Volume 22 - Número 2
EDITORIAL
Encontro histórico
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Keywords:
SPECIAL ARTICLE
Guidelines for surgery of aortic diseases from Brazilian Society of Cardiovascular Surgery
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
ORIGINAL ARTICLE
Hypoplastic left heart syndrome: the report of a surgical strategy and comparative results of Norwood x Norwood-Sano approach
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objectives: To report a surgical strategy for the Norwood procedure in the hypoplastic left heart syndrome (HLHS) that enables short hypothermic circulatory arrest time and aortic arch reconstruction with autologous pericardium patch. To compare the results of the modified Blalock-Taussig (mBT) shunt and the right ventricle-to-pulmonary artery (RV-PA) conduit procedures as the source of pulmonary blood flow.
Method: Retrospective study of 78 newborns consecutively operated between March, 1999 and June 2006. One technique for reconstruction of the neoaorta and two different techniques for reestablishment of the pulmonary blood flow: the mBT shunt in the first 37 newborns and RV-PA conduit in the last 41. Cannulation of the ductus arteriosus for systemic perfusion was the main part of the surgical strategy to reduce the hypothermic circulatory arrest time.
Results: In-hospital survival for the entire cohort was 74,35%, or 67.57% for the mBT shunt and 80,49% for RV-PA conduit groups (p=0,21). Hypothermic circulatory arrest times were 45.79±1.99 min and 36,8±1,52 min (p=0,0012), respectively. Mortality rates between first and second stages were 40% for the mBT shunt and 6,9% for RV-PA conduit groups (p=0,007). Late coarctation of the aorta occurred in five patients Actuarial survival curves(Kaplan-Meier) comparison showed better results with VD-AP conduit (p=0,003).
Conclusions: This surgical strategy resulted in short circulatory arrest time, low mortality and low incidence of aortic coarctation. Although the higher rate of survival to first palliation stage with the RV-PA conduit was not significant, the lower interstage mortality and superior medium-term survival in RV-AP group were statistically advantageous.
Keywords: Hypoplastic left heart syndrome; Circulatory arrest, deep hypothermia induced; Heart defects, congenital; Aortic valve stenosis
Endothelium dysfunction caused by acute pressure distension of human saphenous vein used for myocardial revascularization
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To study morphofunctional alterations induced by brief pressure increases in human saphenous veins utilized in coronary artery bypass grafting.
Method: Saphenous veins of 20 patients undergoing coronary artery bypass grafting, were distributed into four experimental groups, control, 100 mmHg, 200 mmHg and 300 mmHg, and submitted to pressure distention over 15 seconds using Krebs solution. The evaluation included CD34 immunohistochemistry and an In vitro vascular reactivity study in organ chambers.
Results: The main experimental findings were 1) From pressures of 200 mmHg there was a tendency to reduce the CD34 expression which became statistically significant at 300 mmHg; 2) There was no impairment of the contraction and relaxation as evidenced by in vitro vascular reactivity tests.
Conclusion: Although vascular reactivity impairment was not demonstrated in vitro, the CD34 expression, measured by imunohistochemistry, shows there is endothelium dysfunction at pressures of 300 mmHg.
Keywords: Endothelium; Saphenous vein; Nitric oxide; Hydrostatic pressure; Myocardial revascularization
Surgical strategy in transposition of the great arteries with aortic arch obstruction
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To analyze our experience in the surgical correction of transposition of the great arteries associated with aortic arch obstruction.
Method: From January 1998 to December 2005 we performed 223 arterial switch operations for transposition of the great arteries; 21 (9.4%) patients had associated aortic arch obstruction. Aortic arch anatomy showed: localized aortic coarctation (n=10) and coarctation with hypoplastic aortic arch (n=6) and interrupted aortic arch (n=5). Ventricular septal defect was present in 19 (90.5%) patients. Size discrepancy between the aorta and pulmonary artery and complex coronary artery anatomy were common findings. Surgical correction was performed in either one (14) or two stages (7). Aortic arch reconstruction was achieved either by resection and extended anastomoses (13) or by relocation of the ascending aorta (8).
