Volume 12 - Número 1
ORIGINAL ARTICLE
Coronary artery bypass surgery graft in patients with ischemic cardiomyopathy and severe left ventricular dysfunction: short and long-term results
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
Purpose: To evaluate the prognosis value of preoperative parameters, surgical risk, functional benefits and long-term survival after myocardial revascularization.
Methods: Seventy one patients with coronary artery disease and severe left ventricular dysfunction (left ventricular ejection fraction < 30%) and evaluated the myocardial perfusion by TI-201 scintigraphy were studied before and after myocardial revascularization, during the hospitalar period and 48 months (avarage) of late follow up.
Results: The early mortality observed was 2,8% and the survival in 5 years 62,8%. The statistical analysis related to the preoperative clinical parameters in all patients were not significant in: a) severity of congestive heart failure (CHF) or angina; b) presence of Q wave (EKG); c) presence of ischemia (TI-201); d) left ventricular ejection fraction. The statistical analysis related to survivors and no survivors were significant: a) functional class IV of CHF; b) presence of left brunch bundle block (LBBB).
Conclusion: Our results show that functional class IV of CHF and LBBB were related to bad prognosis and demonstrate the difficulty to establish preoperative clinical parameters of prognosis due to the presence of heterogeneous coronary and myocardial pattern of the ischemic cardiomyopathy. Our surgical results confirm that myocardial revascularization is a safe procedure, increases late survival and improves the quality of life of these patients with coronary artery disease and severe left ventricular dysfunction.
Keywords: Myocardial revascularization, surgery; Myocardial ischemia, surgery; Ventricular dysfunction, left, surgery; Myocardial revascularization, follow-up studies; Myocardial ischemia, follow-up studies; Ventricular dysfunction, left, follow-up studies
Surgery in bacterial endocarditis
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
The infective endocarditis continues to have high mortality, although the sophisticated diagnostic and therapeutic methods. Despite the use of the new antibiotics, its evaluation continues to be poor, leading the patients to death or incapacity lesions. The surgery must be achieved precociously, to avoid high mortality with clinical treatment alone. This study assesses the rool of the surgery for the patients with infective endocarditis and high risk complications; 63 cardiac surgeries were carried out to treat infective endocarditis complications, in the HSE-RJ, from May, 82 to October 95. Thirty-two patients (62.3%) had previous cardiac lesions or valvular prosthesis. Rheumatic disease was found in 24 (38.1%) patients. Fever, heart murmur and cardiac failure were found in 100% of the cases. The echocardiography revealed the presence of vegetation or valvular destruction in all cases. The cultures of the valve and the blood were positive in 10 (15.6%) and 29 (38.1%) of the cases, respectively. Criteria for surgical treatment were untreatable cardiac insufficiency in 57 (90.5%) cases, systemic embolization in 29 (46.0%) cases and sepsis persistent in 24 (38.1%) cases; 51 mechanical prosthesis and 22 biological prosthesis were implanted. The tricuspid valvulectomy was carried out in 4 patients. The surgical mortality was 17.5% and all patients that survived remained in functional class I or II without infection.
Keywords: Endocarditis, bacterial, surgery; Endocarditis, bacterial, complications
Predictive factors to sinus rhythm recover after mitral valve surgery in patients with atrial fibrillation
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
Rheumatic mitral valve disease may lead to atrial fibrillation due to anatomical and functional disorders of the left atrial myocardium. After mitral valve surgery some patients in atrial fibrillation recover sinus rhythm, but the majority of them remains fibrillated. This study was undertaken with the purpose of identify, in patients operated on for mitral valve disease with atrial fibrillation, those factors that could predict a return to sinus rhythm post-operatively. The following variables were retrospectively studied: age, gender, duration of the arrhythmia pre-operatively, left atrial diameter, ejection fraction, type of valve lesion, surgical technique for correction, and previous cardiac surgery. Data was obtained from the medical history, ECG, echocardiogram and surgical note. There was no statistical significant difference between patients that returned to sinus rhythm and those that remained in atrial fibrillation, regarding age, gender, arrhythmia duration, left atrial diameter, ejection fraction, kind of technique, and previous heart surgery. Mitral regurgitation associated to left atrial less than 52 mm diameter was predictive for return to sinus rhythm (OR = 1,945; p = 0,02).The prediction of persistent post-operative atrial fibrillation may lead to changing surgical stratergies in patients with mitral valve disease. In this small series of patients, the association of mitral regurgitation and left atrial size less than 52 mm was predictive of conversion to sinus rhythm after conventional post-operative therapy.
