Volume 19 - Número 1
EDITORIAL
The words of Professor Domingo M. Braile
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
SPECIAL ARTICLE
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Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
ORIGINAL ARTICLE
Myocardial revascularization surgery using composite Y-graft of the left internal thoracic artery: blood flow analysis
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
OBJECTIVE: To assess the left internal thoracic artery (LITA) flow pattern, when it was used to supply the left anterior descending artery (LADA) and another branch from the left coronary artery system (LCAS).
METHODS: In the following study, the left internal thoracic artery flow was investigated by echocardiography Doppler, at rest and under dobutamine stress, in two twenty-patient groups. Group A consisted of patients who received only a pedicled LITA graft to the LADA. Group B consisted of patients who received a pedicled LITA graft associated with a vein graft to supply the LADA and another artery from the LCAS. The angiographic study showed graft patency in all patients from both groups. The following parameters were used: systolic flow (SF), diastolic flow, total flow, total flow in stress/total flow at rest ratio (TFS/TFR), systolic peak velocities (SPV), diastolic peak velocities and systolic peak velocity/diastolic peak velocity ratio.
RESULTS: All analysed parameters were considered statistically significant, except SF, TFS/TFR and SPV.
CONCLUSIONS: We concluded that in the same conditions and methodology, the LITA flow in the composite graft (group B) is higher than in the free graft (group A), which shows the great flow adaptability of LITA to respond to flow demand.
Keywords: Myocardial revascularization; Blood flow velocity; Internal mammary-coronary artery anastomosis; Echocardiography, Doppler; Echocardiography, stress
Midterm follow-up with exclusive use of arterial grafts in complete myocardial revascularization of patients with triple vessel coronary artery disease
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
OBJECTIVE: To evaluate the midterm benefits of exclusive use of arterial grafts in patients with triple vessel coronary arteriosclerotic disease who underwent complete myocardial revascularization.
METHOD: Between July 1995 and July 1997, 137 consecutive patients with triple vessel coronary atherosclerotic disease underwent complete myocardial revascularization exclusively using arterial grafts. Of these patients, 112 (81.7%) were male and the ages ranged from 36 to 78 years old (mean 56.5 years). Three hundred and sixty-three arterial grafts were used to perform 442 coronary anastomoses; an average of 3.2 coronary anastomoses per patient. Arterial grafts used were left internal thoracic artery (99.3%), right internal thoracic artery (56.2%), radial artery (94.9%), right gastroepiploic artery (13.9%) and inferior epigastric artery (0.7%). In 80 (58.4%) patients, arterial composite "Y" grafts were constructed with the left internal thoracic artery and another arterial graft.
RESULTS: No operative deaths occurred. Four (2.9%) deaths occurred in the post-operative period and only one (0.7%) patient needed reoperation in the early follow-up. The 7 year actuarial survival was 94.0% and the event free probability (myocardial infarction, angioplasty, reoperation or death) was 87.0%.
CONCLUSIONS: Good early and midterm clinical follow-ups can be achieved by exclusively using arterial grafts in the complete myocardial revascularization of patients with triple vessel coronary arteriosclerotic disease. A long-term follow-up will be necessary to show the influence of exclusive use of arterial grafts in the surgical treatment of coronary insufficiency.
Keywords: Myocardial revascularization; Mammary arteries; Arteriosclerosis
Methylene blue use in coronary artery bypass surgery: a prospective randomized study of the hemodynamic and inflammatory responses
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
OBJECTIVE: To assess the effects of methylene blue infusion on on-pump coronary artery bypass patients in relation to hemodynamic, laboratorial and systemic inflammatory response.
METHOD: Sixty patients were randomized in two groups. Methylene blue was infused in one group. Blood samples were collected before the anesthesia and, 3, 6, 24 and 48 hours after the end of the extracoporeal circulation to determine the IL-1b, IL-6, IL-8, IL-10, IL-12p40, TNFa and nitric oxide levels and perform gasometry and other routine tests.
RESULTS: In the methylene group we observed at different stages, higher systemic vascular resistance, lower TNFa concentrations, fewer leukocytes and neutrophils as well as lower level of nitric oxide. No adverse effects were evidenced.
CONCLUSIONS: Methylene blue infusion showed less tendency of systemic inflammatory responses, lower levels of nitric oxide and a better hemodynamic performance.
