Volume 27 - Número 4

OBJECTIVE: Remain controversies about the use of cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG). The aim of this study was to evaluate the impact of the 2000 Bernstein Parsonnet (2000BP) and EuroSCORE (EU) for choice CPB in CABG.
METHODS: 1.551 consecutive patients underwent CABG. CPB was used in 1.121 (72.3%) patients. The performance of 2000BP and EU was assessed by calibration, discrimination and correlation tests. For both risk scores, increasing the value of the score and presence of CPB were directly related to a higher risk of death (P<0.05). Therefore with these two variables was constructed a logistic regression model for each risk score, in order to determine in which value of score the presence of CPB increases significantly the risk of death.
RESULTS: The calibration, like the area under the ROC curve for the group with CPB [2000BP=0.80; EU=0.78] and without CPB [2000BP=0.81; EU=0.85] were appropriate. The Spearman correlation for groups with and without CPB was 0.66 (P<0.001) and 0.62 (P<0.001), respectively. Using the 2000BP, for a value>17.75 the presence of CPB increased the chance of death to 7.4 [CI 95% (4.4-12.3), P<0.0001]. With the EU, for a value >4.5 the presence of CPB increased the chance of death to 5.4 [CI 95% (3.3-9), P<0.0001].
CONCLUSION: In decision making, the 2000BP>17.75 or the EU>4.5 guide to identify patients who underwent CABG with CPB increases significantly the chance of death.

OBJECTIVES: Rheumatic fever is a highly prevalent disease in Brazil, and it poses a major public health problem. It is the leading cause of acquired heart disease in childhood and adolescence. The aim of this study was to evaluate the gene expression of ET-3 and its receptors, in replaced rheumatic mitral valves.
METHODS: We studied the gene expression of endothelin-3 (ET-3) and its receptors, endothelin receptor A and endothelin receptor B (ETr-A and ETr-B), in the rheumatic mitral valves of 17 patients who underwent valve replacement surgery. The samples also underwent a histological analysis.
RESULTS: Our data showed that almost all patients, regardless of individual characteristics such as gender or age, expressed the endothelin receptor genes, but did not express the genes for ET-3. In quantitative analysis, the ETr-A/GAPDH mean ratio was 33.04 ± 18.09%; while the ETr-B/GAPDH mean ratio was 114.58 ± 42.30%. Regarding histopathological individual features, the frequency of fibrosis is 100%, 88.23% of mononuclear infiltrate, 52.94% of neovascularization, 58.82% of calcification and absence of ossification.
CONCLUSION: The presence of receptors ETr-A and ETr-B in rheumatic mitral valves suggests its interaction with the system of circulating endothelins, particularly ETr-B (known for acting in the removal of excess endothelin) detected in a greater proportion, which could explain the lack of expression of endothelin in rheumatic mitral valve, process to be elucidated.

OBJECTIVE: To determine independent predictors of prolonged mechanical ventilation in patients undergoing coronary artery bypass graft surgery.
METHODS: Data of patients undergoing coronary artery bypass graft surgery were included prospectively from July 2009 to July 2010. All data were input into an electronic database. The resulting cohort included a total of 2952 patients of which 77 remained more than 48 hours on mechanical ventilation. Patients were divided into two groups: 1) a prolonged ventilation group, needing mechanical ventilation for more than 48 hours and 2) not prolonged ventilation group, undergoing a successful extubation within 48 hours.
RESULTS: After adjustment for confounding factors a multivariate analysis identified the following factors as independent predictors of prolonged mechanical ventilation: age (OR 1.06 95% CI 1.03 -1.09; P <0.001), chronic renal failure (OR 3.52 95% CI 1.84 - 6.74; P <0.001), chronic obstructive pulmonary disease (OR 2.65 95% CI 1.38 -5.09; P = 0.004), coronary artery bypass graft associated with other procedures (OR 3.33 95 % CI 1.89 - 5.58; P <0.001) and clamping time (OR 1.01 95% CI 1.00 -1.02; P = 0.018).
CONCLUSION: The identification of these predictors allows the development of preventive strategies that could reduce invasive ventilation time, since patients on prolonged mechanical ventilation present greater morbidity and mortality rates.

