Volume 30 - Issue 6

OBJECTIVE: The present study consisted of patients who underwent on-pump coronary artery bypass grafting (CABG) and off-pump CABG and investigated effect of using cardiopulmonary bypass (CPB) on the amount of postoperative drainage and blood products, red blood cell (RBC), free frozen plasma (FFP) given in the intensive care unit in 60-80-year-old patients who underwent CABG.
METHODS: The present study comprises a total of 174 patients who have undergone coronary artery bypass graft (off-pump or on-pump CABG) surgery in our clinic in between 2012-2015 year.
RESULTS: It was observed that the amount of drainage in the first 24 postoperative hours was lower in the on-pump CABG group (Group 1) when compared to off-pump group (Group 2) (Group 1 vs. Group 2; 703.5±253.8 ml vs. 719.6±209.4 ml; P=0.716). However, the amount of drainage in the second 24 hours was statistically significantly lower in the off-pump CABG group (Group 1 vs. Group 2; 259.8±170.6 ml vs. 190.1±129.1 ml; P=0.016). With regard to the amount of overall drainage, no statistically significant difference was observed between the two groups. Group 1 needed RBC transfusion higher than Group 2 (Group 1 vs. Group 2; 2.2±1.3 bag vs. 1.2±0.9 bag; P<0.001).
CONCLUSION: We can say that CPB influences the amount of second 24-hour drainage which indexed body surface area. In addition, CPB decreases hct, hb, thrombocyte count in ICU arrived, after 24 hours in postoperative period. Reduced thrombocyte counting effect can be appeared after 48 hours in the postoperative period of CPB.

OBJECTIVE: To test several weaning predictors as determinants of successful extubation after elective cardiac surgery.
METHODS: The study was conducted at a tertiary hospital with 100 adult patients undergoing elective cardiac surgery from September to December 2014. We recorded demographic, clinical and surgical data, plus the following predictive indexes: static compliance (Cstat), tidal volume (Vt), respiratory rate (f), f/ Vt ratio, arterial partial oxygen pressure to fraction of inspired oxygen ratio (PaO₂/FiO₂), and the integrative weaning index (IWI). Extubation was considered successful when there was no need for reintubation within 48 hours. Sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were used to evaluate each index.
RESULTS: The majority of the patients were male (60%), with mean age of 55.4±14.9 years and low risk of death (62%), according to InsCor. All of the patients were successfully extubated. Tobin Index presented the highest SE (0.99) and LR+ (0.99), followed by IWI (SE=0.98; LR+ =0.98). Other scores, such as SP, NPV and LR-were nullified due to lack of extubation failure.
CONCLUSION: All of the weaning predictors tested in this sample of patients submitted to elective cardiac surgery showed high sensitivity, highlighting f/Vt and IWI.

INTRODUCTION: Numerous studies have shown that women undergoing coronary artery bypass graft surgery present higher mortality rate during hospitalization, and often complications when compared to men.
OBJECTIVE: To compare the mortality of men and women undergoing coronary artery bypass graft surgery and identify factors related to differences occasionally found.
METHODS: Retrospective cohort study conducted with 215 consecutive patients who underwent coronary bypass surgery.
RESULTS: Women had a higher average age. Low body surface and dyslipidemia were more prevalent in women (1.65 vs. 1.85, P<0.001: 53% vs. 30%, P=0.001), whereas history of smoking and previous myocardial infarction were more prevalent in men (35% vs.14.7%, P=0.001; 20% vs. 2.7%, P=0.007). Regarding complications in the postoperative period, there was a higher rate of blood transfusions in women. The overall mortality rate was 5.6%, however there was no statistically significant difference in mortality between men and women. It was observed that among the patients who died, the average body surface area was lower than that of patients who did not have this complication.
CONCLUSION: There was no difference in mortality between the sexes after coronary artery bypass graft in this service.

OBJECTIVE: To compare the efficacy of a cycle ergometer-based exercise program to a standard protocol on the increment of the maximum distance walked during the six-minute walk test in the postoperative rehabilitation of patients submitted to coronary artery bypass grafting.
METHODS: A controlled clinical trial pilot, blinded to the outcome, enrolled subjects who underwent coronary artery bypass grafting in a hospital from Southern Brazil. Subjects were designated for the standard physical rehabilitation protocol or to an alternative cycle ergometer-based protocol through simple random sampling. The primary outcome was the difference in the maximum distance walked in the six-minute walk test before and after the allocated intervention.
RESULTS: Twenty-four patients were included in the analysis, 10 in the standard protocol and 14 in the alternative protocol group. There was an increment in the maximum distance walked in both groups, and borderline superiority in the intervention group comparing to the control group (312.2 vs. 249.7; P=0.06).
CONCLUSION: There was an increase in the maximum distance walked in the alternative protocol compared to the standard protocol. Thus, it is postulated that the use of a cycle ergometer can be included in physical rehabilitation in the hospital phase of postoperative coronary artery bypass grafting. However, randomized studies with larger sample size should be conducted to assess the significance of these findings.

