Volume 16 - Número 1

Introduction: Myocardial revascularization without cardiopulmonary bypass is today an increasing alternative of revascularization although the limits of applicability are still to be defined. The authors review a series of cases and discuss its indications based upon their results. Patients and Methods: There were analyzed 2495 patients who underwent direct myocardial revascularization without extracorporeal circulation in the period from October 1981 to September 1999, from a total of 10656 patients, submitted to coronary bypass surgery during this period (23.4%). The age varied from 32 to 90 years (medium = 59) with most males (67%). Chronic coronary insufficiency was the most common surgical indication (70.8%) and the majority of the patients received 2 grafts (51.5%). Results: The global mortality rate (30 days) was 1.9% (48/ 2495) and only 45% of these patients needed blood transfusion. The global applicability of this technique was around 23%, however in the last 3 years the applicability was 32.8%, 35.1% and 42.2%. Conclusions: Myocardial revascularization without extracorporeal circulation is a safe tactical alternative for coronary insufficiency and has increased in the last years. This treatment is indicated in this subgroup of lower mortality and small incidence of postoperative complications. In the next years the use of this technique will increase with the use of stabilizers, special manipulation and functional revascularization. Keywords: Myocardial revascularization, methods; Extracorporeal circulation; Cardiac output, low, sugery; Surgical procedures, minimally invasive; Cardiac surgical procedures, methods

Background: This study tests the hypothesis that initial brief periods of ischemia could improve the protection obtained by intermittent aortic cross-clamping. Methods: In the control group (18), the procedure was performed under intermittent aortic cross-clamping at 32oC. Patients in the preconditioned group (17) received a stimulus of two 3-min periods of cross-clamping followed by 2 min of reperfusion prior to standard operation. CKMB, troponin I, adenosine and lactate were obtained from the great cardiac vein at the onset of cardiopulmonary bypass (CPB) (1), at the end of the first anastomosis (2) and at the end of CPB (3). Results: CKMB and troponin I presented a slight trend to be higher at the end of CPB in the control group, while there was no difference between adenosine and lactate levels. Conclusion: Ischemic preconditioning showed no significant improvement in myocardial protection. Keywords: Isquemic preconditioning, myocardial; Myocardial revascularization, methods; Aorta, surgery; Myocardial ischemia, physiology

Background: This study analyzes the experience of 3116 cases of coronary artery by-pass grafting revascularization of our group and define the percentage of early and late patency of the venous grafts. We also look this issue under the new concepts of endothelial reaction, influence of various drugs and improvement of surgical techniques. Material and Methods: From September 1971 until August 1998, 3116 cases of myocardial revascularization with cardiopulmonary by-pass were operated in our service. The surgical procedures were analyzed separately regarding the type of grafts used in each case; exclusively venous grafts, exclusively arterial grafts and venous and combined arterial grafts . We also made the analysis in three different periods, 1971-80, 1981-90 and 1991-98. The incidence of reoperation was analyzed trying to identify the patency of the different types of grafts and their results. Results: The age of the patients varied from 22 to 85, with a mean of 52.4 years, male sex was predominant with 68.4%. The mortality varied from 1.7% for vein grafts revascularization to 15.8% when associated complex procedures were done. Of the 3116 patients, 255 were reoperated, being 3.8% with isolated internal thoracic artery and 8.1 % isolated vein graft. Conclusions: a) The immediate result of vein grafts patency was dependent upon the surgical handling during vein harvesting and preparations, care during anastomosis and quality of coronary arteries. b) The late results in the 5th and 10th year were influenced by the spectrum of the arteriosclerosis. c) Patients with vein grafts represent the majority of reoperations when compared with those who received arterial grafts. d) There is a possibility of increasing vein grafts patency by a better handling of the graft, use of drugs such as calcium blockers, papaverin, aprotinin, nitrates and the prophylaxis of arteriosclerosis. Keywords: Myocadial revascularization, methods; Mammary arteries, transplantation; Saphenous vein, transplantation; Mammary arteries, physiopathology; Saphenous vein, physiopathology

