Volume 20 - Número 3
EDITORIAL
BJCVS implants electronic submission of articles
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Themes for discussion and disagreement
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Reflections on the creation of a new surgical technique
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
The snake's egg hatches in Pandora's Box
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
ORIGINAL ARTICLE
Coefficients of proportions of the atrioventricular valves: an anatomical study of valvar segments of normal individuals
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Objective: To describe the anatomical relationships that exist between the heart valve structures taking into account the segments of the fibrous annuli and the left ventricular volume
Method: Digital photographs of 41 hearts from autopsies performed by a coroner's office were analyzed. The photographs were processed using MATLAB® software, which supplies measurements of the valvar perimeter and area and the left ventricular volume.
Results: The average age of the corpses studied was 33 years old (standard deviation ± 17 years). Several ratios involving the tricuspid and mitral valves were tested, with strongly significant correlations found between the inter-commissural distance (ItD) and the perimeter of the anterior annulus (PA) of the tricuspid valve (r = 0.72; p-value < 0.05) and between the inter-commissural distance (ImD) and the perimeter of the posterior annulus (PP) of the mitral valve (r = 0.63; p-value < 0.05). The proportions between these parameters were PA/ItD = 1.36 ± 0.24 and PP/ImD = 1.38 ± 0.16.
Conclusion: The proportions between the perimeter of the anterior annulus (tricuspid) and the perimeter of the posterior annulus (mitral) and their respective distances have high statistical significance and can be applied during surgery of valvar reconstruction.
Keywords: Heart, anatomy & histology; Mitral valve; Tricuspid Valve
Clinical perspectives of patients with Chagas cardiomyopathy listed as high priority for heart transplantation
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Introduction: Heart failure is responsible for high mortality rates of patients on heart transplantation waiting lists. In Chagas cardiomyopathy, the presence of biventricular dysfunction increases the severity of this situation.
Method: One hundred and forty-one patients suffering from cardiogenic shock, listed as high priority for heart transplantation, were studied. Forty-six patients presented with Chagas cardiomyopathy and 95 with other cardiomyopathies. Heart failure was treated using intravenous inotropic drugs and intra-aortic balloon pump implantation. Five patients with Chagas disease underwent paracorporeal left ventricular assist device implantation.
Results: During a mean follow-up of 2.8 months, 58 (41.1%) of the 141 patients were transplanted, while 73 (53.7%) died and 10 were removed from the waiting list. The mortality rates in chagasic and non-chagasic patients were 45.6% and 54.7%, respectively. The mean expected survival of patients with Chagas disease, who did not undergo heart transplantation, was only 1.5 months, with these patients presenting a relative risk for death of 1.6 compared to patients with other heart diseases (p<0.05). The five chagasic patients submitted to left ventricular assist device implantation were maintained on support for a mean of 22 days, with two of them undergoing transplantation, two died due to multiple organ failure and one remains on circulatory support. None of these patients presented right ventricular dysfunction and there were no device related complications.
Conclusion: The evolution of heart failure seems to be rapid in patients with Chagas cardiomyopathy. Therefore, an early indication of mechanical circulatory support is important as a bridge to heart transplantation in these patients.
Keywords: Chagas cardiomyopathy; Shock, cardiogenic; Heart transplantation; Heart assist devices
Comparison of mononuclear and mesenchymal stem cell transplantation in myocardium infarction
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Background: Bone marrow stem cell (SC) transplantation into failing myocardium has emerged as a novel therapeutic option for the treatment of ventricular dysfunction. Both mononuclear (MoSC) and mesenchymal (MeSC) stem cells have been proposed as ideal cell types to this goal. The objective of this study is to compare the efficacy of these cells in improving ventricular function in a rat model of post-infarct ventricular dysfunction.