Results: Hospital mortality was 23.8% (n=5); with only one death (11.1%) among the last nine patients. Reoperations in the immediate post-operative period included: bleeding (5), residual ventricular septal defect and unrecognized coarctation (1) or residual stenosis of the aortic arch (1). There were two late deaths caused by fungal infections and reoperation for severe aortic regurgitation. Three patients underwent procedures to relieve right ventricular outflow tract obstruction. Two patients have slight to moderate aortic regurgitation.
Conclusion: The surgical treatment of transposition of the great arteries with aortic arch obstruction is complex with high morbidity. Our present choice is one-stage treatment for all patients without using homologous or heterologous tissue for aortic arch reconstruction. We recommend resection and extended anastomoses for localized coarctation and relocation of the ascending aorta for hypoplastic or interrupted aortic arch.
Keywords: Transposition of great vessels; Heart septal defects, ventricular; Cardiac Surgical Procedures, methods
Echocardiographic evaluation of patients submitted to replacement of ruptured chordae tendineae
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: The objective of this study was to evaluate, using echocardiography, the functioning of the mitral valve apparatus in patients submitted to standardized bovine pericardium chordae implantation to substitute ruptured chordae tendineae or elongated chordae with a significant degree of thinning.
Method: Standardized bovine pericardium chordae were implanted in 23 patients with mitral valve insufficiency due to ruptured or elongated chordae with significant thinning. The ages of the patients varied from 23 to 84 years old (mean 62 years old). The most common cause was fibroelastic degeneration affecting 20 (87.0%) patients. The standardized bovine pericardium chordae were manufactured in sets connected at both ends by two polyester-reinforced rods thereby forming a single block. The bovine pericardium chordae measure 2 mm wide with 3 mm between the chordae. The sets of bovine pericardium chordae are produced in lengths varying from 20 to 35 mm. In 17 (73.9%) patients bovine pericardium chordae were implanted in the posterior cusp and in 6 (26.1%) in the anterior cusp. All the patients were evaluated in the postoperative period by echocardiography after a mean follow-up of six months.
Results: The echocardiography in the postoperative period demonstrated an absence of reflux in 11 (47.8%) patients, slight reflux in 8 (34.8%) and slight to moderate reflux in 3 (13.0%). The opening and mobility of the mitral valve was normal in the 22 surviving patients.
Conclusion: The echocardiography demonstrated good functioning of the mitral valve apparatus in patients submitted to the implantation of standardized bovine pericardium chordae to substitute ruptured chordae tendineae or elongated chordae with a significant degree of thinning.
Keywords: Regurgitation; Mitral valve insufficiency; Chordae tendineae, surgery; Prostheses and implants; Biocompatible materials
Risk index for death by infective endocarditis: a multivariate logistic model
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: This study aimed at identifying predictive variables for in-hospital mortality, calculating the probability of death and creating a risk index for death by infective endocarditis by comparing two methods using a Receiver Operating Characteristic (ROC) curve.
Methods: A retrospective study was conducted of 186 consecutive cases of confirmed infective endocarditis divided into two groups: discharged (137) and in-hospital death (49). Based on the odds ratios obtained by multivariate analysis, the probability of death was calculated and a mortality risk index created.
Results: Factors predictive of higher mortality (multivariate analysis) and the risk index, with their repective weights were: age ³ 40 years (OR = 4.16; 95%CI [1.63-10.80] - 4 points), class IV heart failure or cardiovascular shock (OR = 4.93; 95%CI [1.86-13.05] - 5 points), uncontrolled sepsis (OR = 5.97; 95%CI [1.95-18.35] - 6 points), conduction disorder (OR = 5.07; 95%CI [1.67-15.35] - 5 points), arrhythmia (OR = 8.17; 95%CI [2.60-25.71] - 8 points), valve with extensive damage or abscess or prosthesis (OR = 4.77; 95%CI [1.44-15.76] - 5 points) and large and mobile vegetation (OR = 4.36; 95%CI [1.55-12.90] - 4 points). Patients with scores between 0 and 10 had a mortality of 5.26% and scores over 20 of 78.9%.
