Volume 20 - Número 1
EDITORIAL
The words of Prof. Dr. Domingo M. Braile
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Victories, but there are still important challenges
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Echocardiography and diastolic function
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
SPECIAL ARTICLE
Importance of the correct use of descriptors in scientific articles
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
ORIGINAL ARTICLE
Bidirectional Glenn procedure in the staged treatment of hypoplastic left heart syndrome: early and late results
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: To report early and long-term results of bidirectional Glenn procedure as second stage for Hypoplastic Left Heart Syndrome (HLHS) treatment and describe a ministernotomy technique.
Method: From March 1998 to February 2004, 15 patients who had been previously submitted to the Norwood procedure underwent elective partial cavopulmonary anastomosis. Ages ranged from 2 to 6 months (mean 3.46±0.83 months), Six were male. Ministernotomy was performed in 11 (73.3%) patients. In order to obtain adequate initial blood oxygenation, an accessory 3 mm PTFE shunt was useed in nine patients and the right ventricle-pulmonary artery tube was maintained in one case. Clinical and echocardiographic follow-up was obtained in all patients.
Results: Hospital survival was 86.6%, with one early death caused by surgical bleeding and another due to hypoxemia. Postoperative echocardiogram showed some early blood flow in PTFE shunt, and its closure in long-term follow-up.There were two late deaths, one due to tracheostomy complications and another due to infectious meningitis. Seven patients, who are waiting third stage, are doing well clinically. Four patients already undergone the third stage, successfully. The echocardiograms of 11 late survival patients showed good right ventricular function, no tricuspid regurgitation and good cavopulmonary blood flow over a 2.5-years mean follow-up time.
Conclusions: The Glenn procedure in HLHS resulted in a low mortality rate and satisfactory long-term outcomes, and can be performed using the ministernotomy technique. An acessory source of systemic-pulmonary flow in very small infants seems to improve the oxygen saturation.
Keywords: Hypoplastic left heart syndrome, surgery; Heart defects, congenital, surgery; Heart bypass, right, surgery
Myocardial revascularization in octogenarian patients: retrospective and comparative study between patients operated on pump and off pump
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: The purpose of the present study is to compare and analyze the benefits of this operation with and without cardiopulmonary bypass in octogenarian patients.
Method: Retrospective data of the patients aged eighty years or more from December 1995 to December 2003 were analyzed. During this period 73 patients were submitted to coronary artery bypass grafting (CABG), 26 (35.6%) on-pump and 47 (64.4%) off-pump. A comparison was made of the demographic data, preoperative risks, concurrent morbid conditions, types of angina, postoperative complications and surgical outcomes between the on-pump and off-pump groups. The Student t-test was used to compare the groups and the level of significance was set at p-value < 0.05.
Results: Both groups showed a high preoperative risk, although the off-pump group presented less surgical mortality (11.5% vs 2.1%, p < 0.05). No strokes were observed in the patients operated on off-pump (11.5% vs 0.0%, p < 0.005). Atrial fibrillation (AF) in the immediate postoperative period was present less often in the off-pump group (30.8% vs 12.8%, p < 0.005). The postoperative mechanical ventilation time and the presence of respiratory failure were less in the off-pump group (p < 0.005). The presence of acute renal insufficiency (ARI) was 19.2% in the on-pump group and 0% in the off-pump group (p < 0.05). There was less need for transfusion of blood or blood derivatives in the off-pump group (69.2% vs 31.9%, p < 0.005). The mean sojourn in the intensive care unit (ICU) was shorter in the off-pump group (p < 0.05). The percentage of patients with no postoperative complications was higher in the off-pump group than in the on-pump group (89.4% vs 61.5%, p <0.001).
Conclusions: The present study suggests that patients aged eighty years and over benefit when submitted to off-pump CABG and that this procedure is associated with low rates of postoperative complications such as stroke, AF, ARI and respiratory insufficiency, and with less time in the ICU, a shorter hospital sojourn, less use of blood derivatives and lower mortality. In octogenarian patients off-pump CABG surgery is a safe and effective technique, and may be the operation of choice when correctly indicated.
Keywords: Myocardial revascularization, aged; Extracorporeal circulation
Comparison between the decellularized bovine pericardium and the conventional bovine pericardium used in the manufacture of cardiac bioprostheses
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Introduction: In this paper, our objective was to compare the decellularized and conventional pericardium mechanical resistance and also its capability of inducing inflammatory response in an animal experimental model.