INTRODUCTION: Surgical treatment of congenital heart disease in adults showed a significant growth in recent years. But even so, the number of patients who reach adulthood without adequate surgical treatment remains high.
OBJECTIVE: To demonstrate the results and hospital diagnoses of adult patients with congenital heart disease underwent the first surgery.
METHODS: A retrospective analysis of records of patients operated for correction of congenital heart disease and age greater than or equal to 18 years. The exclusion criterium was surgery for reoperation. Period analyzed was from December 2007 to December 2010 with inclusion of 79 patients.
RESULTS: The atrial septal defects were the most prevalent (53.1%), followed by VSD (15.2%), the coarctation (6.3%) and partial atrioventricular canal (6.3%). Thirteen (16.4%) patients had associated disease acquired and 14 (17.7%) congenital disease. Complications occurred in 18 (22.8%) patients, with infections being the most common. The average hospital stay in ICU and hospital were 3.9 and 14.5 days, respectively. Thirty-three (41.8%) patients had pulmonary hypertension. The hospital mortality was two (2.5%) patients.
CONCLUSION: The treatment of congenital heart disease in adults as first surgery has very favorable results. However, in our series, there was an increased length of stay in ICU and hospital.

INTRODUCTION: Extracorporeal circulation (EC) is very important in cardiac surgery but causes significant damage to the blood, including hemolysis.
OBJECTIVE: To quantify the rate of hemolysis at different times during EC in elective coronary artery bypass grafting.
METHODS: We measured rates of hemolysis of 22 patients at 6 different times during myocardial revascularization during EC: T0 - before the start of EC, T1 - five minutes after of the EC initiation, T2 - 30 minutes of EC, T3 - immediately before the aortic unclamping, T4 - immediately before passage of the residual volume to the patient and T5 - five minutes after the passage of the residual volume to the patient. Rates of hemolysis were calculated between the intervals of time: T0-T1; T1-T2; T2-T3; T3-T4 and T4-T5.
RESULTS: The first 5 minutes after the EC showed the highest rate of hemolysis (P = 0.0003) compared to the others calculated rates, representing 29% of the total haemolysis until T4 (Immediately before passage of the residual volume to the patient).
CONCLUSION: There were no significant changes in the rate of hemolysis during the suction in the aortic root (P> 0.38), nor with the procedure used for the passage of the residual volume of blood in the circuit to the patient.

OBJECTIVE: To analyze the functional and anatomical-pathological effect of transplantation of bone marrow mononuclear cells associated to aquatic physical activity after myocardial infarction in rats.
METHODS: Twenty-one rats were induced by myocardial infarction, through left coronary artery ligation. After a week, the animals were subjected to echocardiography for evaluation of left ventricle ejection fraction (LVEF, %) and dyastolic and end systolic volume of the left ventricle (EDV, ESV, ml), randomized and the transplantation of mononuclear stem cells. The animals were divided into four groups: sedentary group without cells (n=5), sedentary with cells (n=5), trained without cells (n=5) and trained with cells (n=6). The physical training was started 30 days after infarction and held in swimming during 30 days. At the beginning and at the end of the physical training protocol were held assay of lactate. The animals have been subjected to new echocardiography after 60 days of myocardial infarction.
RESULTS: Two months after the transplant, were observed decrease in FE in the control group (35.2 to 23.54 P=0.022) and addition of LVEF and stabilization of ventricular remodeling in the group trained with cells (29.85 to 33.43% P=0.062 and 0.71 to 0.73 ml, P=0.776, respectively). Identified the reduction of collagen fibers, myocardial fibrosis regions in the group trained with and without cells.
CONCLUSION: The group trained with cells improves ventricular function compared to the control group, suggesting the benefit of associated cell therapy will physical activity.

OBJECTIVE: Right ventricular (RV) failure during left ventricular assist device (LVAD) support can result in severe hemodynamic compromise with high mortality. This study investigated the acute effects of cavo-pulmonary anastomosis on LVAD performance and RV myocardial compromise in comparison with biventricular circulatory support, in a model of biventricular failure.
METHODS: LVAD support was performed by centrifugal pump in 21 pigs with severe biventricular failure obtained by FV induction. Animals were randomized to be submitted to cavo-pulmonary anastomosis, to biventricular circulatory support or to control group. They were maintained under circulatory support and hemodynamic monitoring for 3h. Venous lactate and cytokines serum levels were also obtained. Endocardium samples were analyzed by electronic microscopy.
RESULTS: FV maintenance was responsible for acute LVAD impairment after 180 min in the control group. cavo-pulmonary anastomosis resulted in non-significant improvement of LVAD pump flow in relation to control group (+55±14 ml/kg/min, P=0.072), while animals under biventricular support maintained higher LVAD flow (+93±17 ml/kg/min, P=0.012). Mean arterial pressure remained constant only in biventricular group (P<0.001), which also presented decrease of right atrial and ventricular pressures. Similar increases in lactate and cytokines levels were observed in the three groups. Ultra-structural analysis documented low levels of myocardial swelling in the biventricular group (P=0.017).
CONCLUSION: The concomitant use of cavo-pulmonary anastomosis during LVAD support in a pig model of severe biventricular failure resulted in non-significant improvement of hemodynamic performance and it did not effectively replace the use of biventricular support.

OBJECTIVE: To evaluate patient with cardiomyopathy's progress after cardiac transplant, by analyzing his survival, complications and cardiovascular responses after nearly four years of surgery.
METHODS: The survey was conducted from February to May 2011, with patients undergoing cardiac transplantation at Dr. Carlos Alberto Studart Gomes Hospital - Messejana Hospital (HDM). The sample consisted of all transplanted patients in 2007 in this hospital. Initially an evaluation form developed by the researchers, which was based on collected data from patients' medical records, was applied, about trans and postoperative period. After collecting these informations, patients underwent the six-minute walk test (6WT). The marks found in walking distance were compared with reference marks expected for this population by using Enright and Sherrill's equation.
RESULTS: From all the 24 patients who underwent cardiac transplantation in HDM in 2007, 14 were evaluated and 10 were excluded. Regarding the complications, in the trans-operatory period, the most evident was the right ventricular dysfunction (64.3%) and tachycardia (64.3%) was more evident on the postoperative period. Analyzing the 6WT it was observed a decrease of 11.6% in walking distance when compared with the estimated distance (486 ± 55 m, 550 ± 59 m, respectively).
CONCLUSION: Survival of heart transplant patients was equivalent to about 70%. The results of this study before the 6WT showed that patients' cardiovascular responses are below the estimated, nevertheless within the normal range established.

OBJECTIVES: To demonstrate the use of minimally invasive surgery for aortic valve replacement and compare your results with the traditional method.
METHODS: Between 2006 and 2011 sixty patients underwent surgery on aortic valve, after written consent, these 40 by minimally invasive technique with right anterior minithoracotomy access (Group 1/G1) and 20 by median sternotomy (Group 2/G2). Compare the operating times and postoperative evolution intra-hospital.
RESULTS: The average times of bypass and aortic crossclamp in G1 were, respectively, 142.7 ± 59.5 min and 88.6 ± 31.5 min and, in G2, 98.1 ± 39.1 min and 67.7 ± 26.2 min (P < 0.05), a difference in medians of 39 minutes in bypass time and 23 minutes in aortic cross-clamp were observed in favour of conventional technique. The blood loss by the thoracic drains was significantly lower in the Group: minimally invasive 605.1 ± 679.5 ml (G1) versus 1617 ± 1390 ml (G2) (P < 0.05).The average time of ICU and hospital stay were shorter in G1: 2.3 ± 1.8 and 5.5 ± 5.4 days versus 5.1 ± 3.6 and 10 ± 5.1 in G2 (P < 0.05), respectively. Vasoactive drug use was also less post-operative at 12.8% in minimally invasive group G1 versus 45% in G2.
CONCLUSION: Aortic valve replacement through minimally invasive techniques, although intraoperative times larger, not demonstrate affect postoperative results that this case proved best when compared to the traditional approach.

OBJECTIVE: Study designed to identify characteristics of patients related to increased hospital mortality after valve replacement, assumed as risk factors.
METHODS: Retrospective study including 808 patients submitted to the implant of St. Jude Biocor porcine bioprosthesis between 1994 and 2009 at Instituto de Cardiologia do Rio Grande do Sul. Primary outcome was hospital death and hospital mortality was related to demographic and surgical characteristics. Statistics include t-test, qui-square test and logistical regression analysis.
RESULTS: There were 80 (9.9%) hospital deaths. Risk factors identified with univariable logistical analysis (and respective odds-ratio) were: tricuspid surgery (OR 6.11); mitral valve replacement (OR 3.98); left ventricular ejection fraction < 30% (OR 3.82); diabetes mellitus (OR 2.55); atrial fibrillation (OR 2.32); pulmonary arterial hypertension (OR 2.30); serum creatinine > 1,4 mg/dL (OR 2.28); previous cardiac surgery (OR 2.17); systemic arterial hypertension (OR 1.93); functional class III e IV (OR 1.92); coronary bypass (OR 1.81); age > 70 years-old (OR 1.80); congestive heart failure (OR 1.73); e female gender (OR 1.68). Multivariable logistic regression for independent factors identified preponderant risk factors mitral valve replacement (OR 5,29); tricuspid surgery (OR 3.07); diabetes mellitus (OR 2.72); age > 70 years-old (OR 2.62); coronary bypass (OR 2.43); previous cardiac surgery (OR 1.82); e systemic arterial hypertension (OR 1.79).
CONCLUSIONS: Mortality rate is within values found in literature. Identification of risk factors could contribute to changes in surgical indication and medical management in order to reduce hospital mortality.

OBJECTIVE: Glutaraldehyde is currently used in bovine pericardium bioprosthesis to improve mechanical and immunogenic properties. Lyophilization is a process that may decrease aldehyde residues in the glutaraldehyde treated pericardium decreasing cytotoxicity and enhancing resistance to calcification. The aim of this study is to evaluate bioprosthetic heart valves calcification in adolescent sheep and to study the potential of lyophilization as a mechanism to protect calcification.
METHODS: Two groups were evaluated: a control group in which a bovine pericardium prosthetic valve was implanted in pulmonary position and a lyophilized group in which the bovine pericardium prosthetic valve was lyophilized and further implanted. Sixteen sheeps 6 months old were submitted to the operation procedure. After 3 months the sheeps were euthanized under full anesthesia.
RESULTS: Six animals of the control group reached 95.16 ± 3.55 days and six animals in the lyophilized group reached 91.66 ± 0.81 days of postoperative evolution. Two animals had endocarditis. Right ventricle/pulmonary artery (RV/PA) mean gradient, in the control group, at the implantation was 2.04 ± 1.56 mmHg, in the lyophilization group, the RV/PA mean gradient, at the implantation was 6.61 ± 4.03 mmHg. At the explantation it increased to 7.71 ± 3.92 mmHg and 8.24 ± 6.25 mmHg, respectively, in control and lyophilization group. The average calcium content, after 3 months, in the control group was 21.6 ± 39.12 µg Ca+2/mg dry weight, compared with an average content of 41.19 ± 46.85 µg Ca+2/mg dry weight in the lyophilization group (P=0.662).
CONCLUSION: Freeze drying of the bovine pericardium prosthesis in the pulmonary position could not demonstrate calcification mitigation over a 3 month period although decreased inflammatory infiltration over the tissue.

INTRODUCTION: Diabetes is a well known risk factor for early and late adverse outcomes in patients undergoing coronary artery bypass graft surgery (CABG); however, few studies have investigated the impact of this risk factor in the group of older patients, especially octogenarians.
OBJECTIVES: To compare in-hospital mortality and morbidity of diabetic and nondiabetic patients aged > 80 years submitted to CABG.
METHODS: A total of 140 consecutive cases were studied, of whom 37 (26.4%) were diabetics, in a retrospective cross-sectional study, that included all patients aged > 80 years submitted to isolated/associated CABG. The patients' mean age was 82.5 ± 2.2 years and 55.7% were males.
RESULTS: The hospital mortality rate did not significantly differ in multivariate analysis: 16.2% diabetic x 13.6% nondiabetic (P = 0.554), as well as morbidity: 43.2% x 37.9%, respectively (P = 0.533). Regarding to operative morbidity, the occurrence of stroke was significantly higher in diabetic patients in the univariate analysis (10.8% x 1.9%, P = 0.042). In multivariate analysis, however, the incidence of stroke was not associated with the presence of diabetes (P = 0.085), but it was associated with atrial fibrillation (P = 0.044). There was no significant difference related to other complications.
CONCLUSION: In this small consecutive retrospectively analyzed series, there was no significant increase in hospital mortality and morbidity related to diabetes for CABG in octogenarian patients. The impact of the results of this study is limited by the sample size and might be confirmed by future randomized clinical trials.

OBJECTIVE: The objective of this study was to evaluate and correlate inspiratory muscle strength using maximal inspiratory pressure (MIP) and sniff nasal inspiratory pressure (Pnsn) in patients with coronary artery disease in pre- and postoperative of myocardial revascularization surgery.
METHODS: Thirty-eight men were studied, divided into a control group (CG) comprised of healthy individuals (n=18), age 55.52 ± 7.8 years and a myocardial revascularization group (MRG), comprised of patients with coronary artery disease submitted to myocardial revascularization (n=20), age 58.44 ± 9.3 years. All volunteers were submitted to MIP and Pnsn measurement, and the MRG was evaluated in the preoperative period and on the first postoperative day (PO1).
RESULTS: MRG presented MIP (80.60 ± 26.60 cmH₂O) and Pnsn (74.70 ± 31.80 cmH₂O) values inferior to CG (MIP: 112.22 ± 32.00 cmH₂O; Pnsn: 103.70 ± 34.10 cmH₂O), and there was significant reduction of these values on PO1 (MIP: 40.05 ± 15.70 cmH₂O; Pnsn: 40.05 ± 16.60 cmH₂O). There was correlation and concordance between evaluation methods in both groups studied, as well as in pre- and postoperative MRG conditions.
CONCLUSIONS: The results showed that the studied patients presented reduced MIP and Pnsn pre- and post-operative myocardial revascularization. Also, the Pnsn correlated with MIP and can be considered suitable for assessing inspiratory muscle strength in this population.

OBJECTIVES: The present investigation aimed to study the protective effect of intermittent normothermic cardioplegia in rabbit's hypertrophic hearts.
METHODS: The parameters chosen were 1) the ratio heart weight / body weight, 2) the myocardial glycogen levels, 3) ultrastructural changes of light and electron microscopy, and 4) mitochondrial respiration.
RESULTS: 1) The experimental model, coarctation of the aorta induced left ventricular hypertrophy; 2) the temporal evolution of the glycogen levels in hypertrophic myocardium demonstrates that there is a significant decrease; 3) It was observed a time-dependent trend of higher oxygen consumption values in the hypertrophic group; 4) there was a significant time-dependent decrease in the respiratory coefficient rate in the hypertrophic group; 5) the stoichiometries values of the ADP: O2 revealed the downward trend of the values of the hypertrophic group; 6) It was possible to observe damaged mitochondria from hypertrophic myocardium emphasizing the large heterogeneity of data.
CONCLUSION: The acquisition of biochemical data, especially the increase in speed of glycogen breakdown, when anatomical changes are not detected, represents an important result even when considering all the difficulties inherent in the process of translating experimental results into clinical practice. With regard to the adopted methods, it is clear that morphometric methods are less specific. Otherwise, the biochemical data allow detecting alterations of glycogen concentrations and mitochondria respiration before the morphometric alterations should be detected

BACKGROUND: Most recent published meta-analysis of randomized controlled trials (RCTs) showed that off-pump coronary artery bypass graft surgery (CABG) reduces incidence of stroke by 30% compared with on-pump CABG, but showed no difference in other outcomes. New RCTs were published, indicating need of new meta-analysis to investigate pooled results adding these further studies.
METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for RCTs that compared outcomes (30-day mortality for all-cause, myocardial infarction or stroke) between off-pump versus on-pump CABG until May 2012. The principal summary measures were relative risk (RR) with 95% Confidence Interval (CI) and P values (considered statistically significant when <0.05). The RR's were combined across studies using DerSimonian-Laird random effects weighted model. Meta-analysis and meta-regression were completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, New Jersey, USA).
RESULTS: Forty-seven RCTs were identified and included 13,524 patients (6,758 for off-pump and 6,766 for on-pump CABG). There was no significant difference between off-pump and on-pump CABG groups in RR for 30-day mortality or myocardial infarction, but there was difference about stroke in favor to off-pump CABG (RR 0.793, 95% CI 0.660-0.920, P=0.049). It was observed no important heterogeneity of effects about any outcome, but it was observed publication bias about outcome "stroke". Meta-regression did not demonstrate influence of female gender, number of grafts or age in outcomes.
CONCLUSION: Off-pump CABG reduces the incidence of post-operative stroke by 20.7% and has no substantial effect on mortality or myocardial infarction in comparison to on-pump CABG. Patient gender, number of grafts performed and age do not seem to explain the effect of off-pump CABG on mortality, myocardial infarction or stroke, respectively.

The need for a new surgical procedure for correction of postoperative pseudoaneurysm of aortic coarctation makes the procedure especially challenging for the surgeon.ta abstract

Aortic dissection type A has a great mortality in its acute phase with low annual survival without surgical treatment. Although the chronic cases are exceptions the late complications exist and should be treated.

The positioning of the internal thoracic artery extra-pleural and perihilar in coronary artery bypass grafting to avoiding anterior aderences and prevent unnecessary damage arterial.