OBJECTIVE: To evaluate the effects of resistance exercise applied early after coronary artery bypass grafting.
METHODS: It is a randomized controlled trial with 34 patients undergoing coronary artery bypass grafting between August 2013 and May 2014. Patients were randomized into two groups by simple draw: a control group (n=17), who received conventional physical therapy and an intervention group (n=17), who received, additionally, resistance exercise. Pulmonary function and functional capacity were evaluated in preoperative period and hospital discharge by spirometry and the six-minute walk test. For statistical analysis, we used the following tests: Shapiro-Wilk, Mann-Whitney, Student's t and Fisher's exact. Variables with P<0.05 were considered significant.
RESULTS: Groups were homogeneous in terms of demographic, clinical and surgical variables. Resistance exercise exerted no effect on pulmonary function of intervention group compared to control group. However, intervention group maintained functional capacity at hospital discharge measured by percentage of predict distance in 6MWT (54.1±22.7% vs. 52.5±15.5%, P=0.42), while control group had a significant decrease (59.2±11.1% vs. 50.6±9.9%, P<0.016).
CONCLUSION: Our results indicate that resistance exercise, applied early, may promote maintenance of functional capacity on coronary artery bypass grafting patients, having no impact on pulmonary function when compared to conventional physical therapy.

INTRODUCTION: The elderly population is growing rapidly. Political and socio-economic changes led to the demographic transition in this population with the highest number of surgeries and as well as many comorbidities.
OBJECTIVE: To evaluate the impact of cardiovascular intervention on quality of life of elderly patients after three and six months.
METHODS: Analytical prospective cohort study with elderly between 60 and 80 years of age, of both sexes, with a diagnosis of coronary artery disease and underwent cardiovascular intervention during the period June 2010 to June 2011. Data were collected by individual interviews in the pre and postoperative periods (after three and six months) by telephone. We used the SF-36 to analyse quality of life in order to assess the physical and mental health of the study population.
RESULTS: Of the 44 individuals evaluated, 59.1% were men, 75% in the range of 65 to 74 years, 38.6% were white and 38.6% were black, 31.8% were uneducated, 43.2% were married and 68.2% had less than a minimum wage. Prevailed patients: non-diabetics (68.2%), non-obese (81.8%), hypertensive (84.1%), non-alcoholic and non-smokers (68.2% and 61.4%, respectively). A significant increase in the average of the SF-36 scores between pre and post-surgical periods (three and six months) for the domains: functional capacity, pain, general health, vitality and emotional aspect.
CONCLUSION: The elderly population undergoing intervention may have cardiovascular benefits and improvements of quality of life. Physical fitness improvement measures can be taken to resume that capability.

OBJECTIVE: The aim of this study was to identify factors associated with intubation time and intensive care unit stay after coronary artery bypass grafting with cardiopulmonary bypass.
METHODS: This was a retrospective study, whose data collection was performed in the hospital charts of 160 patients over 18 years, who underwent surgery from September 2009 to July of 2013 in a hospital in the state of Espirito Santo, Brazil.
RESULTS: The mean age of the subjects was 61.44±8.93 years old and 68.8% were male. Subjects had a mean of 5.17±8.42 days of intensive care unit stay and mean intubation time of 10.99±8.41 hours. We observed statistically significant positive correlation between the following variables: patients' age and intubation time; patients' age and intensive care unit stay; intubation time and intensive care unit stay.
CONCLUSION: In conclusion, the study showed that older patients had longer intubation time and increased intensive care unit stay. Furthermore, patients with longer intubation time had increased intensive care unit stay.

Surgical ablation, concomitant with other operations, is an option for treatment in patients with chronic atrial fibrillation. The aim of this study is to present a literature review on surgical ablation of atrial fibrillation in patients undergoing cardiac surgery, considering energy sources and return to sinus rhythm. A comprehensive survey was performed in the literature on surgical ablation of atrial fibrillation considering energy sources, sample size, study type, outcome (early and late), and return to sinus rhythm. Analyzing studies with immediate results (n=5), the percentage of return to sinus rhythm ranged from 73% to 96%, while those with long-term results (n=20) (from 12 months on) ranged from 62% to 97.7%. In both of them, there was subsequent clinical improvement of patients who underwent ablation, regardless of the energy source used. Surgical ablation of atrial fibrillation is essential for the treatment of this arrhythmia. With current technology, it may be minimally invasive, making it mandatory to perform a procedure in an attempt to revert to sinus rhythm in patients requiring heart surgery.

α-smooth muscle actin, encoded by ACTA2 gene, is an isoform of the vascular smooth muscle actins, typically expressed in the vascular smooth muscle cells contributing to vascular motility and contraction. ACTA2 gene mutations cause a diversity of diffuse vasculopathies such as thoracic aortic aneurysms and dissections as well as occlusive vascular diseases, including premature coronary artery disease and ischemic stroke. Dynamics of differentiation-specific α-smooth muscle actin in arterial smooth muscle cells and proliferation of the proteins have been well described. Although a variety of research works have been undertaken in terms of modifications of α-smooth muscle actin and mutations of ACTA2 gene and myosin, the underlying mechanisms towards the pathological processes by way of gene mutations are yet to be clarified. The purpose of the present article is to describe the phenotypes of α-smooth muscle actin and implications of ACTA2 mutations in vasculopathies in order to enhance the understanding of potential mechanisms of aortic and coronary disorders.

INTRODUCTION: Despite the patient and medical staff exposure to radiation in endovascular aneurysm repair, the benefits of this abdominal aortic aneurysm type of surgical management are justfied by minor recovery time and hospitalization, as well as an option for patients not elected to conventional open repair. In this minimally invasive surgical aproach, time of procedure and radiation doses can be substantial - and the increasing frequency of these procedures and it's complexity have impelled vascular surgeons to face additional and successive risk to occupational radiation exposure. Meticulous study of the computed tomography angiography during the endovascular aneurysm repair preparation allows reduction of unnecessary radiation exposure, as also reduces consecutive image acquisition and contrast use (that may be related to renal overload in susceptible patients). Some studies have proposed strategies to optimize endovascular intervention to reduce contrast use and X-ray exposure. Although they might prove to be effective, they rely on use of additional specific and advanced equipment, available only in major centers. As an alternative to this expensive and restrict technology, it is presented a simpler technique through image manipulation on software OsiriX, aiming to reduce both exposures.
OBJECTIVE: To analyze the efficacy of the adoption of a study protocol and a script-based guide in preparation for endovascular aneurysm repair through verifying it's impact over the surgical procedure - as referred to intravascular contrast infuse, effects over renal function, blood loss and operatory time.
METHODS: A longitudinal prospective study from March 2014 through March 2015, where 30 performed endovascular aneurysm repair were compared to a historic control group. The planning for endovascular aneurysm repair through the patient's tomographic image manipulation in the prospective group was performed with OsiriX MD software. A script-based guide upon gathering detailed computed tomography angiography images was elaborated by the author and distributed to the performing surgical team for appreciation, instruction and pre operatory judgment. Based upon the script, the C-arm gantry angle was specifically corrected in each case of endovascular aneurysm repair, for image optimization and aneurysm's neck visualization. Arteriography was performed under digital subtraction angiography after catheters were positioned according to predicted level description in the referred guide. Statistical analysis were performed with a significance level of 5% (P value<0.05).
RESULTS: There was a statistically significant relationship between the two studied periods and the variables: contrast volume (284.5 vs. 31.8 mL), operative time (207.5 vs. 140.4 min.) and blood loss (798.1 vs. 204.4 mL), revealing that they are considerably larger in the historical control group than in the script guided current group. There was no difference related to the volume of contrast used in the two groups and the occurrence of renal impairment.
CONCLUSION: In the present paper it was possible to demonstrate the impact of the ability to manipulate digital formats of medical images without the need of sophisticated equipment, in adoption of a guide based on the compilation of informations collected with assistance of an accessible software performed on a personal computer. Although we could not prove relation to occurrence of renal impairment, there were direct results on reduction of intravascular contrast use, even as surgical time and blood loss, compared to a previous historical period.