Keywords: Atrial fibrillation, surgery; Mitral valve, surgery; Mitral valve stenosis, surgery; Mitral valve insufficiency, surgery; Sinoatrial node, physiopathology
Surgical treatment of aortic insufficiency associated with aneurysms and acute dissections of the root and ascending aorta using the technique of Tirone David
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
Aneurysms of the root and ascending aorta (AAA) and acute aortic dissections (AAD) are usually associated with valvular aortic insufficiency (VAI) in a large number of patients, caused by a variety of machanisms. In 30% to 50% of these cases the aortic leaflets are morphologically normal and can be spared using the technique of reconstruction of the root and ascending aorta plus the reimplantation of the aortic valve and the coronary arteries in a composite Dacron and bovine pericardium tubular graft. This technique, described and proposed by Tirone David, avoids valve replacement and, in some cases of AAA, may definitely correct the mechanisms involved in the disease. From November 1994 to December 1995, 11 patients were operated upon this technique and divided in two main groups: Group I - AAD, 5 patients, all with Type I DeBakey, 4 with acute and 1 with chronic dissection; Group II - AAA, 6 patients, the majority being over 50 years old. The surgical technique, concerning the Group I, included profound hypothermia (all cases), total circulatory arrest and retrograde cerebral perfusion, (3 cases). In Group II we used moderate hypothermia at 28°C. In both groups the myocardial protection was performed with intermittent antegrade isothermic blood cardioplegia delivered each 10 minutes, associated with iced saline into the pericardium. There were two operative deaths (18.2%) and one late death (9%), all from the Group I, and 9 were discharged from hospital (81.8%) with a maximum follow-up period of 13 months. All patients (9/11) had colour ecodopplercardiographic evaluation before discharge and none of them had aortic valvular dysfunction. The Eco studies were repeated for all surviving patients (8/11) in December 1995, and the results are shown in this paper. We conclude that the aortic valve-sparing operation described by Tirone David is a very reliable and effective method of treatment of the VAI associated with AAA and AAD. Although the number of patients is small and the follow-up period is short in this series, we believe that the efforts to avoid valve replacement in these patients is encouraging for both, the surgeon and the patient, in carefully selected cases.
Keywords: Aortic valve insufficiency, surgery; Aortic aneurysm, surgery; Aneurysm, dissecting, surgery; Aortic valve insufficiency, complication; Aortic aneurysm, complication; Aneurysm, dissecting, complication
Lack of ventriculotomy prevents post-operative ventricular arrhythmias in Tetralogy of Fallot?
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
Right ventriculotomy might be related to late ventricular arrhythmias after surgical correction of Tetralogy of Fallot. This paper presents the incidence of late ventricular arrhythmias comparing groups submitted or not to a ventriculotomy. From 1988 to 1995, 238 patients were consecutively operated upon, 28 by atrial approach exclusively (Group A) and 210 uncluding a right ventriculotomy (Group V). There were no significant differences regarding to age, sex, weight, height or body surface area. There been no previous selection for the approach. Fallow-up time was 45 ± 22 months for Group A and 33 ± 24 months for Group V (NS). The incidence of atrioventricular block and arrhythmias were studied by conventional ambulatory EKG. Group A presented no transient or permanent AV block, while there have been 7% transient and 2% permanent AV block in Group V (NS). Supraventricular arrhythmias were 17,4% in Group A and 12,0% in Group V (NS). There have been no relation between arrhythmias and ventriculotomy. This might suggest that atrial approach, avoiding ventriculotomy, does not prevent late ventricular arrhythmias.
