Volume 19 - Número 4
EDITORIAL
The words of Professor Dr Domingo M. Braile
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
SPECIAL ARTICLE
Authorship criteria for scientific papers: a polemic and delicate subject
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
Aspects related to the authorship of scientific publications, inherent responsibilities, unethical practices and criteria for definition are discussed in this article. Moreover, the article presents a reflection on the role of editors of scientific journals in respect to inpproper authorship, reinforcing the importance of the issue and suggesting ethical criteria for its determination.
Keywords: Authorship; Journal Article (Publication Type); Periodicals; Scientific communication; Scientific production
ORIGINAL ARTICLE
Evaluation of the cardiac morphological alterations secondary to the pulmonary emphysema: experimental study in rats
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
OBJECTIVE: The purpose of this study is to evaluate the occurrence and repercussions of chemically induced pulmonary emphysema and the morphological alterations present in rats' hearts of post-induction and to follow the progression afterwards.
METHOD: Seventy five rats divided into two groups: papain (N=50) and control (N=25), were submitted to intratracheal instillation of papain and saline solution, respectively, and were evaluated. The animals were sacrificed 30, 60, 90, 120 or 180 days post-instillation. Arterial blood gases and cardiac and pulmonary morphometrical analysis were performed.
RESULTS: Papain instillation produced alveolar tissue destruction similar to the morphological alterations observed in pulmonary emphysema. The papain group presented mean alveolar diameter higher than controls in all periods evaluated (p<0.05). Right ventricle wall thickness and interventricular septum did not show significant macroscopic alterations until six months after emphysema induction. The right ventricle area presented enlargement 120 days after induction of the pulmonary emphysema, with mean area higher than control at 120 e 180 days (p=0.001). The left ventricle presented significant cavity area decrease 90 days after induction of the pulmonary emphysema, followed by slight wall thickening.
CONCLUSIONS: The adopted experimental model was efficient to morphologically induce the pulmonary emphysema. The presence of pulmonary emphysema did not provoke morphological changes in the right ventricle wall and interventricular septum. The alveolar destruction induced left ventricular hypertrophy and enlargement of the right ventricle.
Keywords: Pulmonary emphysema, chemically induced; Pulmonary emphysema, physiopathology; Papain, pharmacology; Disease models, animal; Heart ventricle, anatomy & histology
Importance of cardiac troponin-I in the preoperative period of patients without prior cardiac events but suffering from left coronary branch obstruction
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
OBJECTIVE: To evaluate the importance of cardiac troponin-I serum levels in the preoperative period of patients suffering from left coronary branch obstruction but without prior cardiac events.
METHOD: The cardiac troponin-I serum levels of 115 patients with obstructive coronary disease were analyzed. The ages of the patients varied between 32 and 81 years old with a mean age and standard deviation of 59.7 ± 10.5 years. The patients were divided into two groups: Group A, 41 patients suffering from left coronary branch obstruction with the degree of obstruction varying between 20% to subtotal occlusion (about 60%) and Group B, 74 patients without left coronary branch obstruction. All the patients were submitted to catheterism and no evidence of previous acute myocardial infarction (AMI) was identified. Chemoluminescence was utilized to measure the cardiac troponin-I level using the Sanofi-Pasteur Access apparatus, with values of less than 0.l nanograms per milliliter (ng/ml) considered normal.
RESULTS: No association was evidenced between the degree of left coronary branch obstruction and troponin-Ic serum levels (P= 0.4617), however the average serum levels of troponin-I, in Groups A and B were 0.3841 ng/mL and 0.1711 ng/mL respectively (P=0.0324 Mann-Whitney test; OR = 4.44 95% CI 1.60 - 12.31).
CONCLUSIONS: The patients of Group A have 3.44 times higher chance of presenting with myocardial injury as identified by increased cardiac troponin-I levels than Group B, independent of the degree of left coronary branch obstruction. The sensitivity of clinical suspicion of myonecrosis was relatively low (31.7%), but the specificity was high (90.5%). However the clinical importance of the documentation of myonecrosis in a determined percentage of patients with branch injury without electrocardiographic evidence is stressed. Thus, patients with left coronary branch obstruction should be quickly submitted to operative procedures, in order to avoid worsening of the myonecrosis.
Keywords: Troponin I; Biological markers; Coronary disease; Myocardial ischemia; Myocardial infarction
Physiologic left ventricular reconstruction: the concept of maximum ventricular reduction and minimum inflammatory reaction
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
BACKGROUND: The outcome of patients with heart failure, as well as after left ventricular reconstruction, is related to the size of the left ventricular cavity. Also the use of synthetic materials in the ventricular reconstruction could induce a chronic myocardial inflammatory reaction. We report on a modification of the ventricular reconstruction technique that eliminates the need of intraventricular patches and the use of synthetic material.
