Volume 19 - Número 2
EDITORIAL
Words of Prof. Dr. Domingo Braile
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
SPECIAL ARTICLE
The situation of congenital heart surgeries in Brazil
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
ORIGINAL ARTICLE
Clinical and epidemiological characteristics of patients with Chagas' disease submitted to permanent cardiac pacemaker implantation
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
OBJECTIVE: To study patients with permanent cardiac pacemakers, comparing the clinical and epidemiological characteristics of patients with Chagas' disease versus the ones with degenerative or ischemic diseases.
METHOD: 57,632 procedures performed from 1995 to 2003, registered in the Brazilian Pacemaker Register were analyzed: 25,648 patients with Chagas' disease and 31,984 with degenerative or ischemic bradiarrythmias. The comparison of the characteristics of these two populations included Chi-square and t-Student tests, with a 5% level of significance.
RESULTS: There was a predominance of the Chagas' disease in the Centar-west region, in the initial implantations. In re-operations, the population with Chagas' disease represented majority in the Southeast, too. Mean age was 59.3 ± 15.3 and 58.6 ± 14.8, respectively for initial implantations and re-operations in Chagas' disease patients and 73.5 ± 12.6 and 73.7 ± 13.5, in non Chagas'disease patients. There was no difference in respect to both genders and etiology. Syncope episodes and 3rd degree AV block with wide QRS were more frequent in patients with Chagas' disease, and dizziness, heart failure and 3rd degree AV block with in the other patients. Ventricular pacing systems were used in 60% and 63% in the initial implants and 77% and 76% of the reoperations, respectively for Chagas' and non-Chagas' disease patients. The need to change the batteries was the main reason for reoperations in 76.1% and 79.6% of these procedures, respectively for patients with Chagas' disease and the other causes of bradicardia.
CONCLUSIONS: The analysis of data of these two populations demonstrated significant differences in the clinical and demographic characteristics.
Keywords: Cardiac Pacing, artificial; Chagas disease; Bradycardia; Medical Records Systems Computerized
Outcomes of mitral valve repair surgery in under 15-year-old patients
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
OBJECTIVE: To evaluate the evolution of under 15-year-old patients suffering from mitral valve reflux submitted to mitral valve repair surgery.
METHOD: A total of 117 under 15-year-old patients, submitted to mitral valve plasty from May 1980 to November 2001 were evaluated. Their ages ranged from 1 to 15 years old, with a mean age of 10 years. Seventy-four patients (63.2%) were female. The most common etiology was rheumatic disease (81.2%). Eighty-seven patients (74.4%) presented with mitral valve reflux and 30 (25.6%) also suffered from stenosis. Other diseases were associated in 28 patients (23.9%) with aortic valve disease being the most common (13.7%). Several techniques were employed in the valve repair such as the shortening or lengthening of the chordae tendineae and papillectomy.
RESULTS: The late evolution demonstrated that 96.6% of the patients survived and 88.9% retained their native valves. Fifteen patients (12.8%) underwent reoperations. The mitral valve was remodeled in all patients, with Gregori-Braile rings used in 69 (58.9%) of the patients and Carpentier rings in 35 (29.9%). The most commonly used techniques were shortening of the chordae tendineae in 66 patients (56.4%), and commissurotomy and/or papillectomy in 30 patients (25.6%). There was one hospital death (0.9%) and three late deaths (2.6%).
CONCLUSIONS: Reconstruction surgery to treat reflux of the mitral valve is possible, presenting results that support its use in under 15-year-old patients.
Keywords: Mitral valve, children; Mitral reflux, repair techniques
New technical and eletrophysiological approach for atrial fibrillation treatment
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
INTRODUCTION: The maze procedure for primary atrial fibrillation treatment, initially proposed by Cox, is somewhat complex and increases the morbidity risk originating from the isolated mitral valve surgery itself.
OBJECTIVE: To describe the surgical technique, the concepts of electrophysiology considered and the initial results of a new surgical and electrophysiological approach. Also the blocking of main atrial circuits as defined by Frame and optimization of the surgical tactic for atrial fibrillation treatment are considered.