Keywords: Arrhythmia, prevention; Tetralogy of Fallot, surgery; Heart ventricle, surgery; Heart atrium, surgery; Tetralogy of Fallot, postoperative complications
Implantable LVAD at the Cleveland Clinic Foundation: clinical experience and future uses
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
Purpose: To study and evaluate the current use of the Heart Mate® 1000 IP LVAD at the Cleveland Clinic Foundation.
Methods: Between Dec/91 and Sept/94 the Heart Mate pneumatic LVAD was implanted in 33 severely shocked patients. Multiple hemodynamic measurements were done in the OR during implant, 24 hours later and just before the heart transplant. Numbers are presented in mean (+/- standard deviation) and compared by paired T-test. Clinical outcome and complications are discussed.
Results: Hemodynamic parameters markedly improved after device implantation (statistically significant). Support time ranged from 0 to 153 days (mean 76 in the group that reached the transplant). There were 9 (15%) deaths due to right ventricular failure, sepsis and multiple organ failure. No thromboembolic events occurred.
Conclusion: Treatment with the Heart Mate improved clinical outcome in high risk patients. The results encourage its application as a new alternative therapy to heart failure.
Keywords: Assisted circulation; Heart-assist devices; Artificial implants; Myocardial ischemia; Congestive cardiomyopathy, surgery; Hemodynamics, physiology; Left ventricular dysfunction; Heart transplantation; Postoperative complications
Traumatic rupture of the thoracic aorta: surgical treatment
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
From July 1986 to December 1995 twelve patients with traumatic rupture of the thoracic aorta were operated on. Nine patients had an acute injury and three had chronic injury. In all patients the lesion was located in the isthmus. Eleven patients were operated on with simple cross-clamp and in just one patient a shunt without heparin, between the left subclavian artery and thoracic aorta, was done. Medium aortic occlusion time was 33.2 minutes. Eleven patients are alive. There was one hospital death (8.3%) due to bleeding. One patient developed paresis of the lower limbs. Ten patients survived without complications. In our opinion the simple cross clamp technique is acceptable in the surgical repair of the traumatic rupture of the thoracic aorta.
Keywords: Aortic rupture, surgery; Aorta, thoracic, injuries; Aorta, thoracic, surgery; Aortic rupture, etiology; Aortic rupture, accidents, trafic
Cardiac tumors: 10 year experience
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
Purpose: To review the surgical experience of our group in the treatment of primary cardiac tumors, during a 10 year period beginning January 1985 till December 1994.
Material and Methods: From a total of 2268 cardiac surgeries with the aid of extracorporeal circulation performed during this 10 year period, there were 6 cases of intracavitary tumor resection, an incidence of 0.26%. Three were myxomas of the left atrium, 1 papillary fibroelastoma of the mitral valve, 1 rhabdomyoma of the left ventricule and 1 fibroma of the left ventricle. Three patients presented systemic embolism and the other three congestive heart failure. The diagnosis was confirmed by echocardiography (5 cases) and angiography (all 6 cases).
Results: All patients had uneventful revovery, except 1, with atrial myxoma, who developed mediastinitis and sepsys, dying on the 14th. post-operative day and becoming the unique hospital death. The follow up obtained in 4 patients with mean duration of 49 ± 36.8 months (range, 15 to 111 months) showed that all of them were in functional class I (NYHA) and with no evidence of recurrence.
Conclusions: Cardiac tumors are rare, easily diagnosed "as long as you think of them" (Soma Weiss), most of them bening and have a favorable outcome with surgical resection.
