Volume 21 - Número 4
NOTE OF GRIEVANCE
Note of Protest
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
EDITORIAL
Good news at the end of the year
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Can coronary artery bypass surgery provide equivalent outcomes after percutaneous coronary interventions?
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Coronary artery bypass grafting:
Braz J Cardiovasc Surg 21;
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A new medical residence program in cardiovascular surgery with direct access
Braz J Cardiovasc Surg 21;
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ORIGINAL ARTICLE
Sequential histomorphometric study of the left internal thoracic artery
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: The use of left internal thoracic artery (LITA) in coronary artery bypass surgery is currently recognized as the best option, providing lower incidences of cardiovascular events and superior long-term survival. Now, incremental utilization of these grafts makes a reassessment of its histological structure necessary. Therefore, the purpose of this study was to examine and compare the sequential histological structure of LITA.
Method: Specimens of LITA harvested from 18 cadavers, divided into nine proportional segments, were studied. Cuts of each segment were stained by the Verhoeff-Van Gieson technique. The following parameters were analyzed: perimeter of the arterial lumen, thickness of the intima, thickness of the media layer, amount of elastic fiber in the media layer and the elastic fiber density.
Results: The collected data showed that perimeter of the LITA decreases downstream on its course, the thickness of the intima is increased in the proximal segments, the thickness of the media layer diminishes throughout its extension, the number of elastic fibers is concentrated in the intermediate segments and the density of elastic fibers is reduced in the proximal and distal segments.
Conclusion: Therefore, the findings of the present study validate the heterogeneity of the LITA sequential histological structure.
Keywords: Mammary arteries; Myocardial revascularization; Histology, comparative
Use of aprotinin in thoracic aortic operations associated with deep hypothermic circulatory arrest: a meta-analysis
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: To evaluate complications involved in the use of aprotinin in patients after thoracic aortic aneurysm or dissection surgeries associated with deep hypothermic circulatory arrest.
Methods: A systematic review of literature was carried out, with a search strategy of low specificity, in the Medline® and LILACS® databases. Two independent researchers carried out article selection following the criteria adopted for inclusion of studies, grouping them into two groups, one where low doses of aprotinin were employed and the other with high doses. The results are presented as relative risk for the dichotomy variable, and as weighted mean differences for continuous variables, both with 95% confidence intervals.
Results: Seven articles were included in the systematic review selected from 2044 revised studies. Meta-analysis of the only randomized controlled trial did not demonstrate risks with the use of aprotinin, and presented a significant reduction in bleeding and blood transfusion requirements. Meta-analysis of the studies that used low doses of aprotinin was similar. On the other hand, meta-analysis of the studies that adopted high doses of aprotinin did not present statistical significance in any of the studied variables.
Conclusion: Despite of the results not showing any effective risks with the use of aprotinin, the statistical power of the meta-analysis is low. Therefore, new randomized controlled trials are required, in order to detect possible complications in the use of aprotinin in this type of operation.
Keywords: Aprotinin; Aorta thoracic; Hypothermia induced; Meta-analysis
Postoperative pain as a contributor to pulmonary function impairment in patients submitted to heart surgery
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: To evaluate the pain in patients submitted to heart surgery using sternotomy, verifying the location and intensity of pain during the hospitalization period. A second aim was to evaluate its influence on the pulmonary function and its correlation with the characteristics of the individual and the surgical procedure.
Method: The series was composed of 30 individuals with the preoperative pulmonary function assessed by spirometry and incentive spirometry. Patients were followed in the postoperative period using a protocol with information on the surgery and the pulmonary function and a protocol for pain evaluation (visual analogue scale and body picture). Descriptivestatistics, Mann-Whitney test and Spearman correlation were used for statistical analysis.
Results: Coronary artery bypass surgery was the most frequent surgery. The pain intensity in the postoperative period was moderate, initially located near to the sternotomy and persisted until the 5th postoperative day. The maximum inspiratory volume had a significant relationship with pain (r= -0.277; p< 0.05). No significant correlation was observed between pain and others parameters.
