Volume 12 - Número 4
ORIGINAL ARTICLE
Cardiac transplant monitoring through intramyocardial electrogram analysis
Braz J Cardiovasc Surg 12;
Publish in: 8/1/2025
Serial intramyocardial electrogram recordings have been performed for noninvasive rejection monitoring in patients after heart transplantation using implanted telemetric dual-chamber pacemaker and fractally coated endocardial loads. The signals have been evaluated using the CHARM (Computerized Heart Acute Rejection Monitoring) system. The reports containing the trend curves of the rejection sensitive parameters show good correlation with the patients clinical course and the results of endomyocardial biopsy. Long-term cardiac transplant monitoring using intramyocardial electrograms is a valuable tool for clinical patient management.
Keywords: Heart transplantation; Graft rejection, diagnosis; Electrodiagnosis, methods; Pacemaker, artificial
Immediate and late results in the surgical treatment of the aorta (type A) acute dissection
Braz J Cardiovasc Surg 12;
Publish in: 8/1/2025
A retrospective analysis of the surgical treatment of Type A acute aortic dissection was performed during the period Jan.86 and Dec.96. A total of 64 patients were operated on (mean age 52.6 + 10.9 years) with predominance of the male gender (64.1%). In 17 cases there was intrapericardial rupture of the dissection; the intimal tear was located in the ascending aorta in 58 patients (90.6%) and in the aortic arch in the remaining (9.4%). The basic surgical procedure consisted of extensive resection of the ascending aorta with substitution by a bovine pericardial conduit. However, other techniques were employed in a few patients in the beginning of our experience. Deep hypothermia with circulatory arrest was used in 32.8% of the patients, but with increasing frequency in the last years. The native aortic valve was preserved in 76.5% of patients. Total hospital mortality was 28.1% (18 patients), but was significatively lower in the last 4 years (17.8%). Late follow-up showed 4 deaths; CVA and pulmonary embolism were responsible for two of these deaths, respectively. The cause could not be determined in the other two. Reoperations were necessary in 7 patients without mortality; progressive aortic insufficiency was the major indication for reoperation. Structural failures of bioprosthesis and bovine pericardial grafts were not recorded during this period. This experience reinforces our approach to a more radical treatment of Type A acute aortic dissection with probably more use of aortic valve replacements and deep hypothermia with circulatory arrest.
Keywords: Aneurysm, dissecting, surgery; Aortic aneurysm, surgery
Long-term results of a porcine aortic valve monocusp for right ventricular outflow tract reconstruction
Braz J Cardiovasc Surg 12;
Publish in: 8/1/2025
The fate of monocusps for right ventricular outflow tract reconstruction remains controversial. Between June, 1989 and April, 1996, we implanted a porcine aortic valve monocusp mounted on a bovine pericardial patch in 45 patients with a variety of congenital heart defects. Their ages ranged from 2 weeks to 18 years of age (mean 4.8 ± 4.7 years). There were 5 early postoperative deaths, directly related to preoperative clinical condition and unrelated to monocusp function. Thirty seven survivors have been followed for a mean follow-up of 38.5 ± 19.0 months (range 6 to 88 months). There have been no late deaths. Two patients were reoperated. The first one with absent pulmonary valve syndrome required reoperation 24 months postoperatively for severe pulmonary valve incompetence due to mismatch between the monocusp size and pulmonary valve area. The later developed severe residual infundibular stenosis and was reoperated 23 months postoperatively. The reoperations disclosed well preserved monocusps with no signs of tissue degeneration. The remaining 35 patients were all asymptomatic. Thirty-six patients have been evaluated by serial echocardiographic assessment of monocusp motion and hemodynamic function. The monocusp remained mobile in every case with no evidence of graft calcification, stenosis or dilatation. The mean peak systolic pressure gradient across the right outflow tract was 19.0 ± 5.8 mmHg. Pulmonary valve regurgitation was absent in 12 patients (33%), mild in 15 (42%) and moderate in only 9 patients (25%). In conclusion, porcine aortic valve monocusp provides excellent late hemodynamic results, effectively reducing or abolishing pulmonary regurgitation, without evidences of late stenosis. The monocusp has remained functional and synchronous with cardiac cycle up to 7 years after implantation.