METHOD: Eleven consecutive patients presenting with left ventricular aneurysms, evolving to functional class III and IV of the New York Heart Association, underwent direct left ventricular reconstruction surgery without the use of intraventricular patches or prosthetic strips.
RESULTS: There was no operative mortality or need of mechanical circulatory support. The postoperative hospital stay ranged from 4 to 7 days (average 5.3 ± 1.1 days). The serial echocardiogram control showed reduction of the left ventricular diastolic diameter (from 69.0± 7.5 mm preoperatively to 62.6 ± 5.1 mm postoperatively). The left ventricular ejection fraction increased from 47.3% ± 6.6% to 56.3% ±10.5%. One-year follow-up revealed eight patients in functional class I and three in class II.
CONCLUSION: This technique, with elimination of prosthetic materials, could contribute to an improvement of the clinical results in patients who undergo left ventricular reconstruction, providing virtual elimination of left ventricular akinetic areas and potentially attenuating the long-term myocardial chronic inflammatory reaction.
Keywords: Heart aneurysm, surgery; Heart ventricles, surgery; Left ventricular dysfunction; Myocardial revascularization
Similar results of valve replacement with normal aortic annulus or anterior and posterior annular enlargement
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
OBJECTIVE: To compare results of aortic valve replacement in patients with normal valve annulus and in those requiring annular enlargement.
METHOD: Study includes 22 patients submitted to anterior and posterior annulus enlargement and 23 patients with a normal aortic annulus. Both groups were matched in gender, age, valvar lesion, etiology of cardiac disease and associated lesions. Patients with normal annuli had usual valve replacement. For those who required annular enlargement, posterior enlargement was performed by incision in the mid portion of the non-coronary sinus up to the anterior mitral leaflet. Anterior enlargement resulted from an incision between left and right coronary ostia extended to the ventricular septum for 2 cm. The aorta was reconstructed using bovine pericardium patches. The diameter of aortic annulus at surgery, clinical evolution (2 to 11 years follow-up) and left outflow tract obstruction (Doppler echocardiography) were considered.
RESULTS: Enlargement increased aortic annulus from 18.3±2.2 mm to 24.8±2.0 mm (p<0.001), a value similar to those with normal aortic annulus: 24.9±1.5 mm (NS). Cardiopulmonary bypass time was longer in patients with enlargement (122.1±38.9 min vs 91.0±30.7 min; p<0.005), as was aortic cross-clamp time (91.6±20.7 min vs 68.0±23.5 min; p<0.001). For annular enlargement, peak systolic gradient at the prosthesis decreased from 83.6±22.3 mmHg (pre-operative) to 26.7±11.4 mmHg (p<0.01) in the last evaluation. For normal annulus, reduction from 68.2±28.7 mmHg to 32.8±16.2 mmHg occurred (p<0.001) (final values comparable between groups; NS).
CONCLUSION: The anterior and posterior aortic annulus enlargement technique allowed an increase in the annular diameter and valvar prosthesis, providing up to 11 years follow-up, a clinical and echocardiographic result similar to those observed in patients with valve replacement with a normal annulus.
Keywords: Aortic valve stenosis, surgery; Heart valve diseases, surgery; Heart valve prosthesis
Coronary artery bypass grafting with composite grafts: comparison of blood flow to the left coronary artery with the conventional technique
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
BACKGROUND: Composite grafting techniques for coronary artery bypass grafts (CABG) have been widely used. However, it remains unclear whether this technique provides similar blood flow to the left coronary artery when compared to the conventional alternative. We sought to compare the total blood flow to the left coronary branches that are revascularized with left internal thoracic (LITA) and radial artery (RA) grafts using composite and non-composite techniques.
METHOD: A total of 42 patients were randomly assigned to three groups according to the CABG technique to be used: Group A or composite LITA-RA in a Y format (n=14); Group B or modified composite LITA-RA [intercoronary graft with RA and LITA to RA at the level of the left anterior descending artery (LAD), n=14)]; and Group C or pedicled LITA to the LAD and aorto-coronary RA (n=14). The patients were submitted to postoperative blow flow velocity analysis using a 0.014 inch 12 MHz Doppler flowire. Coronary flow reserve (CFR) was calculated by determining the average hyperemic peak velocity (APV) after an injection of adenosine.
RESULTS: Proximal LITA baseline APV was 28.4±4.8 cm/s in group A, 34.4±7.9 cm/s in group B (p=0.0384 x C) and 25.8± 8.6 cm/s in group C. The CFR was 2.1 ± 0.4, 2±0.3 and 2±0.4 in groups A,B and C respectively (p=0.7208 A, B x C). The total Q to LCA branches was 110±30 in group A, 145±59 in B and 133±58 mL/min in C (p=0.3232 A, B x C).