Method: Myocardial infarction was induced in Wistar rats by left coronary occlusion. After 1 week, 42 animals with resulting ejection fractions (EF) lower than 30% were included in the study. MoSC and MeSC were obtained from bone marrow aspirates and separated by the Ficoll-Hypaque method. MeSC were cultured for 14 days before injection. Nine days after infarction, rats received intramyocardial injections of MoSC (n=8), MeSC (n=13) or culture medium as a control (n=21). Echocardiographic evaluation was performed at baseline and after one month.
Results: There were no significant differences in the baseline ejection fractions or the left ventricular end diastolic volumes (LVEDV) between all groups. After 1 month, ejection fraction decreased in the Control Group and remained unchanged in MoSC and MeSC Groups. In all three groups ventricular dilation was observed. Histopathology of the infarcted area where injections were performed identified new smooth muscle cells and endothelial cells in the MeSC Group and only new endothelial cells in MoSC Group
Conclusions: Both MoSC and MeSC provided stabilization in the ejection fraction in this post-infarction ventricular dysfunction model however, no therapy prevented ventricular dilation.
Keywords: Cell transplantation; Myocardial infarction; Rats, Wistar
Standardization of the sodium heparin dose used in off-pump myocardial revascularization surgery
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Objective: To evaluate a methodology of anticoagulation during off pump coronary artery bypass surgery (CABS) that promotes safe anticoagulation during the procedure (Activated Coagulation Time ³200 seconds), using an initial dose of 1 mg of sodium heparin/kg weight.
Method: 40 patients (30 men and 10 women), ages ranging from 41 to 85 years, were submitted to off pump CABS, using an initial sodium heparin dose of 1mg/kg of weight. Ten minutes after that drug was administered, if the ACT was ³ 200 seconds, we initiated the revascularization procedure. If not, we administered an additional of 0.5mg/kg heparin. During the surgery, the ACT was measured at 30 intervals. After revascularization, heparin reversal was achieved with a dose of protamine chloride equal do the total heparin dose infused during the procedure (1:1).
Results: The mean ACT at 10 minutes after heparinization was 372.2 (+/-104.31) seconds, without significant statistical difference between gender and age groups (p>0.05). The ACT values at 30 and 60 minutes remained greater than 200 seconds in all patients. The ACT at 30 minutes showed a significant statistical difference between age groups and gender (p<0.05). After heparin reversal using protamine, all patients returned to their initial hemostasis level (ACT < 200s).
Conclusion: The results show the safety and effectiveness of an initial sodium heparin dose of 1mg/kg of weight during off-pump CABS maintaining safe ACT (³ 200s) even after 60 minutes of heparinization, independently of age and gender.
Keywords: Myocardial revascularization; Heparin; Whole blood coagulation time
Impact of serum troponin I in the long-term evolution of patients submitted to resynchronization with biventricular stimulation: follow-up of up to 59 months
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Objective: To analyze the evolution and prognostic influence of the cardiac troponin I serum levels in patients with congestive heart failure (CHF) submitted to interventricular resynchronization (VR) over a 59-month follow-up period.
Method: Thirty-three patients with idiopathic dilated myocardiopathy in NYHA functional classes III and IV were submitted to VR. The pre- and post-operative quality of life (QV) was analyzed using the Minnesota Code and the left ventricle function was assessed by echocardiography. The cardiac troponin I levels were compared in 23 patients utilizing the Fisher exact test to analyze the correlation with death and the Kaplan-Meier curve was used to analyze the survival rate.
Results: The QV was better after VR with a median of 73 points in the pre-operative period and 36 in the postoperative period (p-value < 0.0001). The left ventricle diastolic diameter (LVDD) reduced from 65 mm in the preoperative period to 60 mm in the postoperative period (p-value = 0.0014) with an increase in the ejection fraction from 37 to 47% (p-value = 0.0004). In 15 patients with normal cardiac troponin I levels, no deaths occurred and of the 8 patients with high levels, six died (p-value = 0.0003). The actuarial survival curve showed a survival rate of 47.1 ± 13.3% at the end of 59 months.