Keywords: Heart valve prosthesis; Heart defects, congenital, surgery; Bioprosthesis; Heart ventricle, surgery
Prognostic factors about, myocardial revascularization in elderly patients
Braz J Cardiovasc Surg 12;
Publish in: 8/1/2025
The trend in Brazil of erroneously delaying myocardial revascularization in the elderly determined this study. Three hundred consecutive elderly patients (mean age: 73,92, standard deviation: 3.32). Between October 1992 and July 1995, 361 consecutive patients underwent isolated coronary artery bypass grafting, of whom 111 (30,7%) were females and 250 (69,35) males. There were 128 (35,5%) diabetic patients and 128 (36,7%) were in NYHA III/IV. Univariate analysis per-operatory of 19 factors followed by multivariate logistic regression analysis of the significant variables (p 0.005) were done. Major complication ocurred in 178 (49.3%) and were independent predictors of operative morbidity: Diabetes mellitus, NYHA funcional classification, urgent cases and DP2. There were 33 (9,1%) in hospital deaths, and diabetes mellitus, NYHA functional classification, unstable pre-operative angina and cerebral vascular acidents, renal failure, infection and insufficiency respiratory failure were independent predictors of operative mortality. We concluded that coronary artery bypass grafting is possible in elderly patients with a favorable outcome, especially when done in patients with normal to moderately depressed left ventricular function.
Keywords: Myocardial revascularization; Coronary disease, surgery; Myocardial revascularization, prognosis; Myocardial revascularization, aged
Mini-sternotomy: a safe approach for cardiac surgery
Braz J Cardiovasc Surg 12;
Publish in: 8/1/2025
Recently, in the constant search for shortening hospital stay and emproving postoperative recovery, many surgical alternatives have been used. We started the use of a partial sternotomy as an approach to different types of cardiac operations. This paper aims to show the hospital outcome of patients submitted to this technique. From November 1996 to March 1997, 51 patients who underwent partial sternotomy were studied. The mean age of the patients was 46.8 years with 26 females. The most common procedures were valve surgeries followed by myocardial revascularization. The approach used in the patients with valve pathologies was a partial sternotomy in an inverted "T" incision in the superior segment of the sternum, for other pathologies a sternotomy in a "T" incision in the inferior segment was the choice and due to technical difficulties imposed by reoperations and in multiple procedures a third variation, partial sternotomy in an "H" incision was used. In the latter, the sternum was cut from the first to the fourth intercostal spaces. The average size of the skin incision was 9.9 cm. There have been 19 "T" incisions, 17 inverted "T" incisions and 15 "H" incisions. The average assisted ventilation time was 2.8 hours, the average ICU stay was 31.5 hours and the average hospital stay was 5.9 days. No complications resulted directly from the approach itself and in only one case was conversion to total sternotomy necessary. After analyzing the outcome of these 51 patients, we can conclude that partial sternotomy is a safe approach for the treatment of several isolated or associated heart diseases reoperations. It achieves a favorable aesthetic result and achieves postoperative recovery. Therefore, it should be part of every heart-surgeon's repertoire.
Keywords: Sternum, surgery; Heart surgery, methods
Intermittent normothermic anterograde blood cardioplegia. II. With and without aminoacids: comparative study in rabbits
Braz J Cardiovasc Surg 12;
Publish in: 8/1/2025
Purpose: The purpose of this investigation was to find out whether the addition of aspartate and glutamate improved the myocardial protection afforded by a normothermic blood cardioplegia solution given anterograde, at 20 minute intervals.
Methods: After a 60 minute period of amino-acid enriched cardioplegic arrest, 10 rabbit hearts were processed for metabolic studies (phase1), while another 10 were reperfused parabiotically with arterial blood and then submitted to biochemical and functional analyses (phase 2). Ventricular myocardium glycogen concentration and mitochondrial respiration were determined for both phases. Left ventricular contractility (dP/dtmax) was assessed during reperfusion in phase 2 animals.
Results: Compared to control levels, non reperfused (phase 1) with and without aminoacids hearts showed a similar and significant drop in glycogen levels (53 % and 58%, respectively). There was no significant difference concerning mitochondrial respiration and myocardial contractility (dP/dtmax) between the experimental groups with and without aminoacids and between these and the control groups.
Conclusion: The addiction of aspartate and glutamate to an "in vitro" intermittent anterograde normothermic (37°C) blood cardioplegia rabbit model did not improve myocardial protection in this study.