Conclusion: Significant damage to the pulmonary function is observed which does not completely recover until the 5th postoperative day. Despite these results, pain is not significantly associated to the characteristics of the individual or the surgical procedure.
Keywords: Postoperative complications; Postoperative pain; Physical therapy modalities; Cardiac surgical procedures
Pain intensity and postoperative functional assessment after heart surgery
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: To evaluate, in patients submitted to heart surgery, the intensity of pain and the level of functionality during the preoperative period, on the 7th postoperative day and at hospital discharge. A secondary objective was to evaluate any possible relationship between pain and functionality taking into account the following variables: gender, age, first heart surgery or re-interventions, use of ecardiopulmonary bypass (CPB), type of surgery and physiotherapeutic follow-up.
Method: Forty-one patients who had undergone elective heart surgery by medium-sternal thoracotomy at the Teaching Hospital of Botucatu/UNESP were studied. Pain intensity was measured by VAS scale and functionality by FIM (Functional Independence Measure) scale in the physical domain.
Results: It was observed that the intensity of pain was higher on the 7th postoperative day when compared with the preoperative period and at hospital discharge. No pain rating score was shown in the preoperative period, while a median pain intensity of 3 (moderate pain), was noted at hospital discharge. The highest levels of functional loss occurred on the 7th postoperative day compared to the total scores obtained in the preoperative period and at hospital discharge. A significant correlation between pain and functionality was observed; a decrease in level of pain between the 7th postoperative day and hospital discharge contributed to an increase in the functional levels.
Conclusion: The evaluations performed in the preoperative period provided predictable results. The evaluations carried out on both the 7th postoperative day and at hospital discharge enabled a classification of patients according to their functional gain or loss, which contributed to indentify those who require more care and training of their abilities.
Keywords: Cardiac surgical procedures; Pain; Pain, postoperative; Pain measurement; Rehabilitation
Comparison of the effects on the flow in the left internal thoracic artery using nimodipine and papaverine as vasodilators
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: To compare the flow of the left internal thoracic artery under a local pharmacological effect caused by the topical action on the arterial pedicle and the intraluminal effect of a calcium channel blocker with a control group using papaverine.
Methods: Over a period from July to November 2004, a prospective study was performed involving 73 patients who were submitted to coronary artery bypass surgery utilizing the left internal thoracic artery as one of a group of grafts. A comparative analysis of the flow was made when using two different pharmacological agents. The patients were randomized to receive either nimodipine or papaverine as vasodilators. Two types of flow were determined: the flow at Time 1 representing the period of topical action of the drug on the arterial pedicle (extraluminal) and the flow at Time 2 representing the intraluminal action of the drug. A comparison of the means of the two types of flow between the two groups of pharmacological agents was carried out using the non-parametric Mann-Whitney test.
Results: There is no evidence that the mean flow using the two pharmacological agents is different at Time 1 (p = 0.534) or at Time 2 (p = 0.063).
Conclusions: There is no evidence that the mean flow varies due to the topical action of one or other drug or that the mean flow is different due to the intraluminal action, proving that nimodipine as a locally acting vasodilator is similar to papaverine.
Keywords: Papaverine; Nimodipine; Mammary arteries; Vasodilator agents
Efficacy of AlCl3 and ethanol in the prevention of calcification of fragments of porcine aortic wall fixed in GDA
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: To evaluate the efficiency of aluminum chloride in isolation or associated with ethanol to prevent calcification and inflammatory reaction with fragments of porcine aortic wall fixed in glutaraldehyde (GDA) and subdermally implanted in young rats.
