solutions. When analyzing the CF, the HTK solution showed better protection against edema.
CONCLUSION: Despite the cardioprotective crystalloid solutions studied are not fully able to suppress the deleterious effects of ischemia and reperfusion in the rat heart, the CEL solution had significantly higher results followed by HTK>KHB>STH-1.

OBJECTIVE: The aim of this study is to evaluate the applicability of a Brazilian score for predicting atrial fibrillation (AF) in patients undergoing heart valve surgery in the Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE (Recife, PE, Brazil).
METHODS: Retrospective study involving 491 consecutive patients operated between May/2007 and December/2010. The registers contained all the information used to calculate the score. The outcome of interest was AF. We calculated association of model factors with AF (univariate analysis and multivariate logistic regression analysis), and association of risk score classes with AF.
RESULTS: The incidence of AF was 31.2%. In multivariate analysis, the four variables of the score were predictors of postoperative AF: age >70 years (OR 6.82; 95%CI 3.34-14.10; P<0.001), mitral valve disease (OR 3.18; 95%CI 1.83-5.20; P<0.001), no use of beta-blocker or discontinuation of its use in the postoperative period (OR 1.63; 95%CI 1.05-2.51; P=0.028), total fluid balance > 1500 ml at first 24 hours (OR 1.92; 95%CI 1.28-2.88; P=0.002). We observed that the higher the risk class of the patient (low, medium, high, very high), the greater is the incidence of postoperative AF (4.2%; 18.1%; 30.8%; 49.2%), showing that the model seems to be a good predictor of risk of postoperative AF, in a statistically significant association (P<0.001).
CONCLUSIONS: The Brazilian score proved to be a simple and objective index, revealing a satisfactory predictor of development of postoperative AF in patients undergoing heart valve surgery at our institution.

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 59^th day after surgery in good clinical ans laboratorial conditions.

A 66-year-old male patient, prior hypertension, a history of orthopnea, palpitations and chest pain of sudden onset, which was diagnosed as spontaneous avulsion of aortic valve commissure and consequent aortic insufficiency progressing to acute left heart failure refractory to medical treatment. The patient underwent early surgical replacement of the aortic valve by a bioprosthesis, and presented satisfactory postoperative course. Currently, four years after the event, he is still in attendance in functional class I.

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.