CONCLUSIONS: The LITA-RA composite graft maintains an adequate CFR and conveys similar blood flow to the left coronary artery branches when compared with conventional CABG technique.
Keywords: Mammary arteries; Radial artery; Blood flow velocity; Cardiovascular surgical procedures; Myocardial revascularization, methods
Anatomical relashionship between the posterior mitral valve annulus and the coronary arteries. Implications to operative treatment
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
OBJECTIVE: This work aimed to analyze the anatomical relationship among the mitral annulus, the circumflex artery and the posterior left ventricular artery, correlating the distance among the structures mentioned to the pattern of coronary network dominance.
METHOD: Eighty-five human hearts, previously preserved in 10% formaldehyde solution, were studied. The coronary network dominance pattern was initially evaluated. Next, atriotomy and left ventriculotomy in the posterior wall of the heart were performed, starting from the lung veins toward the heart apex through the mitral annulus. The atrial wall was removed at the level of the annulus, all around the posterior annulus. Onto the annulus, five points were demarcated: 1 - anterior commissure, 2 - between the anterior commissure and the half-point of the posterior annulus, 3 -half- point of the posterior annulus, 4 - between the half-point of the posterior annulus and the posterior commissure, 5 - posterior commissure. In these points the distance was measured among the structures with an electronic calliper.
RESULTS: Right dominance was observed in 81.17% of the cases, balanced dominance in 16.47% and left dominance in 2.35%. Right dominance hearts showed that the area of lower distance between the annulus and the coronary arteries was the anterior commissure, where the circumflex artery was distant to the annulus 3.996 ± 1.865mm while the area of greater distance was the posterior comissure, measuring 7.783 ± 2.615mm.
CONCLUSION: This study provided better understanding of the anatomical relationship between the mitral valve and the adjacent coronary arteries, therefore helping cardiac surgeons to prevent operative complications.
Keywords: Mitral valve; Coronary circulation; Myocardial infarction
Myocardium stress diskinesia disease
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
OBJECTIVE: To research the myocardium stress diskinesia as another possible cause of the silent myocardium ischemia induced by exercise testing stress and to analyze the efficacy of the myocytic calcium blocker diltiazem for normalization of previously positive testing.
METHOD: In October 2004, ten patients without symptoms of coronary artery disease, presenting positive exercise testing, defined by ST segment depression, with neither precordial pain or arrhythmia during testing (six males - 60%; ages between 42 and 71 years old, mean 58.2 years), were treated with 90 mg of diltiazem in three times daily and re-studied five days after the first examination. Treadmill electrocardiography exercise testing was performed using the Bruce protocol.
RESULTS: Diltiazem administration blocked the ST segment depression, both J point (mean 2.1 ± 0.3mm, in the control and 0.0 depression with treatment; p<0.001) and Y point (mean 1.65 ± 0.7 mm in the control and 0.0 depression with treatment; p<0.001). The Heart rate variations were not significant (p>0.05), with mean values of 156.1 ±12.3 in the control and 151.6 ±23.4 bpm with treatment).
CONCLUSION: The administration of the myocytic calcium inhibitor diltiazem impeded the occurrence of the silent ST segment depression, previously induced by exercise stress testing in patients without symptoms of coronary arterial disease, confirming the involvement of the myocardium contraction diskinesia in the phenomenon genesis.
Keywords: Coronary disease; Myocardial ischemia; Exercise test; Electrocardiography
REVIEW ARTICLE
Myocardial infarction and aortic dissection: an important differential diagnosis
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
We report on a case of a 54-year-old man suffering from untreated high blood pressure who presented with a hypertensive emergency and target-organ damage. Initially, he was treated for myocardial infarction but later was diagnosed as having a type-A aortic dissection which was successfully operated with adequate control of blood pressure within the first 24 hours. We emphasize the necessity of the differential diagnosis of thoracic pain in the hospital emergency department and the correct treatment of arterial hypertension aiming at a better prognostic over the long term.
Keywords: Hypertension; Myocardial infarction; Aortic aneurysm, diagnosis, surgery; Aneurysm dissecting, diagnosis, surgery; Diagnosis differential
EXPERIENCE THE OF SERVICE
Catastrophic events associated to the surgical treatment of ostium secundum atrial septal defects. Reasons for not underestimating this type of congenital cardiopathy
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
OBJECTIVE: The present article was motivated by the frustrating experiences with four patients who underwent surgical treatment of ostium secundum atrial septal defect (ASD-II) and who died in extremely dramatic circumstances.
METHOD: This is a retrospective study based on clinical data. The bibliographical researche included: paradoxical thromboembolism (cerebral, lung or mesenteric), central nervous system vascular malformations and anomalous vena cava connections. This research was based on possible events, unexpected and catastrophic, that could have directly caused the patients' deaths.