Method: Fifteen Sprague-Dawley rats were studied. Three fragments of porcine aortic wall were implanted in the subdermal tissue. The fragments were previously subjected to three different methods of treatment: I (GDA), II (GDA + aluminum), III (GDA + ethanol + aluminum). Explantation was performed after fifteen, thirty and sixty days. Histological analysis was achieved using hematoxylin & eosin (HE) and alizarin-red at pHs of 4.2 and 7.0. Calcium content was determined by atomic absorbance spectroscopy.
Results: HE and alizarin red staining showed that the aortic wall extracellular matrix was best preserved in the fragments of Group III. The intensity of the inflammatory reaction was lower in this group. When stained with alizarin red at pH 4.2, Groups II and III had lower degrees of calcification compared with Group I. With alizarin red staining at pH 7.0, Group III demonstrated less calcification compared with Groups I and II. Atomic absorbance spectroscopy showed similar calcium levels for both Groups II and III, but significantly less than in Group I.
Conclusion: Treatment with aluminum chloride inhibits calcification of fragments of aortic wall after implantation and reduces inflammatory reaction. The combined use of ethanol with aluminum chloride is more efficient to inhibit calcification and also to diminish inflammatory reaction.
Keywords: Aorta; Calcification, physiologic; Ethanol; Aluminum compounds, pharmacology
Adjustable pulmonary trunk banding: comparison of two methods of acute subpulmonary ventricle hypertrophy
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: This study compares ventricular hypertrophy induced by continuous versus intermittent systolic overload of the pulmonary ventricle (RV) of young goats.
Methods: Three groups of seven goats were used (control, continuous, and intermittent). Systolic overload was maintained for 96 hours in the continuous group, while the intermittent group suffered four 12-hour periods of systolic overload, alternating with 12-hour resting periods. Echocardiographic and hemodynamic evaluations were performed every day. The animals were then killed for myocardial water content and weight evaluation.
Results: Both study groups achieved significant increases in RV mass (p<0.05). However, significant increases of the septum mass were observed only in the Intermittent Group (p<0.05). A greater increase in the RV wall thickness was observed in the Intermittent Group (p<0.05). There was a significant difference in RV diastolic volume between the two groups (p= 0.01), with a greater RV dilation in the Continuous Group after 24 hours of continuous overload (p< 0.03). In both groups, the RV ejection fraction was maintained within the normal range throughout the protocol. A smaller RV perimeter was observed in the Intermittent Group after 96 hours of systolic overload (p<0.05). There was no significant difference in RV myocardial water content between the study groups and the Control Group.
Conclusions: Adjustable pulmonary artery bandages permit rapid RV hypertrophy in both groups. Nevertheless, it is more efficient in the Intermittent Group. This study suggests that preparation of the pulmonary ventricle with intermittent systolic overload might provide better results for the 2-stage arterial switch operation.
Keywords: Heart ventricles, physiopathology; Hypertrophy, physiopathology; Right ventricular hypertrophy; Transposition of great vessels, surgery; Cardiac surgical procedures, methods; Goats
Can skin temperature be a clue for predicting excessive postoperative bleeding?
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: The purpose of this study was to explore if postoperative hypothermia evaluated by skin temperature could give a hint of excessive bleeding requiring re-exploration.
Methods: In this retrospective study, the records of 12 patients who needed re-exploration due to bleeding in the postoperative period were reviewed and the time from the first minute in the intensive care unit until skin temperatures reaching 36.5ºC were measured. Cardiopulmonary bypass (CPB) durations were noted as were preoperative and postoperative Activated Clotting Times (ACT). The lowest body temperatures during the operation were measured. A control group was formed of 16 randomly chosen patients who did not need re-exploration with CPB times being similar to study group. All parameters were compared between the two groups using the SPSS software version 10.0.
Results: Durations from the first minute in the intensive care unit until skin temperatures reached 36.5ºC were significantly longer in the study group (p=0.0001). Preoperative and postoperative ACT were not significantly different (p=0.312 and p=0.576 respectively). The lowest body temperatures were also not significantly different (p=0.157).
Conclusions: Our findings show that skin temperature is an important indicator of excessive bleeding with a need for re-exploration. Hypothermia may be a reason for this or may be a result of bleeding.