Conclusion: VR in patients with CHF improves the QV and echocardiographic parameters (ejection fraction and LVDD). It is a good alternative for functional class III and IV patients. The serum levels of cardiac troponin I are predictors of risk to life.
Keywords: Troponin; Arrhythmia; Heart failure, congestive; Pacemaker, artificial
Predictors of perioperative myocardial infarction in surgical myocardial revascularization
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Objective: To evaluate which preoperative and trans-operative variables are predictors for the occurrence of myocardial infarction in the perioperative period of surgical myocardial revascularization in a general hospital in Porto Alegre, Brazil.
Method: A retrospective cohort study was made of the database of heart surgery in the Hospital São Lucas of the Pontifícia Universidade Católica in Rio Grande do Sul analyzing 1471 consecutive patients who underwent on-pump surgical myocardial revascularization from January 1998 to December 2002.
Results: Fourteen percent of the patients presented with perioperative myocardial infarction. The variables that proved to be independent predictors of perioperative myocardial infarction in surgical myocardial revascularization in this study were: prior surgical myocardial revascularization (OR: 2.070 - p=0.036), left main coronary artery lesion (OR: 1.692 - p=0.006), female (OR: 1.572 - p=0.034), preoperative unstable angina (OR: 1.533 - p=0.011), high number of grafts (OR: 1.336 - p=0.001) and prolonged cardiopulmonary bypass time (OR: 1.013 - p<0.001).
Conclusions: Prior surgical myocardial revascularization, left main coronary artery lesion, female, preoperative unstable angina, high number of grafts and prolonged cardiopulmonary bypass time proved to be independent predictors of perioperative myocardial infarction in surgical myocardial revascularization in this study of patients from a general hospital from Porto Alegre, Brazil.
Keywords: Myocardial infarction; Myocardial revascularization; Risk assessment; Coronary disease
Off-pump coronary artery bypass grafting with arterial grafts: analysis of 300 cases
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Objective: The present study reviews our immediate experience of off-pump coronary artery bypass grafting using arterial grafts alone.
Method: Between June 2000 and December 2004, 300 patients were submitted to off-pump myocardial revascularization using only arterial grafts. The left internal mammary artery was the first-choice graft, followed by radial artery and the right mammary artery.
Results: The ages of the patients ranged from 33 to 77 years, with 234 male and 66 female. In respect to risk factors for coronary disease, 77% had hypertension, 66% had history of smoking, 53% had high levels of cholesterol and 21% had diabetes. Eighty-four patients (28%) had a history of myocardial infarction and 77 (25.6%) were using endovenous nitroglycerin in the preoperative period. The ejection fraction was less than 30% in 77 (25.6%) patients. A total of 189 patients had multi-vessel disease. The EuroSCORE ranged from 0 to 12 points with an expected mortality rate of 3.7%. The total numbers of distal anastomoses were 838, with a mean of 2.79±0.97 anastomoses per patient. There were six deaths in this series, one caused by renal failure, one caused by metabolic disorders, two caused by mediastinitis, one caused by pneumonia and one caused by bleeding. Diabetes was the only factor associated with mortality.
Conclusion: The use of arterial grafts in off-pump myocardial revascularization did not increase the immediate mobidity and mortality in this series. The results were similar to the results predicted by EuroSCORE. The use of arterial grafts alone in diabetics patients must be carefully evaluated.
Keywords: Myocardial revascularization; Extracorporeal circulation; Coronary disease, surgery; Internal mammary-coronary artery anastomosis
Technical aspects of lead implantation for left ventricle pacing through the coronary sinus, using anatomic radiology and intracavitary electrography in the cardiac resynchronization therapy
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Objective: To present the experience of 157 implantations using a simplified technique for coronary sinus catheterization, based on the atrial component of the intracavitary electrogram and radiological anatomy, showing the success rate and total time of radioscopy use.
Method: From October 2001 to February 2005, 157 biventricular pacemaker implantations were performed in previously selected patients, using radiological anatomy and observation of the intracavitary electrogram, focusing on the atrial component. Here we show the success rate, complications and total time of radioscopy use.