Background: Cardiac insufficiency is one of the most important problems challenging the public health resources in the modern world. The partial left ventriculectomy (Batista's Operation) is the most recent surgical treatment for the end-stage heart failure but, until now, without specific reports in the cardiovascular literature regarding its results in elderly patients. Objective: To study the results of the Batista's Operation in aged patients. Method: From May 1995 to December 1997, ten patients aged 62 to 78 years, suffering from dilated cardiomyopathy (class IV NYHA), were treated with the partial left ventriculectomy procedure in the Cardiothoracic Surgical Clinic of the Cardiothoracic Surgery Department of Mato Grosso do Sul Federal University ¾ (University Hospital Nucleus). Results: Nine (90%) patients were discharged from the hospital and one (10%) patient died in the 6th postoperative day from respiratory insufficiency. An elliptical resection was performed in the lateral wall of the left ventricle, from the apex to near the atrioventricular groove and between the papillary muscles. Dimensions of the removed fragment (mean values): 10.8+1.3 cm x 5.0+0.6 cm. The echocardiographic control has proved: FE = fractional shortening, EF = ejection fraction, LVSD = left ventricular end-systolic diameter, LVDD = left ventricular end-diastolic diameter, DVL = diastolic volume lowering and SVR = systolic volume rised. In the late follow up three patients were in NYHA class I, three patients in class II and one in class III. The actuarial survival rate were 100%,87%,87% and 67% for 6, 12, 24 and 36 months respectively. Conclusion: The partial left ventriculectomy performed in elderly patients with cardiac insufficiency with severe hemodynamics disfunction resulted in 10% mortality, promoted important recovery of the cardiac performance by: improvement of NYHA functional class, enhancement of the ejection fraction and left ventricular % systolic shortening; reduction of the left ventricular systolic and diastolic diameters and determining better ventricular volume/mass ratio. Keywords: Cardiomyopathy, congestive, sugery; Heart ventricle, sugery; Cardiomyopathy, surgery, aged; Myocardial insufficiency, transplantation

The right ventricle dysfunction in the post-operative period of the heart transplantation (HTx) surgery is a frequent complication with high morbidity and mortality . In order to reduce the high pulmonary vascular resistance (PVR) and pulmonary artery pressure (PAP), often found in the patients candidates to HTx, it is, sometimes, necessary to use endovenous infusion of sodium nitroprusside (NaNTP) (the pharmacologic test), during the pre-operative hemodynamic assessment of the pulmonary circulation, in attempt to reduce the PVR and PAP to compatible levels, allowing the inclusion of these patients in the HTx program protocol. Values of PVR over 6 Wood units without drugs (such as NaNTP) or 2.5 Wood units with drugs will exclude the patient from the HTx program. Between January 1997 and January 2000, 40 patients (70% males) (mean age = 42 +/- 12), candidates to HTx were submitted to cardiac catheterization (right side). 24 patients (59%) had dilated idiopathic cardiomyopathy, 10 (25%) ischemic myocardiopathy. All were in Class IV (NYHA), with mean left ventricular ejection fraction (LVEF) of 0.21 (+/- 0.03). Continuous measurement of the cardiac output, PAP and RVP were done with the help of a special Swan-Ganz catheter. In 5 patients the pharmacologic test was interrupted owing to systemic effects of NaNTP (important drop of arterial blood pressure and cardiac output). Then, they were submitted to inhalation of 20 ppm of nitric oxide (NO), though facial mask, during 10 minutes, in three patients the RVP dropped from a mean of 7.8 (+/- 0.88) to 2.4 (+/- 0.36) Wood units and so they could be included in the transplantation program. The two other patients did not achieve RVP drops enough to be candidates to HTx, once, even though the amount of NO inhaled had reached 20, 30 and 40 ppm, the reduction of the RVP was from 8,4 (+/- 2.12) to 4,9 (+/- 0.42) Wood units. There were no deaths or complications during these producers. The NO inhalation during hemodynamic evaluation of candidates to HTx, owing to its selective vasodilator effect, allows us to identify those patients with pulmonary vascular hyperresistance, who do not respond to the use of endovenous vasodilator drugs, thus avoiding them to be excluded from the benefits of the HTx. Keywords: Nitric oxide, administration & dosage; Vasodilator agents, administration & dosage; Heart transplantation; Hypertension, pulmonary; Ventricular dysfunction, right, prevention & control; Vascular resistance; Preoperative care

Two adjustable pulmonary artery banding devices were implanted in 14 young goats to evaluate their efficacy for the training of the pulmonary ventricle (right ventricle). An obstructing balloon catheter was placed in the lumen of the pulmonary artery in 7 animals (group I) and other 7 animals (group II) underwent implantation of an external pulmonary banding device. As a control group for septum, left and right ventricle weights a third group of 7 animals was used. Right ventricle (RV) load was increased gradually, at 24 hours intervals, for 96 hours. RV muscle mass evolution was assessed by echocardiography and by optical microscopy. All animals completed the protocol. RV to PT pressure gradient, RV to LV ratio, and RV systolic pressure were significantly higher in group II (p<0.05). A significant increase in the RV wall thickness was observed in groups I and II. RV dry weight and indexed weight were higher in groups I and II (p<0.05), with no difference between them (p>0.05). Myocyte perimeter and cross-area increased at the end of the training interval. We concluded that both devices are able to induce a similar degree of pulmonary ventricle hypertrophy, despite higher pressure gradients with the external banding device. Keywords: Heart ventricle, surgery; Pulmonary artery, surgery; Cardiovascular surgical procedures, methods; Hypertrophy, left ventricular, etiology; Heart ventricle, physiology; Hipertrophy, left ventricular, surgery; Ventricular outflow obstruction