Keywords: Myocardial revascularization; Cytokines; Nitric oxide; Methylene blue
Mitral annuloplasty either in isolation or associated with posterior quadrantectomy in young patients
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
OBJECTIVE: To describe the mitral anuloplasty technique either in isolation or associated with posterior quadrantectomy and to analyze the immediate and late results in young patients.
METHOD: Between February 1986 and February 2001, 790 mitral valve procedures were performed in our Institution including 41 annuloplaties in patients with ages ranging from 1 to 20 years (Mean age = 9.7 years). 51.7% were males. The main etiologies were rheumatic disease (92.6%) and myxomatous degeneration (7.4%). Twenty-two (53.6%) patients were preoperatively in functional class III (NYHA), and 19 (46.4%) in class IV (NYHA), some in course of rheumatic fever aggravated by malnutrition. The technique employed was concentric mitral annuloplasty either in isolation or associated with posterior quadrantectomy. The follow-up ranged from 7 months to 15 years.
RESULTS: The hospital mortality rate was 2.4%. All patients were discharged without mitral regurgitation. Two patients coursed with mitral stenosis (after 4 and 11 years respectively) and valve replacement was needed. Two patients coursed with aortic insufficiency (after 12 and 18 months) and died after aortic valve replacement, contributing to a 5% late mortality rate.
CONCLUSION: In conclusion, mitral annuloplasty without ring either in isolation or associated with posterior quadrantectomy is a safe, easily reproducible especially in young patients.
Keywords: Mitral valve, surgery; Heart valve, surgery; Mitral valve insufficiency, surgery; Rheumatic fever, complications
Extended vertical transseptal approach in mitral valve reoperation with a small left atrium
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
OBJECTIVE: To evaluate the efficacy of the extended vertical transseptal approach in mitral valve reoperation with a small left atrium.
METHOD: From January 2001 to December 2002, 15 patients with previous mitral operations, small left atrium and atrial fibrillation underwent mitral valve surgery through an extended vertical transseptal incision. There were nine women and six men. Their ages ranged from 22 to 48 years. The main surgical indication was mitral prosthetic dysfunction in six patients, pure mitral regurgitation in five and mitral stenosis with regurgitation in four. Three patients had associated aortic regurgitation and one patient had associated tricuspid regurgitation. Nine patients (60%) were in congestive heart failure function class III (NYHA) and six patients (40%) in function class IV.
RESULTS: In all patients this approach provided excellent exposure. The cardiopulmonary bypass time ranged from 65 to 150 minutes (mean = 95 minutes). The mitral valve was replaced in 15 patients, the aortic valve in three and the tricuspid valve in one. One patient died secondary to cardiogenic shock and multiple organ failure (hospital mortality 7.1%). Another patient had pneumonia in the postoperative period (morbidity 6.7%). Ten patients remained in atrial fibrillation, three regained sinus rhythm and one was in nodal rhythm. The mean hospital stay was 8.2 days. Twelve patients (85%) have been in NYHA functional class I and two patients (15%) in functional class II. Actuarial survival rate at 22 months is 92.5%.
CONCLUSION: The extended vertical transseptal approach provides excellent mitral valve exposure without inherent complications.
Keywords: Mitral valve, surgery; Reoperation; Heart valve prosthesis implantation, methods; Heart valve prosthesis
Minimally invasive aortic valve replacement: a comparison of results with the traditional technique
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
OBJECTIVE: Minimally invasive cardiac surgeries are approaches used to reduce trauma, to give better cosmetic results and to reduce hospital costs with the same safety than conventional surgery. This study was designed to compare the operative results from patients who underwent minimally invasive aortic valve replacement with those who were submitted to the standard procedure.
METHOD: The operative and immediate post-operative results of 12 consecutive patients who received minimally invasive isolated aortic valve replacements from June 2002 to February 2003 were compared to 12 patients who underwent to traditional approach in the same institution. The minimally invasive access used was superior median hemisternotomy and cardiopulmonary bypass was established through ascendant aorta and right atrium cannulation, similar to the traditional technique.