As Marcelo Giugale published in the Financial Times, Latin America, on the whole, has not excelled at innovation - doing the same things in a new and better way or at doing new things. It has been slow to acquire, adopt and adapt technologies by this time available in other places^[1]. Although extracorporeal membrane oxygenation (ECMO) is not a new technology, its use in Latin America is not widespread as needed. Furthermore, we still have a number centers doing ECMO, not reporting their cases, lacking a structured training program and not registered with the extracorporeal life support organization (ELSO). With this scenario, and accepting that ECMO is the first step in any circulatory support program, it is difficult to anticipate the incorporation of new and more complex devices as the technologically advanced world is currently doing. However, the good news is that with the support of experts from USA, Europe and Canada the results in Latin America ELSO'S centers are improving by following its guidelines for training, and using a standard educational process. There is no doubt that we can learn a great deal from the high velocity organizations - the rabbits - whom everyone chases but never catches, that manage to stay ahead because of their endurance, responsiveness, and their velocity in self-correction^[2].

OBJECTIVE: To report the initial changes after quality-improvement programs based on STS-database in a Brazilian hospital.
METHODS: Since 2011 a Brazilian hospital has joined STS-Database and in 2012 multifaceted actions based on STS reports were implemented aiming reductions in the time of mechanical ventilation and in the intensive care stay and also improvements in evidence-based perioperative therapies among patients who underwent coronary artery bypass graft surgeries.
RESULTS: All the 947 patients submitted to coronary artery bypass graft surgeries from July 2011 to June 2014 were analyzed and there was an improvement in all the three target endpoints after the implementation of the quality-improvement program but the reduction in time on mechanical ventilation was not statistically significant after adjusting for prognostic characteristics.
CONCLUSION: The initial experience with STS registry in a Brazilian hospital was associated with improvement in most of targeted quality-indicators.

INTRODUCTION: In a world in which global communication is becoming ever more important and in which English is increasingly positioned as the pre-eminent international language, that is, English as a Lingua Franca refers to the use of English as a medium of communication between peoples of different languages. It is important to highlight the positive advances in communication in health, provided by technology.
OBJECTIVE: To present an overview on some technological devices of translating languages provided by the Web as well as to point out some advantages and disadvantages specially using Google Translate in Medicine and Health Sciences.
METHODS: A bibliographical survey was performed to provide an overview on the usefulness of online translators for applicability using written and spoken languages.
RESULTS: As we have to consider this question to be further surely answered, this study could present some advantages and disadvantages in using translating online devices.
CONCLUSION: Considering Medicine and Health Sciences as expressive into the human scientific knowledge to be spread worldwidely; technological devices available on communication should be used to overcome some language barriers either written or spoken, but with some caution depending on the context of their applicability.

OBJECTIVE: Mechanical ventilation is frequently necessary, in which case the use of an endotracheal tube is mandatory. The tube has an inflatable balloon in its distal extremity, whose aim is, among other functions, an efficient arterialization. However, serious injuries in the place of contact of the balloon with the trachea can be frequent. Some studies point out that balloons with permanent pressure may reduce this complication. Nevertheless, air scape, expressed by the inspiratory (IV) and expiratory volume (EV) variation (Δ IV-EV), may occur, possibly leading to hypoxemia. Thus, the goal of this study was to verify the efficiency of a modified endotracheal tube on arterializations compared to the traditional endotracheal tube.
METHODS: The modified endotracheal tube presents intermittent insufflation, with three drillings in the internal region of the cuff, allowing for insufflation in the inspiratory phase of the mechanical ventilation. Three animals were used for the control group, with a cuff pressure of 30 cmH₂O, and seven pigs had the modified endotracheal tube. Each animal was kept under mechanical ventilation (FIO₂=0.21) for 6 hours. Arterial and venous gases were measured every three hours (T₀; T₃; T₆).
RESULTS: The gases confirmed the lack of hypoxia between the Groups, with a difference in the ΔIV-EV at T0 (P=0.0486).
CONCLUSIONS: In this study, the lack of hypoxia showed the efficiency of the modified endotracheal tube. However, new studies are necessary, particularly in diseased lungs, in order to evaluate the real efficiency of the mentioned device on the pulmonary gas exchange.

Rupture of the left ventricular wall after mitral valve replacement is an infrequent but lethal complication. Reporting correction technique of ventricular rupture with bovine pericardium patch secured with glue and without suturing: a 51 years-old female patient, with double rheumatic mitral lesion, severe stenosis and discrete insufficiency, who had a mitral valve replacement. During surgery, the patient presented a ventricular rupture of the posterior wall (atrioventricular disruption), which was successfully repaired using bovine pericardium with sutureless biological glue over the epicardium of the damaged area. Sixty months after surgery the patient has no symptoms.