Results: The implantation of the system employing left ventricular pacing via the coronary sinus was not possible in 11 patients. Difficulties in cannulation of the coronary ostium were felt in 20 patients and difficulties of lead advancement through the coronary sinus existed in 39 patients. The mean time of radioscopy use was 18.27 ± 15.46 minutes.
Conclusion: The implantation technique, proposed by the author, using the atrial component morphology of the intracavitary electrogram and radiological anatomy proved to be safe and effective for the cannulation of the coronary sinus ostium requiring shorter radioscopy times.
Keywords: Heart failure, congestive; Cardiomyopathy, congestive; Cardiac pacing, artificial
Evaluation of pulmonary function in patients following on- and off-pump coronary artery bypass grafting
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Objective: To evaluate and compare the pulmonary function in patients following on- and off-pump coronary artery bypass grafting (CABG).
Method: Thirty patients (mean age 56.76 ± 10.20 years) were allocated to two groups, according to the use or not of cardiopulmonary bypasses: group A (n=15) off-pump and group B (n=15) on-pump, with all patients undergoing pre- and post-operative evaluation of the pulmonary function as well as arterial blood gases analysis. Forced vital capacity (FVC) and forced expiratory volume at 1 second (FEV1) were recorded in the preoperative period, and on the first, third and fifth postoperative days. Blood gases were evaluated in the preoperative period and on the first postoperative day.
Results: In both groups, significant falls in the FVC and FEV1 were detected up to the fifth postoperative day (p<0.05). When both groups were compared, the decreases in FCV and VEF1 were higher in group B (p<0.05). PaO2 values and the PaO2/FiO2 ratio presented significant drops on the first postoperative day in both groups, however the fall was higher in group B (p<0.05).
Conclusion: Patients who undergo CABG, regardless of the use of CPB, display a significant reduction in the postoperative pulmonary function. However, patients who undergo off-pump CABG have a better preservation of the lung function compared to on-pump CABG.
Keywords: Myocardial revascularization; Extracorporeal circulation; Respiratory function tests
Changes in profile of patients submitted to coronary bypass graft surgery
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Introduction: The improvement in care and management of ischemic heart disease and the dissemination of percutaneous coronary intervention (PCI) changed the indications for coronary artery bypass grafting (CABG), regarding procedures for patientswith multivessel disease in bad clinical conditions.
Objective: To compare surgical and clinical profiles between two groups of CABG patients at a 10 year interval observing the influence on hospital mortality rates.
Method: Retrospective Cohort study, including 307 CABG patients operated on in 1991to 1992 (n=153) and 2001 to 2002 (n=154). Demographic characteristics, heart disease severity, comorbidities and pre-operative events were evaluated and compared between the groups.
Results: Patients operated in 2001 and 2002 were older, more severely ill (in a worse NYHA classand had higher prevalence of heart failure, and multi-vessel involvement) and with more co-morbidities. Patients operated in 1991 and 1992 had more urgent procedures. The observed surgical mortality rates were similar (3.3% and 1.9%, respectively).
Conclusion: Patients submitted to CABG currently are older and in worse clinical conditions than those operated 10 years ago, but hospital mortality has not altered significantly.
Keywords: Myocardial revascularization; Risk assessment; Heart diseases, surgery
REVIEW ARTICLE
Atrial fibrillation and cardiac surgery: a never ending and always controversial history
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
EXPERIENCE THE OF SERVICE
Cardiac surgery in a multi-ethnic low volume service: the Caribbean Heart Care Experience
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Introduction: The Caribbean is a multi-ethnic society, including Caucasian, Afro-Caribbean, East Indians, Asians, Hispanics, European and natives, which has a broad range of living standards. The incidence and types of heart diseases vary significantly amongst these races. We report the surgical experience (adult and paediatric) of a low volume multiethnic population service based on Trinidad and Tobago.