Keywords: Heart arrest, induced, methods; Amino acids, pharmacology; Myocardium, metabolism, rabbits; Myocardium, drug effects; Ventricular pressure, rabbits
Risk factors in cardiac valve surgery
Braz J Cardiovasc Surg 12;
Publish in: 8/1/2025
Cardiac valve procedures are very commom in heart surgery but its mortality is not yet null. In this study, a retrospective analysis of 412 cases was done between January 1994 and December 1995 to identify increased risk factors in these procedures. The mean age of patients was 48.3 years (13 to 85 years) with 59.3% (244 patients) females. Reoperations for valve diseases were performed on 154 cases (37.4%) and in 24 patients (5.8%) associated myocardial revascularization was necessary. The valves involved were: isolated mitral (55,1%), isolated aortic (27.2%), mitro-aortic (11.4%), mitro-tricuspid (4.4%), tricuspid (0.7%), mitro-aortic-tricuspid (1.2%). The hospital mortality was 8.3%. The following factors were identified to be significant predictors for hospital mortality: age over 60, preoperative atrial fibrillation, valve replacement (impossibility of native valve preservation), preoperative NYHA functional class IV, ventricular dysfunction (left ventricular ejection fraction of less than 0.50), aortic cross clamp time longer than 75 minutes, and duration of cardiopulmonary bypass longer than 120 minutes. Patients submitted to valve reoperations and those with associated myocardial revascularization showed increased mortality (11.7% and 20.8% respectively), but there were no significant statistical differences. On the other hand, there was no significant relationship between risk and the valve involved, prostheses used in valve replacement (bioprostheses or mechanical prostheses) number of prior cardiac valve surgeries previous realized, interval since the last cardiac valve surgery (in reoperations) and (also in reoperations) if the patient was previously submitted to a valve replacement or a conservative operation. A precise surgical indication, the treatment of preoperative arrhythmias, new drugs for controlling congestive heart failure and to improve ventricular function, the improvement and appearance of new operative techniques for conservative management of valvular diseases, and a better hemodynamic support pre, per and post operative are measures that could further reduce mortality in cardiac valve surgery.
Keywords: Heart valves, surgery; Heart valves, surgery, risk factors
Fisics-Incor bovine pericardial bioprostheses: 15 year results
Braz J Cardiovasc Surg 12;
Publish in: 8/1/2025
Between March 1982 and December 1995, 2607 Fisics-Incor bovine pericardial bioprostheses were implanted in 2259 patients. The average age was 47.2 ± 17.5 years, and 55% were male. Rheumatic fever was present in 1031 (45.7%) patients. We performed 1073 aortic valve replacements, 1085 mitral replacements, 27 tricuspid replacements, 195 mitral-aortic replacements, and other 16 combined valve replacements. There were associated procedures in 788 (32.9%) patients, the most frequent being tricuspid valve repair (9.2%) and myocardial revascularization (7.7%). The hospital mortality was 194 (8.6%) patients, 8.6% for the mitral group, 4.7% for the aortic, and 12.8% for the double valve replacements. The linearized rates for calcification, thromboembolism, rupture, leak and endocarditis were, respectively, 1.1%; 0.2%; 0.9%; 0.1% and 0.5% patient-year. The actuarial survival curve was 56.7 ± 5.4% in 15 years. Free from endocarditis was 91.9 ± 2%, thromboembolism 95 ± 1,7%, rupture 43.7 ± 9.8%, leak 98.9 ± 4.5%, and calcification 48.8 ± 7.9% in 15 years. In the late post-operative period, 1614 (80.6%) patients were in NYHA functional class I. We conclude that the results with the Fisics-Incor bovine pericardial bioprostheses were satisfactory in our group of patients.
Keywords: Bioprosthesis, methods; Heart valve prosthesis
Surgical correction of ostium atrioventricularis communis in infants
Braz J Cardiovasc Surg 12;
Publish in: 8/1/2025
Between May 1987 and December 1996, repair of the "Ostium Atrioventricularis Communis" (OAVC), with total shaping by means of a double bovine pericardial patch and tricuspidation of the left atrioventricular valve (AVV) was performed on 34 consecutive patients with overall mortality of 5 patients (pat.) (14.7%). Group I: Less than 6 months (m) 12 pat. (1 death: 8.3%); Group II: 7m to 12m, 15 pat. (4 deaths: 26.6%) and Group III: between 1 and 5 years (y) 7 pat. (no deaths). Two deaths occurred later (residual mitral insufficiency + congestive heart failure and pneumonia + respiratory insufficiency). Two children received implants of definitive pacemakers (after 45 days and 4 years). Despite the fact that 2 registered insufficiency of the left AVV and one showed insufficiency of the right AVV, these cases were controlled clinically and no children were reoperated. The remaining children are classified between degree I and II of the New York Heart Association (NYHA). Although 29 patients weighted less than 10 kg, extracorporeal circulation was utilized together with hypothermia at 25°C without total circulatory interruption. The repair was inillated at the apposition zone of the single AVV with one or two stitches in figure-of-8s, preserving the tricuspid. Suturing the first bovine pericardial patch in drop-shape and fifting it between the chordae tendineae of the right side of the septum, followed by suturing of the second patch with simultaneous apposition with the single AVV and in this way, septing the 4 cavities. The advantages of this technique are: preservation of valve integrity, greater functional durability of the left AVV and reduced possibility of reoperation even in younger patients. The operation is performed preferably at the age of about 6 months.