RESULTS: The patient's demographics were similar in both groups. There were no significant differences between aortic clamping time, total bypass time and operating time. The skin incision length was statiscally shorter in minimally invasive group. In the postoperative course, the mechanical ventilation time and the total hospital stay were shorter, but not statiscally significant, in the minimally invasive group. The morbidity was the same in two groups.
CONCLUSIONS: This surgical approach provides adequate exposure of the cardiac structures necessary to perform a safe valve replacement. With the same instrumental used in the traditional surgery we can offer the benefits of a less invasive access with the same efficiency as in the conventional approach without add any risks to our patients.
Keywords: Aortic valve, surgery; Heart valve prosthesis implantation, methods; Heart valve diseases, surgery; Thoracotomy, methods; Surgical procedures, minimally invasive surgery
Modified Norwood procedure for hypoplastic left heart syndrome
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
OBJECTIVE: To show current results of a modified Norwood procedure, where only autologous tissues are used in the reconstruction of the new aortic arch.
METHOD: Between January and December of 2002, five neonates with hypoplastic left heart syndrome underwent the modified Norwood operation. Their ages ranged from two to nine days and their weight from 2.5 to 3.7 kg. The mean diameter of the ascending aorta was 6.2 mm. The surgical technique described by FRASER and MEE was employed using exclusively autologous tissue to achieve aortic arch reconstruction.
RESULTS: The systemic-pulmonary shunt was perfomed with a 3.0 mm PTFE graft in three patients and with 3.5 mm graft in the other two. Deep hypothermic and circulatory arrest were used in all patients with CP bypass time ranging from 128 to 212 minutes (mean: 154) and circulatory arrest from 41-60 min (mean: 52). There were no intraoperative deaths and all patients underwent delayed sternal closure. There was one postoperative death (9th day) caused by sepsis. There was one death two months after discharge cause by aspiration and pneumonia. One child underwent a 2-direcional Glenn and the other two are still waiting for the second stage.
CONCLUSION: After this initial experience with this modified Norwood operation we think this is an excellent alternative to correct hypoplastic left heart syndrome in neonates.
Keywords: Hypoplastic left heart syndrome; Heart defects, congenital, surgery
Effects of the pleural drain site on the pulmonary function after coronary artery bypass grafting
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
OBJECTIVE: To analyze the pulmonary function changes and pain in patients undergoing off-pump coronary artery bypass grafting utilizing a left internal thoracic artery graft, comparing the pleural drain insertion through the intercostal space and subxyphoid approach.
METHODS: Twenty eight patients (mean age 57.4 ± 8.4 years) were divided into two groups, according to the pleural drain site. Group IL (n=15) had the pleural drain inserted through the sixth left intercostal space at the mid-axillary line and in the IM group (n=13) the drain was placed through the subxyphoid region. All the patients underwent pre- and post-operative evaluation of pulmonary function tests as well as arterial blood gas analysis. Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were recorded in the preoperative period, and in the first, third and fifth postoperative days. The pain sensation was evaluated using a standard score from 0 to 10.
RESULTS: In both groups falls in FVC and FEV1 were noted, up to the fifth postoperative day (P<0.001). However, the decrease was higher in the IL group, when compared to the IM group (p<0.05). Also arterial blood gas analysis showed a decline of the partial oxygen pressure in both groups on the fist postoperative day, but more significantly in the IL group (p=0.021). The pain sensation was higher in the IL group (p=0.002).
CONCLUSION: Off-pump coronary artery bypass grafting with using of left internal thoracic artery, disregarding the pleural drain site, leads to a significant decrease of postoperative pulmonary function. However, the subxyphoid technique of drain insertion has shown a better preservation of the lung function when compared to the intercostal drain site.
Keywords: Coronary artery bypass surgery; Pleural drain; Pulmonary function
REVIEW ARTICLE
Stress echocardiography in coronary artery disease
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
Doppler echocardiography is a simple, fast and non-invasive method to identify abnormal regional and global left ventricular function. One could consider this non-invasive method to be the best approach within imaging techniques.
Stress echocardiography techniques are used for the diagnosis, risk stratification, prognosis and the study of myocardial viability in the ischemic heart disease. There are many ways to subject the heart to stress for echocardiographic studies. For physically fit patients exercise stress testing using a treadmill or bicycle is unemployed and patients who are unable to exercise undergo pharmacological tests.