Introduction: Permanent pacing implantation is a very low risk procedure. However, infectious complications, specially in the pacemaker generator pocket, are the most common one with incidences (1 to 5%). These patients have been treated by many different therapeutic proceduros with controversial results. It has been well demonstrated that eradication of the infection is extremely difficult and the best results are reached through radical surgery consisting of removal of the pacemaker generator and electrode associated to antibiotic therapy. These procedures are related to high morbidity and expense. Muscle flaps are thought to have the ability to survive a bacterial inoculation and control infection. It also brings a rich network of blood supply to an infected and poorly vascularized area. Based in these facts we developed a new technique for the treatment of the generator pocket infection that is the subpectoral pacemaker implantationn. Material and Methods: Between January 1996 and March 2000, a total of 574 pacemakers were implanted or reimplanted at Santa Casa de São Paulo. Infection at the site of implantation developed in 6 instances (incidence of 1.11%) and two extrusions of generator without apparent infection. Four patients had infection involving only the pacemaker pocket and two patients had sepsis. The organisms cultured were Staphylococcus aureus, Streptococcus epidermis and Pseudomonas. At pacemaker pocket infection instances and in the pacemaker extrusion the patients were treated by this new approach associated to antibiotic therapy. Results: There were no deaths, reinfection or failure of treatment. The mean hospital stay was 7.3 days and antibiotic therapy 7 days. The follow up is five months to four years. Conclusions: The subpectoral pacemaker implantation technique is a good alternative for cases of pocket generator infection with low morbidity and good finals results. Keywords: Cardiac pacing, artificial; Cardiac stimulation, artificial; Cardiac pacemakers implantation; Cardiac pacemakers, adverse effects; Pacemakers, artificial, adverse effects; Bacterial infections, therapy

Because of the low patency rate of saphenous vein grafts, the use of arterial grafts for myocardial revascularization has been increased. The revascularization of the left anterior descending coronary (LAD) with the left internal thoracic artery (ITA) is the gold standard in almost all centers in the last 15 years. There are also evidences that one additional arterial graft decrease short and long-term (10 years) morbi-mortality. Radial artery is an excellent choice for the second arterial graft because of good midterm patency (84-92% vs 70-80% of saphenous vein in 5 years). Spasm, a potential problem in arterial grafts, occurs in 5 to 10% of radial grafts. Nitroglicerin and nitrates are the most effective drugs in its control and calcium antagonists did not show any clinical benefit. The Allen test alone has been effective to assess patency of collateral blood flow and palmar arch continuity. It seems reasonable, therefore, to suggest association of another arterial graft with left ITA in attempting to improve the results of CABG and that this other graft be the radial artery. Keywords: Myocardial revascularization, methods; Mammary arteries, transplantation; Radial artery, transplantation; Saphenous vein, transplantation

The case of a patient presenting sternum erosion provoked by aneurysm of the ascending aorta and proximal hemi-arch of syphilitic etiology is described, the surgical approach was bilateral thoracotomy, using deep hypothermia and total circulatory arrest. A bovine pericardium patch was anchored for reapair of the ascending aorta and proximal aortic hemi-arch and another patch placed between the brachiocephalic trunk and the lateral wall of the bovine pericardium patch. The anterior interventricular artery was revascularized orving to occlusion of the ostium of the left coronary artery. Three years after surgery the patient is asymptomatic. Keywords: Aortic aneurysm, thoracic, surgery; Sternum, surgery; Sternum, pathology; Aortic aneurysm, complications; Aorta, surgery

Infective endocarditis is a frequent complication for valvar prosthesis currently treated with surgery, orving to its difficult control and poor response to therapy with antibiotics. Although conservative surgery for infective endocarditis of prosthesis is not a procedure of choice, this report shows a case of infective endocarditis of aortic and mitral prosthesis, after 24 months of implantation, treated by conservative surgery with favorable outcome. Keywords: Endocardites, bacterial, surgery; Heart valve prosthesis implantation, adverse effects; Aorta, surgery; Mitral valve, surgery; Aortic valve, surgery

The objective of this paper is to present a new systematization of the Vineberg Procedure's technique providing a valid and feasible operation. It consists in implanting a long segment of the internal thoracic artery into the ventricular wall utilizing an introductory sheath to create the tunnel. Keywords: Myocardial revascularization, methods; Cardiovascular surgical procedures, methods; Extracorporeal circulation; Thoracic artery, left, surgery; Thoracic artery, left, transplantation