METHOD: Eight patients with chronic atrial fibrillation and mitral valve dysfunction and with tricuspid valve regurgitation in one case were operated on. The following modifications of the classic Cox procedure were employed: 1. - Exclusion of the left atrium appendage by internal suturing to close its left atrial ostium; 2. - Exclusion of the right atrium appendage by one purse string suture used for the fixation of the superior vena cava draining cannula; 3. - Single atrial incision; 4. - Transendocardial electrocauterization of the left atrium wall around all the pulmonary vein ostia; 5. - Substitution of the incisions and sutures in the left atrium by transendocardial electrocauterization.
RESULTS: The cardiopulmonary bypass time varied from 64 to 133 min (mean 107.5 min) and the cardioplegia time was from 40 to 105 min. (mean 76.7 min). At the end of the surgery all patients were in regular atrial rhythm. The postoperative period was uneventful with all patients discharged from hospital showing regular atrial rhythm, without definitive pacemaker implantation. Six months after surgery, six patients were in regular atrial rhythm (75%) with preserved atrial contractions, and two (25%) with atrial fibrillation, clinically controlled (NYHA II). There was no evidence of embolic complications or thrombosis seen by Doppler echocardiography.
CONCLUSION: It is concluded that in this initial series of cases, the electrophysiolgical approach and the surgical technique employed improved the surgical treatment of atrial fibrillation enabling the correction of mitral and tricuspid valve lesions without additional morbidity.
Keywords: Atrial fibrillation, surgery; Atrial fibrillation, etiology; Arrhythmia, surgery; Heart valve diseases, surgery; Cardiac surgical procedures; Electrophysiology
Precocious structural and molecular (cDNA) changes in the human saphenous veins cultivated under arterial hemodynamic conditions
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
OBJECTIVE: The saphenous vein (SV) used in coronary artery bypass grafting is submitted to elevated and continuous shear stress. Occlusion of the grafts can occur in response to the new hemodynamic conditions. The aim of this study is to compare the precocious structural and molecular (cDNA) changes in saphenous veins grafts submitted to low pressure hemodynamic conditions versus systemic hemodynamic conditions.
METHOD: Forty sections of SV were cultivated "ex-vivo" under venous hemodynamic conditions (VHC) (without pressure, flow: 5 mL/min) and under arterial hemodynamic conditions (AHC) (pressure: 80 mmHg, flow: 50 mL/min). The following variables were analyzed: cellular viability (MTT assay) cellular density (hoeschst 33258 staining) and apoptosis (TUNEL assay), before and 1, 2 and 4 days after the procedure. "cDNA microarray" analysis of the SV sections was used to determine the precociously changed molecular targets in the veins cultivated under arterial conditions. The identification of these targets was achieved using a RNA homogenized pool of these vein sections, interacting on slides with 16,000 pre-determined human genes (Agilent Technologies slide). The genes with changed expressions were verified by real time PCR in the veins of 16 patients.
RESULTS: There was a gradual reduction in the cellular density and in the tissue viability in the saphenous veins cultivated under AHC, whereas no alterations were observed in the saphenous veins cultivated under VHC of up to 4 days. In the AHC group there were signs of a cellular apoptotic process (positive - TUNEL) from the first day after cultivation. In the VHC group these alterations were not observed. Although the cellular density was the same in the veins submitted to arterial conditions, after 24 hours of cultivation, many cells already showed signs of the apoptotic process. The Oncogene 3 and the Interleucin 1ß were the most common sites with alterations identified in this research. The Oncogene 3 expression was elevated in 11 (68.7%) of the veins cultivated under AHC, and the Interleucin 1ß expression was elevated in 9 (56.2%) of these vein sections (p<0.05).