Conclusions: The higher the score, the higher the mortality rate. The mortality risk index may be used to estimate mortality in Infective Endocarditis.
Keywords: Endocarditis; Mortality; Prognosis
Cardiopulmonary bypass time as a risk factor for acute renal failure
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: Acute renal failure following heart surgery is a major complication. The aim of this study was to evaluate if duration of cardiopulmonary bypass (CPB) is an important factor that influences kidney dysfunction.
Methods: One hundred and sixteen patients from a single center referred for heart surgery were evaluated. Demographic factors, clinical data, operative and postoperative variables were evaluated. Serum creatinine and creatinine clearance were calculated until the fifth postoperative day. Acute renal failure was defined as the requirement of dialysis therapy. Patients were divided into two groups, the CPB £70min Group, patients with CPB duration equal to or less than 70 minutes and the CPB³ 90min Group, patients with CPB duration equal to or more than 90 minutes.
Results: The median increases in serum creatinine were 0.18 + 0.41(CPB£70min) and 0.42 + 0.44 (CPB³ 90min - p=0.005). Dialysis was indicated in 1.3% (CPB£70min) and 12.5% (CPB³ 90min - p = 0.018). The odds ratio for dialysis was 1.12 (95% CI; 1.00-1.20) for CPB³ 90min. There was no significant difference in mortality (5.2 versus 7.5%, p = 0.631).
Conclusion: The greatest likelihood of developing kidney failure after heart surgery is observed when CPB is at least 90 minutes, although creatinine clearance was not significantly altered between the groups studied.
Keywords: Extracorporeal circulation; Dialysis; Renal insufficiency
Technical aspects in skeletonization of the internal thoracic artery using an ultrasonic scalpel
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To describe the technique and evaluate the immediate results of using an ultrasonic scalpel in the skeletonization of the internal thoracic artery for coronary artery bypass grafting surgery.
Methods: From January 2000 to October 2006, 188 patients were submitted to coronary artery bypass grafting with the internal thoracic artery skeletonized using an ultrasonic scalpel. Seventy-one patients (37.8%) were women. The patients' ages varied from 28 to 81 years old. The entire internal thoracic artery was exposed opening the endothoracic fascia using scissors as close as possible to the arterial adventitia. An ultrasonic scalpel was used to transect and coagulate all the intercostal branches, thereby minimizing the use of metallic clips.
Results: The skeletonized internal thoracic arteries presented with excellent flow, obviating the need for intraluminal manipulation for vasodilatation. In the immediate postoperative period, two patients were found to have temporary left-sided diaphragmatic paralysis. There were no sternal wound infections in this series. The dissection can be performed in approximately 33 minutes however with more experience this time may be reduced.
Conclusion: This technique facilitates and shortens the internal thoracic artery skeletonization procedure and does not cause arterial spasms. Cauterization of the collateral branches with an ultrasonic scalpel is efficient and the use of metallic clips is almost unnecessary. It is a procedure that is easy to reproduce and may be recommended as the first-choice technique for the dissection of the internal thoracic artery.
Keywords: Myocardial revascularization; Coronary artery bypass; Mammary arteries
Evaluation of the NNECDSG Score in a Brazilian public hospital
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To compare the observed incidence of mediastinitis and strokes versus the expected incidence according to the NNECDSG score (Northern New England Cardiovascular Disease Study Group) in a population submitted to coronary artery bypass graft surgery.
Methods: A retrospective consultation was made of medical records of all patients submitted to isolated CABG from January 1st, 2000 to December 31st, 2004, at the Cardiac Surgery Service of the Triângulo Mineiro Federal University (UFTM). Data regarding the incidences of observed mediastinitis and strokes and those estimated by the NNECDSG score were submitted to the Kolmogorov-Smirnov normality test. A comparison was achieved using the paired Student t test, with the level of significance determined as p=0.05.