Method: In order to study these properties, we divided the pericardia into two groups: Group I - pericardium conventionally treated with GTA - and Group II - pericardium previously decellularized and then treated with GTA in the conventional way. After the chemical treatment, Group II samples were histologically evaluated to confirm the efficacy of the decellularization process. Then, only for the analysis of mechanical resistance, pericardia were divided in: Groups 1 (conventional pericardia with criteria of approval), 2 (conventional pericardial with criteria of disapproval) and 3 (decellularized pericardia). The capacity of inducing inflammatory response was tested in a rat experimental model with 50 Wistar rats, in which rats of each group received patches of the pericardia in the abdomen. Our third step of analysis was manufacturing three decellularized pericardium bioprosthesis which were submitted to hydrodynamic evaluation together with a conventional bioprosthesis test.
Results: The histological analysis showed complete decellularization. Mechanical resistance gave statistical differences in the "tension of rupture" and "tenacity index" tests. We found no difference in the inflammatory activity in the animal model. Hydrodynamic performance was similar and all prostheses reached 150 million cycles. The final histological analysis assessed the standard microscopic pattern, and no rupture or abnormal fragmentation caused by mechanical stress.
Conclusion: The decellularization technique maintains the physical resistance of the pericardium when compared with the conventionally prepared pericardium. And also, there was no difference in both groups regarding to inflammatory response studied in the animal model.
Keywords: Heart valve prosthesis; Bioprosthesis; Pericardium; Comparative study
Health-related quality of life in patients with Chagas' cardiomiopathy and complete atrioventricular block at elective pulse generator replacement: effects of pacing mode upgraded from VVI to DDD
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: Health-related quality of life in patients with Chagas' cardiomyopathy and complete atrioventricular block at elective pulse generator replacement: effects of pacing mode upgraded from VVI to DDD.
Method: From September 8, 2001 to March 18, 2004, at the Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo and Hospital de Beneficência Portuguesa de Ribeirão Preto, a total of 27 patients with chronic Chagas' cardiopathy, complete atrioventricular block and implanted ventricular pacemaker were upgraded to a dual-chamber pacing mode. At the beginning of the study and after 90-days periods under each pacing modes, the patients' quality of life was evaluated. Statistical analysis was made at basal, VVI and DDD conditions using the analysis of repetitive measures.
Results: No significant differences in the health-related quality of life, across the three studied variables (physical function, vitality and general health), were detected after the change of pacing mode from VVI to DDD. There were three cases of complications related to pacing mode upgrade: two cases of atrial tachycardia triggered to ventricles through DDD pacemaker and one atrial lead displacement.
Conclusions: No benefits no quality of life were detected after the change of pacing mode VVI to DDD during elective replacement of pulse generator, in patients with Chagas' cardiomyopathy and complete AV block.
Keywords: Chagas' cardiomyopathy; Heart block; Pacemaker, artificial; Cardiac pacing, artificial; Quality of life
Off-pump grafting of the circumflex artery with pedicled retro-aortic right internal thoracic artery graft
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: Off-pump coronary artery bypass surgery (OPCAB) has been demonstrated to provide a reduction of cardiovascular events and mortality. Also, the bilateral use of the internal thoracic arteries (ITAs) can offer additional benefits, improving survival. We present the technique of OPCAB using both pedicled ATI grafts, with the right ITA (RITA) routed retro-aortic through the transverse sinus, to revascularize the branches of the circumflex artery (Cx).
Method: Twenty-six patients, who underwent OPCAB with bilateral ATI grafts, were studied, where the left ATI (LITA) was used to revascularize the left anterior descending artery (LAD) and the pedicled RITA, routed through the transverse sinus and anastomosed to the branches of the Cx. Twenty-one patients were male and five female, the age ranging between 42 and 74 years. The morbidities observed in this cohort were previous myocardial infarction in 18 (69%) patients, diabetes mellitus in 10 (38%), renal failure in four (7.7%) and AIDS in one (3.8%) patient.
Results: No patient presented ECG changes or enzymatic increases in the postoperative period. The grafts per patient varied from two to four (average 3.0 grafts/patient). No cases of sternal infection or dehiscence were observed. One patient had a stroke on the 4º postoperative day and died. The postoperative hospital stay varied between 3 to 12 days (average 5.8±2.0 days). No late deaths or cardiovascular events were recorded.
Conclusions: This technique makes off-pump grafting of the circumflex artery branches using the pedicled RITA possible and potentially enhances the benefits of coronary artery bypass surgery.
Keywords: Myocardial revascularization; Internal mammary-coronary artery anastomosis; Mammary arteries; Extracorporeal circulation
Off-pump coronary artery bypass with multiple arterial conduits
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: To analyze intra-hospital results in patients undergoing elective off-pump total arterial revascularization and identify morbidity and mortality predictors using this surgical strategy.