CONCLUSION: The "ex vivo" study model was able to mimic events that occur "in vivo" by SVs utilized in the coronary artery bypass grafting. In the AHC group precocious loss of cellular viability (apoptosis) and significant elevation in the Oncogene 3 and Interleucin 1ß genic expressions were observed. The long-term follow up of these patients is important to determine the real effect of these immediate changes in the patency of the vein grafts.
Keywords: Myocardial revascularization; Gene Expression; Saphenous Vein
Left ventricular function after plication of the left ventricular free wall in dogs*
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
OBJECTIVE: We tested a new surgical technique, the plication of the left ventricular free wall, to reduce left ventricular area and volume and improve left ventricular systolic function, without using a cardiopulmonary bypass.
METHODS: Dilated cardiomyopathy was induced in eight dogs by the injection of doxorubicin. Plication of the left ventricular free wall was performed in four dogs with induced cardiomyopathy and in five control dogs. Two dogs not submitted to surgery. The other two dogs died during the induction phase. Cardiac output, 2-dimensional and M-mode echocardiography, arterial blood pressure and electrocardiography were recorded over a 180 days period. Ambulatory electrocardiography of 24 hours was performed during the first postoperative day.
RESULTS: The cardiomyopathy-induced group had significant improvements in cardiac output, ejection fraction, shortening fraction and reductions in the left ventricular end-systolic, end-diastolic area and volume after the surgery. One dog died. Electrocardiography and Holter revealed premature ventricular complexes, which improved spontaneously at the first week. The cardiomyopathy-induced dogs that did notundergo surgery deteriored and died about 40 days after the induction of cardiomyopathy. Hemodynamic values did not change in the normal dogs submitted to the surgery.
CONCLUSION: The plication of the left ventricular free wall reduced the left ventricular area and volume and improved left ventricular systolic function in dogs with doxorubicin-induced cardiomyopathy giving low morbidity and mortality.
Keywords: Myocardial diseases, surgery; Cardiomyopathy, congestive, surgery; Heart ventricles, surgery; Doxorubicin; Dogs
In vivo endothelialization of cardiac bioprostheses: conventional versus non-aldehyde preservation
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
OBJECTIVE: A protective layer of endothelial cells (EC) of host origin on the entire surface of bioprosthetic heart valves has never been reported. Current commercial bioprosthetic heart valves are commonly preserved in glutaraldehyde (GA) and are cytotoxic to host cells preventing spontaneous endothelialization. The aim of this study is to demonstrate the potential for in vivo endothelialization of heart valves treated by the L.-HydroT preservation process.
METHOD: L-HydroT preservation process consists of mild extraction of antigenic substances by the action of polyethyleneglycol and incorporation of an anti-inflammatory and a anti-thrombotic agent. Seven stented porcine valves treated by the L-HydroT process and three GA-fixed porcine valves were implanted in the mitral position of juvenile sheep. The valves were evaluated by echocardiography and angiography prior to sacrifice at five months. Recovered valves were also histologically and histo-chemically evaluated.
RESULTS: There were no hemodynamic differences between the groups. However, scanning and transmission electron microscopy showed a nearly complete coverage of EC on the surfaces of all leaflets in the L-HydroT treated valves. The EC were in direct contact with the underlying collagen layer and expressed von Willebrand-related antigens (vW). The surfaces of the GA-treated valves were covered by fibrin deposition, macrophages, calcium and thrombotic material. Only sparse EC were observed and contact of the EC where the underlying tissue was incomplete.
CONCLUSION: These data indicate that L-HydroT treated porcine valve tissues are capable of inducing spontaneous endothelialization with evidence of strong cell attachment of the new endothelium to the collagen matrix.
Keywords: Bioprosthesis; Heart valve prosthesis; Glutaral
Minimally invasive procurement of saphenous veins for coronary artery bypass grafting
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
OBJECTIVE: To comparatively analyze minimally invasive procurement of saphenous veins using Mini-Harvest® system and a technique using adapted traditional instruments.
METHOD: From June 1996 to January 1999, 63 patients who were submitted to Coronary Artery Bypass Grafting Surgery had their saphenous veins resected using minimally invasive techniques. In the first 30 patients of the series, a direct visualization method employing two Langenbeck's retractors was utilized and for the 33 remaining patients the Mini-Harvest® technique was utilized.