Keywords: Induced hypothermia, adverse effects; Blood loss, surgical; Preoperative care, methods; Cardiopulmonary bypass
Lecompte procedure for correction of the transposition of the great arteries associated with ventricular septal defect and left ventricle outflow tract obstruction
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objetive: To evaluate the Lecompte procedure used for the correction of the transposition of the great arteries (TGA) associated with ventricular septal defect (VSD) and the left ventricle outflow tract obstruction (LVOTO) and to present the intermediate and long-term results of the surgery.
Methods: Between February 1994 and July 2005, seven patients with ages between 2 and 8 years (median: 3.0) suffering from TGA, VSD and LVOTO underwent corrective surgery. In six cases, the Lecompte procedure was performed. This technique consists in right ventriculotomy, extensive resection of conal septum and construction of a ventricular tunnel connecting the left ventricle to the aorta (LV-Ao). The remaining case presented with obstruction of a valvular prosthesis implanted between the right ventricle and the pulmonary artery (RV-PA) and RV failure. This case was converted to the Lecompte procedure.
Results: The cardiopulmonary bypass time varied from 105 to 194 minutes (Median: 130) and the aortic clamping time varied from 65 to 90 minutes (Median: 78). There was one death in the immediate post-operative period due to coagulopathy followed by RV failure. Six patients were released from hospital between the 5th to 30th postoperative day (Median: 11) and the follow up period was from 12 to 144 months (Median: 73.6).
Conclusions: The Lecompte procedure presents the following advantages: 1. Surgical indicationfor infants; 2. Low morbility and mortality rates; 3.Free from reoperation over the long term. 4. Possibility of conversion of the Rastelli procedure into the Lecompte procedure.
Keywords: Heart defects, congenital, surgery; Cardiac surgical procedures; Transposition of great vessels, surgery; Heart valve prosthesis
REVIEW ARTICLE
Aminoglycoside nephrotoxicity
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Aminoglycosides are frequently used due to their high efficacy against gram-negative bacteria and their positive synergism with other antibiotics against gram-positive organisms. They are commonly used for the prevention and treatment of infectious complications after cardiothoracic surgery. The principal side effect of this class of antibiotics is nephrotoxicity, which may occur in up to 20% of exposed patients. Although usually reversible, aminoglycoside-induced renal injury prolongs hospitalization time and increases patient cost. Even more important, the occurrence of nephrotoxicity is associated with higher patient mortality. There are some known risk factors for nephrotoxicity development and some measures that may prevent it. This review will cover the most relevant aspects of this important side effect of aminoglycoside therapy.
Keywords: Aminoglycosides; Acute renal Insufficiency; Kidney, drug effects
SPECIAL ARTICLE
Pediculated autologous vascularized pericardial flap aortoplasty for correction of simple aortic coarctation or associated with hypoplasia, atresia or interruption of aortic arch
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: Eighteen years ago, two young male patients of 8 months and 13 years with aortic coarctation associated to aortic hypoplasia between the left subclavian artery and the aortic coarctated area, were submited to surgical correction using a new world-pioneering surgical technique developed in our service.
Method: This technique consists of sectioning the patent ductus arteriosus, followed by ressection of all the coarcted tissue in the aortic wall and aortoplasty correction by means of the lengthwise implantation of a pedicled autogenous pericardial flap. This flap is inserted into the thoracic aorta, from the root of the left subclavian artery to 2.0 cm below the coarctated area.
Results: For both patients, the blood pressure and arterial pulses of both arms and legs have been normal since the surgery until the present moment. Clinical examination and Doppler evaluation evidenced no pressure gradient between arms and legs, normal blood flow and no pressure gradient through the coarctated area. Both patients were submited to other evaluations 18 years after surgery, including cardiac and thoracic aortic catheterization followed by aortography. These evaluations demonstrated normal aortic configuration, with normal diameter, including the areas above and below the coarctated site. There was no evidence of any kind of degenerative lesions of the vascularized pericardial flap or re-coarctation of the lesion and no signs of aneurysms forming or the presence of atherosclerosis of the flap. Moreover, and very importantly, it was evident that the pedicled completely vascularized autologous pericardial flap had been kept alive and has grown in diameter as well as in length.