Keywords: Heart neoplasms, surgery; Myxoma, surgery; Fibroma, surgery; Rhabdomyoma, surgery; Heart atrium, surgery; Mitral valve, surgery; Heart ventricle, surgery; Heart neoplasms, diagnosis
Single lead DDD pacing with overlapping biphasing atrial stimulation: first clinical results
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
Single lead, dual chamber (DDD) pacing with an atrial floating electrode is limited by high atrial capture thresholds. We evaluated a new atrial stimulation lead with two atrial ring electrodes on a single lead and overlapping unipolar square wave pulses of an opposite polarity. The first pulse is applied to the distal electrode and is positive, the second pulse is to the proximal electrode and is negative, both with respect to the pacemaker housing. The delay between the two pulses is programmable between 0.0 ms to 1.0 ms. The distance between the atrial electrode rings is 10 mm and the distance from the distal atrial ring to the unipolar ventricular electrode can be selected to be 11, 13 or 15 cm. The positioning of the atrial ring is selected according to the measured overlapping biphasic pulse thresholds, including respiratory maneuvers to confirm continuous capture/sensing. The pulse generator has a single lead connection and the capability of delivering the two atrial square wave opposite programmable pulses, with delays from 0.0 to 1.0 ms. The generator may be programmed to the single lead unipolar VDD mode. This system was implanted in 4 patients with complete AV block with normal sinus mode fuction. Atrial and diaphragmatic thresholds for various pulse configurations, widths and delays were measured intra and postoperatively. The midportion of RA was selected as the best location for the atrial rings with continuous capture during deep inspiration. The intra and postoperative (48hrs) measurements were:
THRESHOLD INTRA-OP POSTOP. (48HRS)
Atrial unipolar 3.2 + 0.47 V not measurable
Atrial (overlapping biphasic) 1.6 + 0.37 V 3.37 + 0.84 V
Diaphragmatic above 7 V 5.21 + 0.3 V
wave sensing 2.35 + 1.3 mV 1.27 + 0.8 mV
The patients were discharged in the VDD mode. Evaluation thirty days after showed transient loss of atrial capture during inspiration in one patient in spite of absence of other threshold changes compared to the 48 hours evaluation. In conclusion, overlapping biphasic stimulation reduces the atrial pacing thresholds while maintaining adequate atrial sensing with a safe margin regarding diaphragmatic stimulation.
Keywords: Artificial cardiac pacing, methods; Heart block, surgery; Atrial function; Implanted electrodes; Artificial pacemaker
High degree atrioventricular block after cardiac surgery: study of reversibility criterions.
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
High degree atrioventricular (AV) block is manifested in low incidence (2,1%) during postoperative heart surgery and could be transient or permanent. In the absence of block reversibility criterions. permanent pacemaker (PPM) implantation is recommended when AV block is persistent longer than 15 days. In isolated cases the block could be reversible after this period. Av block occurred in 4 of 300 patients who underwent cardiac surgery. We reviewed their records and confirmed that neither the heart rate nor compared QRS characteristics in the periods before, during or after block, is usefully to predict block reversibility. The intracardiac electrophysiologic study is unnecessary to indication of PPM. Corrected pacemaker recovery time greater than 2 seconds indicates junctional or idioventricular activity uncertain and should be investigated as block reversibility criterion.
Keywords: Heart surgery, adverse effects; Heart block, therapy; Pacemaker, artificial; Artificial cardiac pacing, methods
Surgical treatment of postinfarction ventricular septal rupture, free wall rupture and rupture of the posterior wall of the left ventricle after mitral valve replacement, using the Ventricular Isolation Device: experimental study
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
The rupture of the ventricular free wall, and the ventricular septal rupture are two catastrophic events that can complicate the outcome of acute myocardial infarction. The opportunity to use surgical treatment, the access to the ventricular septal rupture as well as the ideal surgical technique are very much discussed in the literature but the results are almost unanimous: an elevated mortality. The rupture of the posterior wall of the left ventricle after mitral valve replacement is not a rare complication and it is almost always fatal. Our objective is to discuss a new alternative for surgical treatment of those serious pathologies without the direct handling of the necrotic cardiac muscle. We developed and tested in animals (sheeps) the Ventricular Isolation Device. From 7/12/95 to 1/10/96, we implanted this device in 12 adult sheeps. During the first period of learning the surgical technique and developing the device, we operated on 7 animals, without success. On a second turn, we performed the procedure in 5 animals and by then the Ventricular Isolation Device was completely developed and the surgical technique already standardized, resulting in the survival of all animals with normal cardiac output, as shown by echocardiography and ventriculography. We observed the complet isolation of the ventricular cavity with the use of Ventricular Isolation Device and obtained the temporary treatment of those fatal pathologies.