Keywords: Heart valves, surgery; Heart ventricle, abnormalities; Heart ventricle, surgery; Atrium, surgery; Atrium, pathology
CASE REPORT
Utilization of auto-expandable stent introduced through the femoral artery for treatment of dissective aneurysm of the descending aorta
Braz J Cardiovasc Surg 12;
Publish in: 8/1/2025
We present a case of dissection of the thoracic descending aorta that underwent treatment with an auto-expandable Dacron - covered stent. The stent was deployed through the femoral artery in the hemodynamic laboratory after sedation, local anesthesia in both inguinal areas and systemic heparinization. The catheter with the stent was introduced through a cutdown in the left femoral artery till the area in the thoracic aorta with a previously diagnosed tear in it. The stent was expanded with immediate occlusion of the false lumen: the whole procedure took ninety minutes and the patient was discharged, without complication, 48 hours later. We believe that stent utilization is an important step to contribute to improve treatment results in type B dissection.
Keywords: Stents; Aneurysm, dissecting, surgery; Aortic aneurysm, surgery; Femoral artery, surgery
Left atrial myxoma: report of three cases
Braz J Cardiovasc Surg 12;
Publish in: 8/1/2025
Between October 1987 and July 1994 three patients presenting left atrial myxoma underwent surgery in our Service - Clínica Cárdio Cirúrgica de Juiz de Fora. Ages ranged from 20 to 35 years (average 29.6 years) and 66.6% of these cases were female patients. The occurrence of tachycardic palpitations was reported by all the patients (100%) following effort with dypnea, precordial discomfort and episodes of dizziness in two cases (66.6%). Non specific manifestations such as general uneasiness, prostration, anorexia and emaciation were reported by one patient (33.3%). None of the patients in this series presented previous embolic accident.The diagnosis of cardiac tumor was accomplished with the help of the two-dimensional echocardiography and the hemodynamic study. The confirmation of the myxoma was given by the histopathological study. Extracorporeal circulation was used in the surgeries and left atriotomy was used as an approach to the tumor. There were no complications during the surgery and post-operatively the patients evolved satisfactorily. All the patients were asymptomatic when discharged from the hospital.
Keywords: Myxoma, surgery; Heart neoplasms, surgery; Heart atrium, surgery; Myxoma, diagnosis; Heart neoplasms, diagnosis
Subclavian artery pseudoaneurysm after clavicle fracture: a case report
Braz J Cardiovasc Surg 12;
Publish in: 8/1/2025
The authors describe the left subclavian artery pseudo-aneurysm formation after blunt trauma followed by left clavicular fracture. Comments and a brief review of the literature are also mentioned.
Keywords: Aneurysm, false, etiology; Clavicle, injuries; Fractures, complications; Subclavian artery; Aneurysm, false, surgery; Subclavian artery, surgery
Aortocoronary bypass associated to Bentall - De Bono surgery: case report
Braz J Cardiovasc Surg 12;
Publish in: 8/1/2025
The Bentall and DeBono procedure is the surgery of choice for the repair of annulo-aortic ectasia. The association of such degenerative disease with coronary atherosclerosis is unusual. We report the case of a 57-year old patient with such association who underwent a Bentall and DeBono procedure and concurrent coronary artery by-pass graft (CABG). With the support of extracorporeal circulation and myocardial protection through retrograde cold blood cardioplegia, the following procedure was performed: composite replacement of the aortic valve and the ascending aorta for a valvular bovine pericardium tube graft, and CABG, using the anastomosis of the internal thoracic artery to the left interventricular artery and a segment of the saphenous vein connecting the internal thoracic artery with the marginal branch of the circunflex artery. Both, the surgery and the post operative period, were uneventful.
Keywords: Coronary arteriosclerosis, surgery; Aortic aneurysm, surgery; Aortic valve insufficiency, surgery; Myocardial revascularization