Conclusion: The surgical technique using a pedicled vascularized autologous pericardial flap is the most complete and adequate for the correction of the different types of simple or complex forms of thoracic aortic coarctation in all age groups,including newborn babies when compared to all the existing techniques.
Keywords: Aorta, surgery; Aortic coarctation, surgery; Cardical surgical procedures
EXPERIENCE THE OF SERVICE
Surgical treatment of the ascending aorta and aortic arch with antegrade cerebral perfusion and moderate hypothermia
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: To retrospectively evaluate the technique of antegrade cerebral perfusion via the innominate artery associated with moderate systemic hypothermia (28-30°C) in adults operated on for aneurysms or proximal aortic dissections.
Method: Twelve consecutive adult patients who presented with proximal aortic dissections or aneurysms were operated on. Of these, seven presented with aortic dissections and five presented with ascending aortic or aortic arch aneurysms. Arterial perfusion was achieved using an 8.0 mm PTFE graft anastomosed to the innominate artery; the brachiocephalic trunk was occluded proximally for antegrade cerebral perfusion. Systemic hypothermia of 28-30°C was used during circulatory arrest with the mean arterial pressure of the right radial artery maintained between 50-60 mmHg.
Results: There were no neurological or bleeding complications. In ten cases, the aortic valve was preserved by resuspension or remodeling. The mean time of circulatory arrest with antegrade cerebral perfusion was 24 minutes (range from 20 to 35 minutes).
Conclusion: Antegrade cerebral perfusion through the innominate artery associated with moderate hypothermia (28-30°C) seems to be effective to protect the central nervous system and possibly to avoid excessive bleeding in the post operative period.
Keywords: Aorta, pathology; Aorta, surgery; Aneurysm dissecting, surgery; Extracorporeal circulation
CASE REPORT
Inhalation of hypertonic saline solution as coadjuvant in respiratory physiotherapy to reverse atelectasis in the postoperative of pediatric heart surgery
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
The case of an eleven-month-old female child is presented diagnosed as having congenital heart disease with pulmonary hyperflow, who was submitted to a surgery to close an interventricular communication, interatrial communication and arterial canal ligature. The infant evolved with persistent atelectasis at the right lung base in the postoperative period which did not respond to conventional physiotherapeutic measures. Inhalation of hypertonic saline solution with 6% NaCl was associated as a coadjuvant therapy, giving a total cure of the atelectasis after three days of treatment.
Keywords: Hypertonic saline solution; Atelectasis; Physical therapy modalities; Mucociliary clearance
Iliofemoral arterial malformation
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
During routine dissection, an iliofemoral arterial malformation was noticed in a 65 year old male cadaver. The abdominal aorta was considerably laterally displaced and also bifurcated higher up. The common iliac artery divided one vertebral level higher and the femoral artery gave origin to the profunda femoris artery about 1.2 cm below the inguinal ligament, which is considerably proximal to its usual level of origin. A brief review of literature and embryological basis of the anomalies are discussed.
Keywords: Arteries, abnormalities; Abdominal aorta; Iliac artery; Femoral artery
BRIEF COMMUNICATION
Inicial experience using valved porcine xenografts in the rigth ventricule outlet for congenital anomalies
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
CLINICAL-SURGICAL CORRELATION
Anomalous origin of the left coronary artery from pulmonary artery: Takeuchi operation
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
The Ross operation in the treatment of calcified bicuspid aortic valves
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
LETTERS TO THE EDITOR
Letters to the Editor
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
REVIEWERS RBCCV
Reviewers BJCVS 2006
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025