Methods: The Adult Heart Surgery program started in November 1993. The data on a total of 878 cases (629 male, median age 67, range 18-88 years old) is reported. Of these 39.4% were diabetics and 46.5% hypertensive. The procedures performed include coronary artery bypass grafting, valve repair and replacement, and major aortic surgery including emergency dissection.
The paediatric heart surgery program started in Sept 1998 and a total of 279 operations have been performed (Age range, 2 weeks to 21 years)
Results: Adult - Overall mortality was 3.8%. The majority of procedures were CABG (82.3%) with an overall mortality of 2.8% (0% in 2004). Off pump CABG accounts for 43% of the total procedures (71.2% in 2004). Aortic valve surgery was carried out in 49 patients and mitral valve replacement/ repair in 96 either with or without CABG. Paediatric - The majority of the procedures were VSD 111, ASD 57, TOF 23, and 88 others (including A-V canal, BT shunt, aorta coarctation) with an overall mortality of 1.5%.
Conclusion: Heart surgery in a multiethnic low volume service can be performed with excellent results comparable to international standards for adults and paediatrics.
Keywords: Cardiac surgical procedures; Hospitals, statistics & numerical data; Myocardial revascularization; Extracorporeal circulation
CASE REPORT
Operative management of aortoiliac occlusive disease in presence of horseshoe kidney: report of a case
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Coexistence of aortoiliac arteriosclerosis with horseshoe kidney in a 57-year-old man is presented. Diagnosis of this unusual combination was made shortly before surgery. Magnetic resonance angiography is the most important preoperative diagnostic tool for surgical planning. A transabdominal approach provides excellent exposure of the abdominal aorta in patients with a horseshoe kidney without risk of injury to renal accessory arteries or to a ureter in an anomalous position. Implantation of an aorto-bifemoral Y prosthesis was made using a Dacron bifurcation. By diffuse atherosclerotic lesion and in presence of horseshoe kidney, an end-to-side proximal anastomosis of the aorta was carried out.
Keywords: Iliac artery, surgery; Arteriosclerosis; Kidney, abnormalities
PREVIUS NOTE
New technical approach for crossed papillopexy in mitral valve replacement surgery: short term results
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Objective: To present the crossed papillopexy technique and its initial results in the preservation of papillary muscles in mitral valve replacement and ventricular remodeling surgeries for heart failure (CHF).
Method: Ten patients, 70% male, with ages between 15 and 75 years old (mean 44.4 ± 18.7 years old), suffering from rheumatic mitral valve disease (50%), mitral valve prolapse (10%) or dilated cardiomyopathy (40%), were studied. After opening the left atrium and adequate exposure of the mitral valve, the anterior leaflet already free of its annulus fixation was centrally divided and each half, with its cordae tendineae complex fixed to the commissure on the opposite side. Following this, mechanical (seven cases) or biological (three cases) prostheses were implanted using single sutures in the valve annuli, with reduction of the mitral valve annulus for better ventricular remodeling in CHF cases.
Results: All patients were discharged from hospital in good clinical conditions. Additionally all presented with great improvement in the cardiac performance at the end of the first month of follow-up, with significant reductions in the left ventricular and left atrium systolic diameters (p<0.05) and mean increases in the left ventricle ejection fraction of from 46.7 to 56.4 % (p<0.05).
Conclusion: The crossed papillopexy technique in valve replacement surgeries for mitral valve lesions and CHF presented significant increases in the left ventricular function and improvement of ventricular remodeling in the studied postoperative period.
Keywords: Mitral valve, surgery; Papillary muscles, surgery; Heart valve prosthesis
CLINICAL-SURGICAL CORRELATION
Case 5/2005 - Extracardiac total cavopulmonary connection using a corrugated bovine pericardium graft without using cardiopulmonary bypass case 5/2005
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
Case 6/2005 - Extracardiac total cavopulmonary connection with cryopreserved homograft Case 6/2005
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025
LETTERS TO THE EDITOR
Letters to the Editor
Braz J Cardiovasc Surg 20;
Publish in: 8/1/2025