Method: From May 1999 to February 2004, 203 myocardial revascularization procedures with total arterial revascularization without cardiopulmonary bypass (off-pump) were carried out in patients with multivessel disease (three vessels 81.7 %, one vessel disease was excluded). We report pre-surgical variables and co-morbidities: average age 63.9 ± 9.13 years, men 182 (89.5%), hypertension 132 (65%), smokers 125 (61%), hypercholesterolemia 152 (74.8%), previous myocardial infarction (> 30 days) 73 (35%), moderate to severe ventricular dysfunction 31 (15%), redo five (2.5%). Total arterial revascularization included T-grafts and sequential grafts with left internal mammary (100%), right internal mammary (56.6%) and radial (63%) arteries. The total number of distal anastomosis was 576 (mean of three grafts/patient), all carried out with external mechanical stabilizers. There were no proximal aortic anastomoses. Conversion to on-pump surgery occurred in three (1.5%) patients; 90% of the patients was extubated in the operating room. The multiple logistic regression test was used for statistical analysis.
Results: The postoperative incidence of atrial fibrillation was 12.8% (26), oligoanuric renal failure 3% (six), dialysis 0.49% (one), postoperative myocardial infarction 1.47% (three), low cardiac output 4% (eight), Redo for bleeding 1.47% (three), mediastinitis 1.47% (three), stroke 1.47% (three). Intra-hospital mortality was 2.45% (five). The only independent 30 day morbidity predictor was age (p=0.033; OR 1.04; IC 95%: 1-1.08).
Conclusion: Off-pump myocardial revascularization with arterial conduits for multiple vessel disease is feasible with a low 30-day morbidity and mortality.
Keywords: Myocardial revascularization; Mammary arteries; Extracorporeal circulation
Comparative study between inverted "L" mini-sternotomy and complete sternotomy for the surgical treatment of the atrial septal defect (ASD)
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: To compare the results obtained from two distinct surgical approaches in patients undergoing surgical correction of an atrial septal defect (ASD).
Method: The study series consisted of 20 patients, with a mean age of 24.1±14.2 years, distributed in two groups. In group A, 10 patients (80% female, with a mean age of 20.9±12.0 years) underwent surgical correction of ASD through a complete sternotomy. In group B, 10 patients (80% female, with mean age of 27.4±16.1 years), were operated through an inverted "L" mini-sternotomy. A p-value < 0.05 was considered statistically significant.
Results: There was no statistical significance for demographics variables, duration of surgery, cardiopulmonary bypass time, clamping time, amount of cardioplegia administered, thoracic drainage, ICU stay, duration of mechanical ventilatory support, amount of blood and its components transfused, arrhythmia or pacemaker usage. There was statistical significance (p= 0.00001) between incision size performed by complete sternotomy (group A) and inverted "L" mini-sternotomy (group B), with mean incision size of 15.7±0.8 e 6.8±0.6cm, respectively. There was a difference in the mean hospital stay between the groups but without statistical significance (7.5±1.6 days in group A and 6.4±1.3 days in group B, with a p-value = 0.12). There was no mortality or complications reported in either surgical approach.
Conclusion: There was not difference in the operative and postoperative periods between the techniques that were performed except the incision size, with a better cosmetic result seen with the inverted "L" mini-sternotomy.
Keywords: Heart septal defects, atrial, surgery; Surgical procedures, minimally invasive surgery
Total myocardium revascularization without extracorporeal circulation: five-year experience
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: To evaluate the immediate postoperative results of off-pump myocardium revascularization surgery by analyzing complications and mortality.
Method: A total of 1440 patients were submitted to off-pump myocardium revascularization. The surgical technique is consisted in proximal occlusion of the approached artery, the application of the LIMA graft in the posterior pericardial deflection and stabilization of the target artery with a suction stabilizer. The distal anastomoses were performed first.
Results: Among the patients evaluated, 924 were male and 516 were female,with a mean age of 63.12 ± 8.76 years. The ejection fraction was normal in 749 patients, 740 (51.4%) patients had suffered previous myocardial infarction and 687 (47.6%) patients were in functional class III or IV. The mean EuroSCORE was 4.93 ± 3.32. The mean number of dial anastomoses was 3.12 ± 1.23 per patient. A total of 1173 (81.5%) patients remained less than 12 hours on mechanical ventilation and among them, 888 (61.7%) remained for less than six hours. The stay in the ICU was of one night for 330 (22.8%) patients, for two nights for 930 (64.6%) patients and 182 (12.4%) patients remained three or more nights. In regards to complications, three (0.2%) patients presented with renal insufficiency, six (0.4%) patients suffered stroke, 19 (1.3%) patients were reoperated for bleeding, 19 (1.3%) patients had mediastinitis, 18 (1.25%) patients suffered severe myocardial infarction and 212 (14.7%) presented atrial fibrillation. There were 50 (3.5%) deaths, 29 (2.5%) of them being among the 1148 operated electively, nine (4.7%) among 190 patients submitted to coronary re-operation and 12 (11.7%) among 102 patients undergoing emergency operations.
Conclusion: With the evolution of biomedical technological, all the vessels of the heart are now approached. These data suggest that the operation for myocardial revascularization is safe and efficient. It can be applied to all patients who need coronary surgery, with low rates of complication and mortality.
Keywords: Myocardial revascularization, methods; Extracorporeal circulation; Coronary artery bypass
The use of the radial artery as the second choice for arterial graft in patients over 70 years of age
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: Retrospective study eveluating the morbid-mortality and hospital behaviour in patients over 70-years -od patients submitted to myocardial revascularization involving the radial artery as the second arterial graft.
Method: During the period of August 1994 to December 2002, 2487 cases of myocardial revascularization were performed by the group of the Juiz de Fora Heart Institute, 476 of whom were 70 years of age or older and 36 (Group II) received the radial artery as the second arterial graft. The same type of surgery was performed in 142 patients under 70-year-old (Group I). Reoperations, off-pump operations (OPCAB) or associated procedures were excluded from this study.
Results: The median age was 72.5 years, the mortality rate was 6% in this group of patients and the incidence of complications was low, comparable to the 142 under 70-year-old patients (Group I) submitted to the same type of surgery.
Conclusion: The resultsachieved with this study lead the authors to believe that the radial artery can be safely used as the second arterial graft in well selected septuagenarian patients, despite the major risk of co-morbidities related to this age.
Keywords: Coronary artery disease, surgery; Radial artery; Myocardial revascularization, old age
EXPERIMENTAL WORK
Echocardiographyc analysis of the ventricular diastolic function after myocardial infarction in rats
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: To evaluate the diastolic left ventricular function by echocardiography one and three weeks after acute myocardial infarction (AMI).
Method: Nineteen Wistar rats (mean 209 g) were utilized. After anesthesia with ketamine (50mg/kg) and xylazine (10mg/kg), the left coronary artery was ligated after left thoracotomy to cause myocardial infarction. The animals were divided in two groups: group A (control, n=7) and group B (n=9). Echocardiographic evaluation was undertaken in the control group and one week (B1, n=9) and three weeks (B3, n=8) post-AMI in group B animals. The cardiac function was evaluated using a 21275 A HP Sonos 1500 Echocardiography equipped with 7.5/5.5 MHz transducer. Diastolic function was evaluated by transmitral flow, by analysis of the A wave, E wave and atrial left volume (LAV). Histological specimens were evaluated on third week.
Results: There were no differences on E wave analyses (A=62cm/s, B1=65cm/s, B3=69cm/s) or A wave analyses (A=43cm/s, B1=40cm/s, B3=41cm/s) between the groups. There was an increase in LAV; A vs B1 and A vs B3 (A=0.05mL vs B1=0.15mL, p=0.04 e A vs B3=0.14mL, p=0.01). Histological examination confirmed AMI in all animals.
Conclusions: The LAV may be useful to assess the diastolic function in rats with AMI. LAV could reflect increases in left ventricular end-diastolic pressure secondary to systolic or diastolic dysfunction.
Keywords: Myocardial infarction; Myocardial contraction; Echocardiography
REVIEW ARTICLE
Polarizing cardioplegic solution: state of the art
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
The mean of the term "cardioplegia" is "lesion, attack, wound or blow", very different to how its is most commonly understood in most heart centers, where it relates to cardiac protection. Thus, "cardioplegic solution" is better defined as a solution capable of inducing cardiac arrest. Cardiac arrest induced by cardioplegic solutions can occur by hyperpolarizaton, depolarization or by inhibiting the calcium channels of the myocardial fibers. This paper discusses hyperpolarizing cardioplegic solutions, which arrest the heart in the diastolic phase, thus decreasing the ATP depletion and improving the conditions of the heart to be reanimated at the end of the procedure.