RESULTS: All patients were female, the operations were performed under cardiopulmonary bypasses with less than 20 minutes of aortic cross-clamping. The causes of death were: non-occlusive intestinal ischemia, rupture of a cerebral aneurysm of the anterior communicating artery, cor pulmonale associated with pulmonary arterial hypertension and thromboembolism and probable cerebral thromboembolism in a child that needed to be reoperated to correct anomalous inferior vena cava drainage into the left atrium.
CONCLUSION: Even being technically easy to treat, death due to atrial septal defects in extremely dramatic circumstances is possible, so "Do not underestimate the atrial septal in congenital heart surgery".
Keywords: Heart septal defects, atrial, surgery, complications; Heart defects, congenital, surgery, complications; Extracorporeal circulation
HOW I DO IT
The use of autologous pericardium to reinforce the aorta suture in the surgical treatment of the aortic valve
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
The repair of the aortotomy in the surgical treatment of aortic valve can be achieved using different techniques. Nevertheless, in some cases, the ascending aorta is atherosclerotic, thin and friable, making the risk of aorta rupture and late aneurysm development higher. This article describes the technique and the results obtained from the reinforcement of aortic suture with autologous pericardium by retrospective analysis of 23 cases from the Heart Institute of São Paulo, between 1999 and 2003.
Keywords: Pericardium; Suture techniques; Surgical flaps; Cardiac surgical procedures
CASE REPORT
Neonatal correction of ectopia cordis and onphalocele: successful case report
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
Female neonate diagnosed with ectopia cordis and onphalocele was submitted to an operation at 6 hours of age to reconstruct the abdominal wall and place the heart in the left pleural space. After initial hemodinamic instability the patient was reoperated to open the sternum; with progressive recovery, extubation ocurred on 15th postoperative day and she was discharged in 40th day. With 8 months of life a new operation was successfully performed to close the sternum and reconstruct the abdominal wall. After four years, the child is asymptomatic with no necessity of medications or physical restrictions.
Keywords: Heart defects, congenital, surgery; Abdominal wall, abnormalities, surgery; Abnormalities, multiple, surgery
Correction of anomalous origin of left coronary artery with mitral insufficiency and mechanical hemolisys
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
A 2 months-old girl, presenting with heart failure and murmur was investigated using echocardiography and cardiac cathetherization revealing an anomalous left coronary artery origin from the pulmonary trunk and massive mitral regurgitation. The patient was submitted to surgery under cardiopulmonary bypass: the anomalous coronary was implanted in the aorta and the mitral valve repaired by annuloplasty. In the postoperative period the patient had important mechanical hemolysis caused by mitral annuloplasty. The patient underwent a second intervention to remove a piece of bovin pericardium. A postoperative echocardiogram revealed mild mitral insufficiency and the patient is free of symptoms.
Keywords: Coronary vessel anomalies, surgery; Pulmonary artery, abnormalities, surgery; Anemia hemolytic; Hemolysis; Mitral valve insufficiency
Aortic arch aneurysm with aorto-pulmonary fistula: successful surgical repair
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
Aortic arch aneurysm associated with an acute aorto-pulmonary fistula is rare and usually diagnosis is made during the postmortem. Few reports of successful surgical management have been reported and a high mortality rate remains. The authors report on a 78-year-old male patient with an acute aortic arch aneurysm communicating with the main pulmonary artery suffering from cardiac chest pain, hemodynamic instability and lung congestion. The patient underwent surgery to replace the distal ascending aorta, transverse aortic arch and proximal descending aorta as well as fistula closure. The operation was successful.
Keywords: Arterio-Arterial fistula, etiology, surgery; Aortic aneurysm, complications, surgery; Aortic rupture, complications
Thoracoabdominal aneurysm rupture: a modification of the visceral perfusion circuit
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
A patient with ruptured type IV thoracoabdominal aortic aneurysm (TAAA), underwent surgical treatment utilizing visceral perfusion assisted by a centrifugal pump and neonatal membrane oxygenator. This circuit allows visceral perfusion with oxygenated blood during the ischemic period and the fast infusion of intravenous volume after clamp removal.
Keywords: Aortic aneurysm, thoracic, surgery; Aortic aneurysm, abdominal, surgery Perfusion; Infusion pumps
CLINICAL-SURGICAL CORRELATION
Case 7/2004 - Pediatric Heart Surgery Service - Hospital de Base, Medical School, São José do Rio Preto
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
Case 8/2004 - Pediatric Heart Surgery Service - Hospital de Base, Medical School, São José do Rio Preto
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025
LETTERS TO THE EDITOR
Letters to the Editor
Braz J Cardiovasc Surg 19;
Publish in: 8/2/2025