RESULTS: The mean age of the patients was 61 ± 8.75 years old. Fifty-two patients were male and 11 female. Forty-five patients were diabetics, 45 were overweight or obese, 25 were smokers and 32 presented history of myocardial infarction. The mean time to resect the saphenous vein using the Langenbeck's retractors was 34.2 ± 8.14 minutes and using the Mini-Harvest® it was 39.20 ± 9.12 minutes. The lenghts of the extracted veins were similar in both groups, varying between 10 and 30 cm. There was one case of superficial dehiscence in the Langenbeck group. With two patients in the Mini-Harvest® group and one in Langenbeck's group it was necessary to revert to the traditional method of procurement. The incidence of tran-soperative infarction was 4.5% (three patients) in Langenbeck's group and 3.1% (two patients) in the Mini-Harvest® group.
CONCLUSIONS: We can conclude that the minimally invasive procurement methods of the saphenous vein by direct visualization are effective and safe, both when employing adapted traditional instruments and using purpose-made retractors. We stress, however, that the Mini-Harvest® method does not require an assistant.
Keywords: Myocardial revascularization; Cardiac surgical procedures, methods; Saphenous vein, surgery, methods; Surgical procedures, minimally invasive
Effects of diazepam, midazolam, propofol and etomidate in myocardial contractility and coronary blood flow: comparative analysis in isolated rat's hearts
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
OBJECTIVE: The effects on myocardial contractility (dT/dtmax) and coronary blood flow (CBF) of common drugs used in clinical practice (diazepam, midazolam, propofol and etomidate) were studied.
METHOD: Fifty Wistar rat's hearts were divided into five groups of ten, and perfused by Langendorff method with Krebs-Henseleit solution (K-H), with the perfusion pressure stable at 90 cm H2O and temperature at 37.0+0.5 °C. With the exception of the Group I (control), they were submitted to single one-minute infusions of diazepam (50 micrograms) - Group II; midazolam (25 micrograms) - Group III; propofol (25 and 50 micrograms) - Group IV and etomidate (25 micrograms) - Group V. The drugs were diluted in 0.1 mL of K-H solution and the CBF rate and the perfusion pressure controlled during their infusion.The heart rate (beats per minute), myocardial tension (grams) and coronary blood flow (millimeters per minute) were measure at 1, 3, 5, 10, 15, 20, 25 and 30 minutes. The myocardial contractility was obtained by calculating the first derived tension/time (dT/dtmax), at each time interval.
RESULTS: The heart rate showed variations in Groups I, III and IV. A variation in the myocardial tension was seen in all groups except Group I and alterations in the CBF were seen in all groups, except in Group IV during the experiment. The myocardial contractility decreased in all groups, except for Group I.
CONCLUSION: The assayed drugs diminished the myocardial contractility (p<0.05); the variations of the coronary blood flow were not directly correlated to those that occurred with the myocardial contractility.
Keywords: Myocardial contraction; Diazepam; Midazolam; Propofol; Etomidate
Predictors of mediastinitis after cardiac surgery
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
INTRODUCTION: Mediastinitis is a serious complication of open-heart surgery, with an incidence that varies from 0.4% to 5%, mortality from 10% to 47% and a high morbidity rate.
OBJECTIVE: To identify preoperative and trans-operative risk factors of mediastinitis after open-heart surgery in our hospital.
METHOD: This was a prospective study of 1298 patients submitted to the open-heart surgery in São Lucas hospital in the period from March 1997 to May 2000. Nine potential risk factors associated with mediastinitis were studied (obesity, diabetes mellitus, chronic obstructive pulmonary disease -COPD-, internal mammary artery, cardiopulmonary bypass time, smoking, gender, ejection fraction and previous heart surgery) using univariate analysis, where necessary followed by multivariate logistic regression.
RESULTS: Of the 1298 studied patients, 62.6% were men and 18.3 suffered from diabetes. Thirty-eight patients (2.9%) presented with mediastinitis postoperatively, and six (15.8%) of these died. Four variables identified as risk factors by univariate analysis (p<0.05) and were after analysed by logistic regression. Three variables were identified as independent predictors of mediastinitis: obesity (p=0.008), COPD (p=0.007) and diabetes mellitus (p= 0.009), even when gender and age were analysed. The internal mammary artery graft was observed as risk predictor only when associated to the obesity.
CONCLUSION: In our hospital, mediastinitis occurs most frequently in patients suffering from obesity, diabetes, and/or COPD and in the obese patients in which internal mammary artery was used.
Keywords: Mediastinitis; Mediastinal infection; Cardiac surgery, infection; Surgical infection
REVIEW ARTICLE
Robotic systems in cardiovascular surgery
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
The development of robotic systems for surgery started in the 80's, motivated by the US army's need for surgical procedure in field hospitals with surgeons in a distant location (tele-presence). But the first human application of robotic surgery occurred years later in a transurethral resection for benign prostatic hyperplasia.
Cardiac surgeons were attracted to the robotic techniques because of the potential reduction in the invasive character of the procedures. This results in reduced trauma, a reduction of pain and morbidity, a faster recovery and lower cost of surgery. Robotic systems were developed, allowing totally thoracoscopic cardiac surgery for myocardial revascularization and multi-site pacemaker implantation in selected cases. Video-thoracoscopic support systems for internal thoracic artery harvesting, mitral valve reconstruction and correction of congenital heart defects also exist. We used the AESOP® system with HERMES® voice control to harvest the internal thoracic artery, trans-thoracic implantation of the left ventricular electrode and as an approach to congenital heart defects for surgical repair.
In spite of scientific enthusiasm related to robotic surgery, there is no clear evidence of superiority of this technique when compared to conventional procedures in terms of results. The same is true with the cost of the procedures, and even if a single robotic surgery is less expensive, the initial investment for a complete robotic system (console, video control, instruments) can be compensated only with many procedures over the long term. But there is no doubt that robotic surgery will have a place in the future of surgery, providing tele-presence of the surgeon, enabling teaching and training and performing less invasive surgical procedures.
Keywords: Cardiac surgical procedures, methods; Surgical procedures, minimally invasive; Robotics
HOW I DO IT
Endoscopic harvest of internal thoracic artery with robotic assistance
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
Robotic surgery is today a reliable method to reduce trauma and related comorbidities in cardiac surgery. In our institution, robotic assistance has been effectively used for thoracoscopic implantation of epimyocardial leads for biventricular pacing. The objective of this article is to describe the technique that we developed to dissect the internal thoracic artery using thoracoscopy assistance with the AESOP robotic system and to report the initial results obtained with its use in nine patients.
Keywords: Robotics; Cardiac surgical procedures, methods; Surgical procedures, minimally invasive
CASE REPORT
Surgical treatment of aortic-left ventricular fistula
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
An 8-months-old boy, presenting with heart failure and murmur was investigated using echocardiogram and cardiac catheterization revealing a fistula (aortic-leaft ventricular tunnel) between the aorta and the left ventricle, bypassing the aortic valve and thereby causing massive regurgitation through this tunnel as was demonstrated by Doppler ultrasonography. The patient was submitted to surgery to occlude the tunnel through the aortic orifice under cardiopulmonary bypass. A postoperative echocardiogram revealed complete occlusion of the tunnel and the patient is completely free of symptoms.
Keywords: Tunnel, heart; Tubular communication, aortic regurgitation; Surgery
CLINICAL-SURGICAL CORRELATION
Case 3/2004 - Pediatric Heart Surgery, Hospital de Base Medical School, São José do Rio Preto
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
Case 4/2004 - Pediatric Heart Surgery, Hospital de Base, Medical School, São José do Rio Preto
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
LETTERS TO THE EDITOR
History of female doctors in Brazilian Cardiovascular Surgery
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025