Keywords: Heart rupture, post-infarction, surgery; Ventricular septal rupture, surgery; Heart assist devices; Heart ventricle, artificial
Protective effect of crystalloid cryocardioplegia in the global ischemia and reperfusion during cardiopulmonary bypass: an endothelium - dependent mechanism
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
Previous experiments showed evidence of impaired receptor-mediated production of EDRF/NO following reperfusion injury could be due to G-protein dysfunction which links endothelial cell receptors to the pathway of EDRF/NO synthesis. This experimental research suggested that criocrystalloid cardioplegia, associated to topic hypotermia, could prevent or reverse the endothelium disfunction under same experimental conditions. More experiments will be necessary to get definitive conclusions, because fine statystical analysis suggested increasing the number of experiments. Otherwise, the present study proved for the first time that hypothermia alone can cause the release of PGI2 and EDRF/NO from the endothelium. This suggests that the endothelium could be an important temperature sensor and has important implications for the understanding of cardiopulmonary bypass physiology and local vascular autoregulation.
Keywords: Heart arrest, induced, methods; Myocardial ischemia; Myocardial reperfusion; Cardioplegic solutions, pharmacology; Hypothermia, induced; Acetylcholine, pharmacology; Adenosine diphosphate, pharmacology
The use of pure oxygen and venous arterial shunt in membrane oxygenators
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
Fifty patients, age from 32 to 82 years, were submitted to extracorporeal circulation using a membrane oxygenator (D.M.G.) in which a venous arterial shunt was employed so that only one third to one half of the venous blood were gone through the oxygenator. The gas used in the oxygenator was pure oxygen. The patients were kept with temperature of 34 to 36°C, anestetized with phentanil and full curarization, to decrease to a minimum the O2 comsumption. The average arterial SO2 was ± 90% and the venous saturation ± 70%. There were no significant variations in PCO2 and PH. During perfusion the arterial and venous saturations were monitored with an oxymeter and also the volume of the shunt measured by an electromagnetic flowmeter (Biopump). There were two deaths in the post operative period (two weeks and three weeks after surgery) not related to the perfusion method. We conclude that the use of a venous arterial shunt and pure oxygen in membrane oxygenators can substitute the gas mixture routinely used in these devices and has as advantage to reduce in theory the inflamatory responses produced by the artificial oxygenators.
Keywords: Arteriovenous shunt, surgical methods; Oxygenators, membrane; Perfusion; Hemodilution; Extracorporeal circulation
Anatomical study of internal thoracic artery applied to cardiovascular surgery
Braz J Cardiovasc Surg 12;
Publish in: 8/2/2025
The internal thoracic artery (ITA) was studied because of its increased utilization in myocardial revascularization surgery due to the excellent long-term results. A review of its anatomical characteristics to clear some morphological aspects was made, aiming to help the extension of its utilization and prevent operative complications. The study was carried out in 100 cadavers; the anterior sternocostal wall of the thorax was removed and the arteries were injected with Neoprene Latex. The ITA originated directly from the subclavian artery in 82.5% and from a common trunk with other arteries in 17.5%. Its lenght was 20.4 ± 2.1 cm in average and the most frequent end point was the 6th intercostal space (52.5%). The end point form was as bifurcation in 93% and as trifurcation in 7%. The relation of ITA with the sternal margins was, on average, 10.3 ± 3.2 mm at the level of first intercostal space and 19.2 ± 6.0 mm at the level of 6th intercostal space. It was covered by the transverse muscle of thorax in a distance of 7.5 ± 2.7 cm long (average) and the lateral costal branch was present in 15%. The ITA was crossed anteriorly by phrenic nerve in 70% and posteriorly in 30%. Informations provided by this study may help prevent complications in ITA dissections and to improve our knowledgement on its anatomical characteristics.
Keywords: Thoracic arteries, anatomy and histology