Results: A group of 230 patients were analyzed, including 144 (62.60%) men and 86 (37.39%) women. Sixty-one (26.52%) presented with diabetes, 30 (13.04%) with chronic obstructive pulmonary disease (COPD) and 23 (10%) had peripheral vascular disease (PVD). Emergency surgery occurred in 34 (14.78 %) cases. In 37 (16.08%) patients an ejection fraction (EF) of less than 40% was identified. Mediastinitis occurred in 12 (5.21%) patients and despite the greater general incidence in the sample studied, no statistical significance was found. Strokes occurred in 12 patients (5.21%) and in spite of the higher mean percentage incidence of observed strokes for all scores, a level of statistical significance was not found.
Conclusions: Although the incidences of mediastinitis and strokes were greater in the population studied, these values showed no statistical significance, confirming the score recommended by the NNECDSG as a safe and efficient method for predicting postoperative mediastinitis and strokes in patients submitted to myocardial revascularization surgery in the UFTM.
Keywords: Mediastinitis; Cerebrovascular accident; Myocardial revascularization; Risk assessment
Mitral valve replacement with the preservation of the entire valve apparatus
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: The papillary muscles and the chordae tendineae of both mitral leaflets contribute to the preservation of the left ventricular function. Most surgeons, however, routinely excise the anterior mitral leaflet.
Methods: In a group of nine patients, six of them underwent mitral valve replacement alone and three underwent both aortic and mitral valve replacements, all the mitral apparatus was preserved. All of these patients had mechanical valves using CarboMedics cardiac prosthesis (CarboMedics, Inc. Austin, Texas).
Results: There was no mortality. Postoperative echocardiographic assessment revealed maintained left ventricular function with no interference with the prosthetic leaflet mobility and no left ventricular outflow tract gradient.
Conclusion: We believe that in most patients with long-standing mitral valve regurgitation, thinned out papillary muscles and elongated chordae tendineae that are not amenable to repair, valve replacement with the preservation of the entire native valve is possible and should be encouraged. This is especially valuable for those with depressed left ventricular function, who might otherwise suffer from left ventricular dysfunction in the long-term if the entire mitral valve apparatus were to be excised.
Keywords: Mitral valve, surgery; Mitral valve insufficiency, surgery; Heart valve prosthesis implantation, methods
Spiral blood pump: conception, development and clinical application of the original project
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Introduction: This paper addresses an original project that encompasses the conception, development and clinical application of a helical bypass pump called the Spiral Pump, that uses the association of centrifugal and axial propulsion forces based de the Archimedes principle. This project has obtained a Brazilian Patent and an International Preliminary Report, defining it as an invention.
Methods: The aim of this work was to evaluate the hemodynamic capacity and the impact of its application on blood cells by means of experimental in vitro tests, including hydrodynamic efficiency, effect on hemolysis and flow visualization. Moreover, in vivo experimental tests were carried out on lambs that were submitted to cardiopulmonary bypass for six hours and in 43 patients submitted to heart bypass surgery using the Spiral Pump.
Results: When the rotor-plastic casing gap was 1.5mm, the flow generated was nearly 9 L/min, the pressure was greater than 400 mmHg at 1500 rpm, and the normalized hemolytic indexes were not greater than 0.0375 g/100L in high-flow and pressure conditions. Additionally, by the flow visualization techniques, stagnation was not seen inside the pump nor was turbulence identified at the entrance or exit of the pump, or at the ends of the spindles. In the in vivo tests using cardiopulmonary bypasses for 6 hours in lambs, the pump maintained adequate pressure rates and the free hemoglobin levels ranged between 16.36 mg% and 44.90 mg%. Evaluating the results of the 43 patients who used this pump in heart bypass operations we observed that the free hemoglobin ranged from 9.34 mg% before to 44.16 mg% after surgery, the serum fibrinogen was from 236.65 mg% to 547.26mg%, platelet blood count from 152,465 to 98,139 and the lactic dehydrogenase from 238.12mg% to 547.26mg%. The Activated Coagulation Time was close to 800 seconds during the bypass.