Keywords: Cardioplegic solutions; Heart arrest, induced; Myocardium, metabolism
EXPERIENCE THE OF SERVICE
Infective valve endocarditis treated by surgery: analysis of 64 cases
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: To identify some aspects of the infective valve endocarditis treated by heart surgery, as well as antibiotic therapy, in a public hospital, in the city of Fortaleza, Ceará state, Brazil, from1988 to 2003.
Method: A retrospective and observational study of 64 patients with Infective Valve Endocarditis who required aortic and/or mitral valve replacement, tricuspid vegectomy and repair or pulmonary valve valvulectomy, as well as antibiotic therapy, during their in-hospital stay. They were analyzed in respect to gender, age, time elapsed from hospital admission to the surgery, time elapsed from hospital admission to hospital discharge, valve lesion, blood culture result, surgical treatment and mortality.
Results: Infective valve endocarditis treated with heart surgery was more frequent in the third decade of life. Most of patients (81.2%) were males. The patients who died spent a shorter time from hospital admission to the surgery than the patients who survived. The aortic valve was affected in 65% of cases. Positivity blood culture were seen in 42% and Staphylococcus aureus was isolated in 52.4% of these cases. Valve replacement was necessary in 93.7% of cases. The in-hospital mortality rate was 14.1% which was not influenced by the age of the patient or the blood culture result.
Conclusion: Infective valve endocarditis treated by heart surgery was more frequent in men and in the third decade of life. It mostly affected the aortic valve. Staphylococcus aureus was the more common pathogen found. Almost all the patients needed replacement of the infected valve and the in-hospital mortality rate was 14.1%.
Keywords: Endocarditis, surgery; Heart valve diseases; Bacterial infections; Staphylococcal infections
CASE REPORT
Late dead space fraction (fDlate) before and after pulmonary embolectomy
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
This report presents data on the late dead space fraction (fDlate) of a patient submitted to surgical pulmonary embolectomy. Pulmonary thromboembolism (PTE) was diagnosed by echo-Doppler ultrasound of the lower limbs, lung scintigraphy, computerized helical tomography and angiography. The fDlate was calculated based on volumetric capnography as well as on arterial blood gases according to ERIKSSON et al. [1]. The preoperative fDlate value was 0.16, which was considered positive for the diagnosis of PTE, as it was higher than the cut-off point of 0.12. The postoperative fDlate value was - 0.04, which was below 0.12 and was characterized as negative. The agreement of fDlate with the imaging results confirms the validity of this new, noninvasive diagnostic tool.
Keywords: Pulmonary embolism; Pulmonary gas exchange; Capnography
Single stage surgical approach for arch and descending thoracic aorta aneurysm
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
We report on a 61-years-old male patient, who had an extensive arch and descending thoracic aorta aneurysm diagnosed while treating a pulmonary infection. The objective of this work is to report an unusual single stage surgical approach to correct an extensive arch and descending thoracic aorta aneurysm.
Keywords: Aorta, surgery; Aortic aneurysm, thoracic, surgery
Acute dysfunction from thrombosis of a mechanical mitral valve prosthesis
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
An 64-year-old man received a 31-mm CarboMedics mechanical prosthesis for severe mitral regurgitation. After four days the patient presented fatigue and dyspnoea with rest; transthoracic and transesophageal Doppler echocardiographic study confirmed a failing mobility of prosthetic valve leaflet from thrombosis and an emergency operation was done. The postoperative course was uneventful. This is an unusual case of acute dysfunction from thrombosis of a mechanical mitral valve prosthesis in a patient on oral anticoagulant therapy and calciheparin.
Keywords: Thrombosis; Echocardiography; Mitral valve replacement
Management of bullets lodged in the heart
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
A 29-year-old man presented with a bullet lodged in his heart. He arrived at the hospital in a hemodynamically stable condition. The transesophageal echocardiogram performed for diagnosis revealed the location of the bullet. After 18 days, he underwent an elective off-pump cardiac surgery fto remove the bullet from the right ventricle wall and interventricular septum. The postoperative evolution was uneventful. The authors discuss the therapeutic options for removing bullets from thr heart, based on published data. They concluded that some asymptomatic patients with a bullet embedded in the heart should undergo surgery.
Keywords: Wounds, gunshot, surgery; Foreign bodies, surgery; Heart injuries; Heart septum, injuries, surgery; Heart ventricles, injuries, surgery
CLINICAL-SURGICAL CORRELATION
Caso 1/2005 - Pediatric Heart Surgery Service - Hospital de Base, Medical School, São José do Rio Preto
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Case 2/2005 - Pediatric Heart Surgery Service - Hospital de Base, Medical School, São José do Rio Preto
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025