Although accurate diagnosis and a high prognosis value are achivied with both methods, there are new techniques under study, including the utilization of echocardiographic contrast with microbubbles for endocardial edge evaluation and for myocardial perfusion studies.
Keywords: Stress; Echocardiography; Coronary disease
Malignant cardiac tumours
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
Neoplasms of the cardiovascular system are rare pathologies associated with non-specific signs and symptoms. Cardiac neoplasms should be considered when treating cardiac arrhythmia, Hiss-Purkinje conduction system dysfunction and ischemic syndromes. Tumors of the cardiac muscle are rhabdomyosarcomas that develop frequently in the left chambers, mainly the left ventricle.
Among endovascular tumors, the most common one is the myxoma of left atrium and its variant forms. Metastatic tumors of the heart, among them the malignant melanoma, affect the right ventricle more commonly (anterior wall and septum, with invasion of the left ventricle), in the non-disseminated form. Late diagnosis results in high morbidity and mortality rates whether surgical treatment is given or not. The authors describe the case of a right ventricle melanoma patient, comparing the diagnostic approach and treatment with published data. The treatment of choice of cardiac muscle malignant tumors (both primary and metastatic) is non-conclusive according to our literature review. Due to the low incidence of this pathology, the authors suggest additional meta-analytic studies should be performed to establish diagnostic and therapeutic criteria for the malignant tumors of the heart.
Keywords: Heart neoplasms; Melanoma; Myxoma; Arrhythmia; Cardiac surgical procedures
EXPERIMENTAL WORK
Experimental study with deccelularized porcine heterografts - the prosthesis of the future
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
OBJECTIVE: To make a comparative evaluation of the behaviour of cryopreserved homografts and deccelularized porcine heterografts implanted in the right ventricular outflow tract of juvenile sheep as well as to report the initial clinical experience with deccelularized pulmonary homografts in patients submitted to the Ross procedure.
METHOD: In group A, four cryopreserved homografts were implanted and group B consisted of four heterografts deccelularized with deoxicolic acid. In each group, two animals were sacrificed at 90 days and the other two at 150 days. The explants were evaluated macroscopically, and radiologically, besides histological examination with HE, Gomori and Sirius Red staining,. We also report our initial clinical experience with deccelularized pulmonary homografts in four patients submitted to the Ross procedure.
RESULTS: A ll the animals survived. By echo all the implanted valves had normal function. Although the cusps had normal appearance in both groups, calcium content was higher in the cryopreserved valves and radiologically there were traces of calcification in the cryopreserved valves but none in the deccelularized valves. Cryopreserved homografts lost their cellularity while deccelularized heterografts were progressivelly repopulated by fibroblasts and were partially reendothelized. Four patients submitted to a Ross operation with deccelularized homografts had a good clinical outcome with normal function in their right sided homografts.
CONCLUSIONS: Deccelularized heterografts were progressivelly repopulated by autologous cells and exhibted minimal tendency to calcification in this model. These results suggest that deccelularized heterografts may have some regenerative capacity and thus potencially greater durability than conventional cryopreserved homografts.
Keywords: Homografts; Tissue Engineering; Heart valve, surgery
CASE REPORT
Pedunculated thrombus at the transition of the ascending aorta to the aortic arch
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
A 52-year-old male alcoholic patient with hypertension and a prior history of brain ischemia was admitted to the neurosurgery department with signs and symptoms of ischemic stroke. A transesophageal echocardiogram and computed tomography suggested a possible pedunculated thrombus at the transition of the ascending aorta to the aortic arch. The therapeutic option was surgical treatment using cardiopulmonary bypass, deep hyperthermia and total cardiac arrest. The procedure involved resection of the aortic wall together with the thrombus to avoid recurrence. There were no adverse consequences and the patient was released from hospital with the use of oral anticoagulant drugs.
Keywords: Aorta, surgery; Aorta, pathology; Thrombosis; Thrombectomy
CLINICAL-SURGICAL CORRELATION
Case 1/2004 - Pediatric cardiology department, Hospital de Base, Medical School of São José do Rio Preto
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
Case 2/2004 - Pediatric cardiology department, Hospital de Base, Medical School of São José do Rio Preto
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025
LETTERS TO THE EDITOR
Letters to the Editor
Braz J Cardiovasc Surg 19;
Publish in: 8/1/2025