Conclusion: The Spiral Pump was very effective in generating adequate flow and pressure and caused no excessive harm to the blood cells.
Keywords: Heart-assist devices, classification; Flow mechanics; Hydrodynamics; Hemolysis
REVIEW ARTICLE
Cerebral protection: sites of arterial cannulation and brain perfusion routes
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Brain perfusion for adequate cerebral protection has changed over the years. The limitations of the time during total circulatory arrest with deep hypotermia, the inefficient cerebral metabolism during retrograde perfusion and special care to prevent cerebral embolism during antegrade perfusion have resulted in the development of different methods of cerebral protection during the evolution of aortic arch operations. Antegrade cerebral perfusion associated with moderate hypothermia is today, considered the best option for cerebral protection.
Keywords: Extracorporeal circulation; Brain; Perfusion; Hypothermia, induced
CASE REPORT
Fistula between anterior intraventricular coronary artery and the pulmonary artery trunk: Five operated patients
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
The current study reports on the operative experience of patients with coronary artery fistulas between the anterior intraventricular coronary artery and pulmonary trunk. Of the five patients operated, 60% were women and the ages ranged form 40 to 46 years old. Stress echocardiogram and coronary cineangiography were accomplished for all patients. No deaths occurred in the postoperative period nor were symptoms reported. We believe that the surgical procedure is the first choice treatment for coronary artery fistulas, as it safely and effectively prevents the complications of arteriovenous shunts.
Keywords: Arterio-arterial fistula, surgery; Angina pectoris, etiology; Pulmonary artery, pathology; Coronary vessel anomalies, surgery
Thoracic ectopia cordis with anatomically normal heart
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Ectopia cordis is a rare congenital malformation, which is commonly associated with other intracardiac defects. A two-day-old full-term baby girl was admitted to Santa Casa de Montes Claros Hospital, with thoracic ectopia cordis. A transthoracic echocardiographic study did not identify any associated congenital heart diseases. The infant underwent surgical treatment using a rib graft to create a neo-sternum. She was discharged after a good evolution on the 20th postoperative day.
Keywords: Heart defects, congenital; Ectopia cordis; Thoracic wall, abnormalities; Infant, newborn
Surgical removal of a posttraumatic intracardiac foreign body in a child
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
The authors report the successful surgical removal of a foreign body (7 x 1 cm wooden stick) from the right atrial of a 8 year-old child 77 days after a transfixing chest trauma caused by falling over a fence. The clinical presentation was infective endocarditis confirmed by the presence of an intraatrial mass at echocardiography. The postoperative course was uneventful. At 6 months follow-up, the patient is in Function Class I (NYHA) and in complete remission of infection.
Keywords: Foreign bodies, complications; Heart injuries, surgery; Heart injuries, etiology
Giant mediastinal teratoma found during surgery after thoracic trauma
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Most mediastinal tumors are incidentally diagnosed because they are asymptomatic. The aim of this paper is to report on the case of a 29-year-old male patient, who had an increase in cardiac area after blunt thoracic trauma. He was submitted to thoracotomy when a large mediastinal mass was found. The histopathological diagnosis was a mature mediastinal teratoma.
Keywords: Teratoma, surgery; Mediastinal neoplasms, surgery; Mediastinum
CLINICAL-SURGICAL CORRELATION
IAortic coarctation: Aortoplasty with interposition of the left subclavian artery (the Teles Mendonça Technique)
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Aortic coarctation: Insertion of a tubular graft for post-endocarditis aneurysm
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Cor triatriatum with mitral insufficiency and atrial fibrillation in a 36-year-old man
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
LETTERS TO THE EDITOR
Keywords: