Volume 28 - Número 2
Authorship in the scientific paper: defining the role of each one
SYNTAX from the evidence to the disobedience
A debt with our nation's health: the case of congenital heart diseases
Doppler echocardiographic criteria in patency assessment of composite grafts from left internal thoracic artery
OBJECTIVES The purpose of our study was to establish, with an entirely noninvasive method, transthoracic Doppler echocardiography, criteria for patency of composite left internal thoracic artery grafts when placed on the left anterior descending artery and other branches of the left coronary system.
METHODS: The control group comprised 20 patients with single graft and 20 patients with composite graft; all forty having their patency confirmed by coronary angiogram (CA). In this control group, two Doppler echocardiographic variables, diastolic mean velocity-time and integral diastolic peak velocity to systolic peak velocity ratio were recorded. For each variable, established cut-off points were established, using the ROC (Receiver Operator Characteristic) curves, to identify criteria which could differentiate the composite grafts. Only patients with composite grafts were included in the 159-patients study group. The criteria established by the cut-off points in the control group were then applied to detect patency using a diastolic fraction of > 0.5 as the gold standard. The sensitivity, specificity, and positive and negative predictive values of these two criteria were determined.
RESULTS: In the control group, cut-off points of 0.71 and 0.09m were established for the diastolic peak velocity/systolic peak velocity ratio and for diastolic mean velocity-time integral, respectively. In the study group phase, the sensitivity and negative predictive value of the diastolic peak velocity/systolic peak velocity > 0.71 criterion were 36% and 11%, respectively. Diastolic mean velocity-time integral > 0.09m criterion, were 40% and 10.48%. The specificities and positive predictive values of each criterion were 100%.
CONCLUSION: Values reaching the criteria established for each variable indicate high probability of composite graft patency. Lower values have a large proportion of false negatives and are not conclusive as patency criteria.
Results of Castro Bernardes intraluminal ring in surgery for ascending aortic aneurysms and dissections
OBJECTIVE: To demonstrate surgical results using Castro Bernardes intraluminal ring in ascending aorta surgery, instead of conventional suture.
METHODS: 95 patients underwent ascending aorta surgery from December 2008 to April 2011 at Madre Tereza Hospital (Belo Horizonte, MG, Brazil), using Castro Bernardes intraluminal ring instead of conventional suture of the aorta.
RESULTS: Ninety five patients underwent ascending aorta surgery with Castro-Bernardes intraluminal ring. Thirty patients presented acute dissection and 65 aneurism. Overall postoperative mortality was 15.78% (15/95). Nine patients in 15 (60%) died due to acute type A dissection. For acute type A dissection, mortality was 30% and for aneurism mortality was 9.23%. The intraluminal ring was inserted in distal position in 89 patients and in proximal and distal position in 6 patients. Mortality was related to Bentall & De Bono or Cabrol associated techniques. Average extracorporeal circulation time was 57.4 minutes and average aortic cross-clamping time was 37 minutes.
CONCLUSION: The use of Castro Bernardes intraluminal ring in ascending aortic surgery avoiding conventional suture reduces extracorporeal circulation time and aortic cross-clamping time, improving surgical results. This approach simplifies ascending aortic surgery whether the disease is type A dissection or aneurysm, and may be considered a good alternative technique.
Impact of autologous blood transfusion on the use of pack of red blood cells in coronary artery bypass grafting surgery
OBJECTIVE: To evaluate the impact of Cell Saver autologous blood transfusion system (CS) on the use of packed red blood cells (pRBC) in coronary artery bypass grafting (CABG) surgery.
METHODS: We carried out a retrospective cross-sectional study in 87 patients undergoing primary elective CABG with miniaturized cardiopulmonary bypass (miniCPB), divided in two groups: 44 without-CS and 43 with-CS. We investigated the necessity of absolute use and the volume of packed red blood cells (pRBC) in each group, as well as cardiovascular risk factors, presurgical variables and intraoperative surgical parameters. All data were collected from medical records and there was no randomization or intervention on group selection. Statistical analysis was performed with Student t-test, Mann-Whitney U-test and χ2 test, with a 5% significance level.
RESULTS: There were no significant differences between the two groups in terms of cardiovascular risk factors and pre and intraoperative variables. Evaluating the absolute use of pRBC during surgery, there was a statistically significant difference (P=0.00008) between the groups without-CS (21/44 cases; 47.7%) and with-CS (4/43 cases; 9.3%). There was also a statistically significant difference (P=0.000117) in the volumes of pRBC between the groups without-CS (198.65±258.65ml) and with-CS (35.06±125.67ml). On the other hand, in the early postoperative period (up to 24h) there was no difference regarding either the absolute use or the volumes of pRBC between both studied groups.
CONCLUSION: Autologous erythrocyte transfusion with CS use reduces the use of intraoperative homologous pRBC in coronary artery bypass grafting surgeries associated with miniCPB.
Reinforced aortic root reconstruction for acute type A aortic dissection involving the aortic root
OBJECTIVE: There are debates regarding the optimal approach for AAAD involving the aortic root. We described a modified reinforced aortic root reconstruction approach for treating AAAD involving the aortic root.
METHODS: A total of 161 patients with AAAD involving the aortic root were treated by our modified reinforced aortic root reconstruction approach from January 1998 to December 2008. Key features of our modified approach were placement of an autologous pericardial patch in the false lumen, lining of the sinotubular junction lumen with a polyester vascular ring, and wrapping of the vessel with Teflon strips. Outcome measures included post-operative mortality, survival, complications, and level of aortic regurgitation.
RESULTS: A total of 161 patients were included in the study (mean age: 43.3 ± 15.5 years). The mean duration of follow-up was 5.1 ± 2.96 years (2-12 years). A total of 10 (6.2%) and 11 (6.8%) patients died during hospitalization and during follow-up, respectively. Thirty-one (19.3%) patients experienced postoperative complications. The 1-, 3-, 5-, and 10-year survival rates were 99.3%, 98%, 93.8%, and 75.5%, respectively. There were no instances of recurrent aortic dissection, aortic aneurysm, or pseudoaneurysm during the entire study period. The severity of aortic regurgitation dramatically decreased immediately after surgery (from 28.6% to 0% grade 3-4) and thereafter slightly increased (from 0% to 7.2% at 5 years and 9.1% at 10 years).
CONCLUSION: This modified reinforced aortic root reconstruction was feasible, safe and durable/effective, as indicated by its low mortality, low postoperative complications and high survival rate.
Mediastinitis: mortality rate comparing single-stage surgical approach and preconditioning of wound
OBJECTIVE: This study aims to compare hospital mortality rate of surgical debridement followed by primary wound closure versus surgical debridement with closure after preconditioning of the wound.
METHODS: A historical cohort of 43 patients with postoperative mediastinitis type III and IV between 2000 and 2008. The diagnosis of mediastinitis was based on physical examination and laboratory tests. Patients were divided into two groups: patients who received the protocol of preconditioning of the wound (Group 2) and those who did not (Group 1).
RESULTS: Of the 43 patients, 15 received the protocol and were assigned to Group 2, and 28 patients to Group 1. Myocardial revascularisation was the surgical intervention most affected by infection, accounting for 69.8% of patients in Group 1 and 64.3% in Group 2.Staphylococcus aureus was the predominant pathogen, accounting for 58.1% of all cases, 50% in Group 1 and 73.3% in Group 2. Hospital mortality rate was 42.9% in Group 1 and 20% in Group 2 (P=1.86), with relative risk of 2.14 and CI [0.714-6.043]. Among the 28 (65.1%) patients who underwent single-stage surgical approach, 12 (27.9%) underwent primary wound closure with irrigation, seven (16.3%) only primary closure, six (14%) omental flap, and three (7%) pectoralis muscle flap.
CONCLUSION: Due to the lack of established guidelines, the choice of the surgical approach is based largely on low-level evidence references. Preconditioning of the wound appears to lead to a reduction in mortality in these patients, being a good surgical option.
Initial and pioneer experience of transcatheter aortic valve implantation (Inovare) through femoral or iliac artery
OBJECTIVE: This paper demonstrates the initial and pioneering experience implant of the Inovare prosthesis implant through transfemoral or iliac artery route.
METHODS: Six patients underwent transcatheter aortic valve implantation. The access was femoral or iliac through which the delivery device, a latex balloon catheter with the crimped prosthesis, was inserted. Through the femoral introducer 24 Fr Gore® DrySeal sheath, an extra stiff guide wire with non-traumatic tip was positioned in the left ventricle by passing through the valve ring. After balloon valvuloplasty, in cases of native valve stenosis, the prosthesis implantation was performed after hypotension induced by tachycardia and controlled by temporary pacemaker. The valve positioning was guided by TEE (transesophageal ecocardiography) and fluoroscopy, aiming to position a third of the length of the prosthesis into the left ventricle cavity.
RESULTS: The successful valve implantation was possible in six cases. There was no need of conversion to open surgery due to inability to access or graft migration. There were no intraoperative or hospital deaths. We observed a significant reduction in the mean gradient of 66.84±15.46 mmHg to 19.74±10.61 mm Hg postoperatively (P=0.002), a reduction of 70.46%.
CONCLUSION: Inovare prosthesis, implanted by femoral or iliac artery was feasible, and determined adequate hemodynamic performance in the postoperative follow-up, showing no mortality in this small series.
Pulsatile stent graft: a new alternative in chronic ventricular assistance
OBJECTIVE: Heart failure is currently one of the most common hospitalization causes. Several chronic circulatory assist devices have been tested and are highly complex. The objective is the description of a pulsatile endoprosthesis capable of applying a chronic pulse within the descending aorta, similar to that produced by intra-aortic balloon.
METHODS: Pulsatile stents composed of nickel-titanium were built and positioned to engage latex tubes simulating the aorta. Different electric currents were applied to units connected in series in order to cause structure contraction and displacement of a liquid column. There were two sequence tests: first composed of two metallic cages and the second composed of five cages. At first sequence tests was applied a voltage of 16.3 volts and a current of 5 amperes. In the second, voltage of 15 volts and current of 07 amperes.
RESULTS: In the first sequence was obtained the pulsatile effect of stent, with contraction of the tube and displacement of the water column sufficient to validate the pulsating effect of the endoprosthesis. The two structures ejected a volume of 2.6 ml per cycle, with a range of 29 mm in height of the column of water equivalent to 8% shrinkage during the pulse. In the second sequence, it reachead a variation of 7.4 mL per cycle.
CONCLUSION: The results obtained confirm the stent pulsatile contractility activated by electrical current. The continuity of the study and material improvement are necessary to obtain more efficient model from the point of view of energy and pulse, to allow ejection volumes comparable with the intra-aortic balloons.
Comparison between the Doppler flowmetry and the free flow of dog's internal thoracic artery with and without use norepinephrine
OBJECTIVE: This work aims to study comparatively the free flow and the Doppler flowmetry of the internal thoracic artery in anesthetized dogs, with and without continuous intravenous administration of norepinephrine.
METHODS: The sample was made up of ten mongrel dogs, which dissected the left and right internal thoracic arteries and evaluated your stream; first, by Doppler flowmetry and then by free flow. The mean arterial pressure and the diameter of the arteries at the beginning of the procedure were registered. The workflow checks by two methods occurred in three times: zero time, 10 and 25 minutes. After the first check in time zero, the continuous infusion of norepinephrine in the right atrium; other checks were made in the same way that the first time, to 10 and 25 minutes, in the same arteries and by two methods, each one in his artery, noting the results, as well as the corresponding average blood pressure.
RESULTS: The results of the flowscan, between Doppler flowmetry and free flow, there were similar; being the first, zero times, ten and twenty-five minutes, respectively, 183, 230.1 and 237 ml/min compared to seconds, 168.6, 226.8 and 226.4 ml/min (P=0.285). The mean arterial pressures of three times and the average diameter of the arteries, showed no statistically significant differences between the methods, so did not influence on the comparison of the results.
CONCLUSION: The evaluations, both from Doppler flowmetry and free flow, were similar in three times checked.
Acute kidney injury after coronary artery bypass grafting: assessment using RIFLE and AKIN criteria
OBJECTIVE: To compare the RIFLE (Risk, Injury, Failure, Loss and End-stage Renal Failure) and AKIN (Acute Kidney Injury Network) criteria for diagnosis of acute kidney injury after coronary artery bypass grafting.
METHODS: Retrospective cohort. 169 patients who underwent coronary artery bypass grafting from January 2007 through December 2008 were analyzed. Information was entered into a database and analyzed using STATA 9.0.
RESULTS: Patients' mean age was 63.43 ± 9.01 years old. Predominantly male patients (66.86%) were studied. Acute Kidney Injury was present in 33.14% by AKIN and in 29.59% by RIFLE. Hemodialysis was required by 3.57% and 4.0% of the patients when AKIN and RIFLE were applied respectively. There was 4.0% and 3.57% mortality of patients with Acute Kidney Injury according to the RIFLE and AKIN criteria, respectively. In 88.76% of the cases, there was good agreement between the two methods in the detection (kappa=0.7380) and stratification (kappa=0.7515) of Acute Kidney Injury.
CONCLUSION: This study showed that the RIFLE and AKIN criteria have a good agreement in the detection and stratification of acute kidney injury after coronary artery bypass grafting.
Cardiovascular prevention in coronary heart disease patients: guidelines implementation in clinical practice
OBJECTIVE: To demonstrate the utilization of a clinical improvement program in stable coronary artery disease patients to increase the evidence-proven treatment utilization, and to describe the ongoing clinical practice and lifestyle change counseling.
METHODS: Cross-sectional study followed by a longitudinal component in which the tools utilization to improve clinical practice was assessed by means of additional cross-sectional data collection. 710 consecutive patients were included (Phase 1). After tools implementation, within 6 months period, 705 patients were included (Phase 2) for comparative analysis. Randomly, 318 patients from Phase 1 were selected, 6-12 months after the first evaluation (Phase 3).
RESULTS: Phase 1 to Phase 2: there were improvement on smoking cessation (P=0.019), dyslipidemia (P<0.001), hypertension and physical activity (P<0.001). There was significant difference on angiotensin converting enzyme inhibitors - ACEI (67.2% vs. 56.8%, P<0.001); angiotensin II receptor blockers - ARB II (25.4% vs. 32.9%, P=0.002) and beta-blocker (88.7% vs. 91.9%, P=0.047). Phase 1 to Phase 3: there was both weight (P=0.044), and blood pressure reduction (P<0.001). There was statistical significant difference on ACEI (64.8% vs. 61.6%, P=0.011) and ARB II (27.0% vs. 31.3%, P=0.035).
CONCLUSION: There was no significant change on the evidence-based pharmacological treatment utilization between pre and post-intervention phases; there was significant improvement concerning smoking and physical activity in phase 2; substantial improvement on blood pressure levels in both comparisons (Phase 1 to 2 and Phase 1 to 3). The inclusion of a case-manager for the process management was crucial for program efficacy. Comprehensive programs for clinical practice should be pursued for longer follow-up period.
Cardiac surgery: the infinite quest. part III - pediatric cardiac surgery: a discipline on its own
Regionalization of Brazilian pediatric cardiovascular surgery
Heart surgery programs innovation using surgical risk stratification at the São Paulo State Public Healthcare System: SP-SCORE-SUS STUDY
Cardiovascular diseases represent the greatest burden of morbidity and mortality for the health system and cardiac surgery has an important impact on their resolutivity. The association and correlation of patients' demographic and clinical relevant information with the resources required for each stratum represent the possibility to adapt, improve and innovate into the healthcare programs. This project aims to remodel the "InsCor" risk score for the formulation of the SP-SCORE (Sao Paulo System for Cardiac Operative Risk Evaluation) in order to better reflects the complexity of cardiac surgical care. The participating hospitals include the Health Technology Assessment Centers in of the Health Secretariat' HTA Network of São Paulo State (HTA-NATSs / SES-SP). The SP-SCORE will use 10 variables of the InsCor model and others 8 variables with presumed influence in Brazil. The primary endpoints are morbidity and mortality. Bootstrap technique besides automated selection of variables (stepwise) will be used to develop a parsimonious model by multiple logistic regression. This project will contribute for the SUS-SP regionalized health-care (RRAS) sustainability and financing of the CABG and/or heart valve surgery programs promoting equitable allocation, increasing access and effectiveness, as well as characterizing the magnitude of available resources and its impact.
Keywords: Morbidity; Database; Risk Factors; Hospital mortality; Cardiovascular surgical proceduresClinical and ultramicroscopic myocardial randomized study of beating versus arrested heart for mitral surgery
INTRODUCTION: Beating heart surgery on normothermic bypass simulates physiologic cardiac status.
OBJECTIVES: This study compared clinical and transmission electron microscopic aspects of myocardial protection during mitral valve replacement using warm retrograde perfusion in empty beating versus arrested heart with cold blood anterograde cardioplegia.
METHODS: Randomized study to evaluate myocardial cellular ischemia-reperfusion of both techniques to replace the mitral valve. Thirty-four patients were randomly assigned into group A (beating heart) and group B (arrested heart). The following parameters were assessed: echocardiography, blood chemistry, hemoglobin, lactate. During the surgical procedure a total of 102 myocardial biopsies were performed for ultrastructural analysis from anterior left ventricular wall: before cardiopulmonary bypass, before aortic desclamping and 10 minutes after reperfusion.
RESULTS: Elevation of lactate at 3 hours during the procedure was higher in group A, but similar at the end of surgery (P=0.06). Cardioversion was necessary in 5/17 (A) vs. 13/17 (B) P=0.07. Median intraoperative systemic temperature was significantly lower in the group B compared to A (32ºC vs. 36ºC), P<0.001. There was no significant difference of the ultramicroscopic aspects of the heart biopsies before, during and after surgery in both groups. Cellular and mitochondrial transient abnormalities such as mitochondrial swelling, glycogen loss and cytosol swelling were detected independently of the moment of the biopsies.
CONCLUSION: Myocardial protection and ultrastructural abnormalities were similar for both types of mitral valve replacement beating or arrested heart techniques.
The use of the virtual reality as intervention tool in the postoperative of cardiac surgery
INTRODUCTION: Cardiac surgery has been the intervention of choice in many cases of cardiovascular diseases. Susceptibility to postoperative complications, cardiac rehabilitation is indicated. Therapeutic resources, such as virtual reality has been helping the rehabilitational process. The aim of the study was to evaluate the use of virtual reality in the functional rehabilitation of patients in the postoperative period.
METHODS: Patients were randomized into two groups, Virtual Reality (VRG, n = 30) and Control (CG, n = 30). The response to treatment was assessed through the functional independence measure (FIM), by the 6-minute walk test (6MWT) and the Nottingham Health Profile (NHP). Evaluations were performed preoperatively and postoperatively.
RESULTS: On the first day after surgery, patients in both groups showed decreased functional performance. However, the VRG showed lower reduction (45.7±2.3) when compared to CG (35.06±2.09, P<0.05) in first postoperative day, and no significant difference in performance on discharge day (P>0.05). In evaluating the NHP field, we observed a significant decrease in pain score at third assessment (P<0.05). These patients also had a higher energy level in the first evaluation (P<0.05). There were no differences with statistical significance for emotional reactions, physical ability, and social interaction. The length of stay was significantly shorter in patients of VRG (9.4±0.5 days vs. 12.2 ± 0.9 days, P<0.05), which also had a higher 6MWD (319.9±19.3 meters vs. 263.5±15.4 meters, P<0.02).
CONCLUSION: Adjunctive treatment with virtual reality demonstrated benefits, with better functional performance in patients undergoing cardiac surgery.
Cardiogenic shock due to coronary artery disease associated with interrupted aortic arch
Acute pulmonary edema is a serious event. Its occurrence in association with interrupted aortic arch and coronary heart disease is rare. Recently, an old patient developed cardiogenic shock and acute pulmonary edema due to acute coronary insufficiency, associated with interrupted aortic arch. The coronary angiography revealed occlusion of the right coronary artery and 95% obstruction in the left main coronary artery, associated with interruption of the descending aorta. Coronary artery bypass graft was performed, without extracorporeal circulation, to the anterior descending coronary artery. We discuss the initial management, given the seriousness of the case.
Keywords: Acute coronary syndrome; Shock, cardiogenic; Aorta, thoracic; CardiomyopathiesExtracorporeal membrane oxygenation as a support for TGA/IVS with low cardiac output syndrome and pulmonary hemorrhage
A 15-day-old neonate with complete transposition of the great arteries/intact ventricular septum was admitted with life-threatening hypoxemia and heart arrest. After successful resuscitation, heart beat recovered but blood lactate began to arise and maintained above 15 mmol/L 6 hours later. Emergency arterial switch operation was done at 20 hours after resuscitation. Planned extracorporeal membrane oxygenation support was employed postoperatively. The baby experienced severe pulmonary hemorrhage and severe hypoxemia after weaning from cardiopulmonary bypass, which were treated with extracorporeal membrane oxygenation support.
Keywords: Extracorporeal membrane oxygenation; Extracorporeal circulation; Transposition of great vessels; Low cardiac output; Cardiopulmonary bypassUse of autologous pericardium for mitral leaflet reconstruction in a child with endocarditis
We present a case of successful repair of the mitral valve for active infective endocarditis. Mitral valve repair was performed through debridement of vegetation and abscess, resection and repair of the posterior mitral leaflet and posterior repair with autologous pericardium. Postoperative period was uneventfully, with no evidence of recurrent infection, and echocardiogram showed mitral valve competence with mild mitral regurgitation. We demonstrate that valve repair is a feasible choice in cases of active endocarditis in children.
Keywords: Endocarditis, subacute bacterial; Child; Mitral valve/surgery; Pericardium