Volume 24 - Número 1
EDITORIAL
Another dream has come true
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
MY OPINION
Process improvement: the sorcerer and the sorcerer's apprentice
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
ORIGINAL ARTICLE
Results of beating heart mitral valve surgery via the trans-septal approach
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
Objective: Mitral valve surgery can be performed through the trans-atrial or the trans-septal approach. Although the trans-atrial is the preferred method, the trans-septal approach has also been used recently and has a particular value in beating-heart mitral valve surgery. Herein we report our experience with beating-heart mitral valve surgery via trans-septal approach, and discuss its advantages and pitfalls. Methods: Between 2000 and 2007, 214 consecutive patients were operated upon utilizing beating heart technique for mitral valve surgery. The operation was performed via trans-septal approach with the aorta unclamped, the heart beating, with normal electrocardiogram and in sinus rhythm. Results: Mean age was 56.03 + 13.93 years (range: 19-86 years; median: 56 years). There were 131 (61.2%) males and 83 (38.8%) females. Of the prostheses used, 108 (50.5%) were biological, and 39 (18.2%) were mechanical. Mitral repairs were performed in 67 (31.3%) patients. Mean hospital stay was 17.4 + 20.0 days (range: 3-135 days; median: 11 days). Intra-aortic balloon pump (IABP) utilization was required in 12 (5.6%) of 214 patients. One-month mortality was 7.4%, and re-operation for bleeding was needed in 15 (7%) patients. Conclusions: Beating-heart mitral valve surgery is an option for myocardial protection in patients undergoing mitral valve surgery. This technique is facilitated by the trans-septal approach due to reduced aortic insufficiency and improved visualization of the mitral apparatus.
Keywords: Mitral valve, surgery; Heart valves, surgery; Heart valve diseases; Heart arrest, induced
The importance of troponin I in the diagnosis of myocardial infarction in the postoperative of coronary artery bypass graft surgery
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
OBJECTIVE: The aim of this study is to establish a cut-off value for troponin I by correlating it to occurrence of postoperative myocardial infarction. METHODS: 180 consecutive patients with coronary disease referred for surgery were included. The mean age of the patients were 60.6 (±9.3) years, with 119 (66.1%) males and 61 (33.9%) females. The patients were divided into two groups: group without myocardial infarction (A) - 170 patients - and with myocardial infarction (B) - 10 patients.The troponin I was collected from each patient at the beginning of anesthesia and on the second postoperative day by correlating it to presence or not of postoperative myocardial infarction. StatsDirect 1.6.0 for Windows was used for statistical analysis. RESULTS: Preoperative troponin I was 1.0 (±6) ng/ml as mean. Univariate logistic regression showed correlation of troponin I of the second postoperative day with myocardial infarction (P=0.0005). ROC curve was used to define the cutoff value, and 6.1 ng/ml (sensitivity=90.0%, specificity=82.1%, OR=49.8 with CI=95% 6.1- 410.4, P<0.0001) were found. CONCLUSION: The chance of a patient with postoperative myocardial infarction to present troponin I equal to or higher than 6.1 ng/ml is 49.8-fold higher than the chance of a patient without infarction to present troponin I higher than this value.
Keywords: Myocardial infarction; Troponin I; Cardiac surgical procedures
Decellularized heterografts versus cryopreserved homografts: experimental study in sheep model
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
OBJECTIVES: The aim of this study is to assess the biological behaviour of porcine decellularized heterografts (Desc group) compared with cryopreserved homografts (Crio group) implanted in juvenile sheep. METHODS: Decellularized porcine pulmonary heterografts were implanted in five animals and cryopreserved pulmonary homografts in another five. The animals were followed-up for a mean of 280 ± 14 days. The valve diameter was measured by echocardiography, which was performed at the 30th postoperative day, and before the explantation. The valves were also assessed macroscopically. Histological evaluation was performed using H.E., Gomori and Weigert staining. Immunohistochemistry specified different cell types (Factor VIII, CD3, Vimentin and CD68). Calcium quantity was analyzed using atomic absortion spectometry. RESULTS: There was one death in the Desc group due to endocarditis. The valves of Crio group showed decrease in the cellularity whereas the valves of Desc group showed matrix repopulation with endothelial and interstitial cells. Loss of collagen density and disarrangement of the normal fiber architecture was observed in Crio group. Calcium content demonstrated higher levels on the cusps and conduits in Crio group comparatively with Desc group. (P=0.016). The mean valvular diameter at the explantation was significantly increased (P=0.025) in the Desc group. CONCLUSIONS: Decellularized heterografts had a different biological behaviour when compared to cryopreserved homografts and become repopulated by cells with fibroblasts and endothelial cells characteristics. The matrix was preserved and some regenerative potential was present
Keywords: Transplantation, homologous; Transplantation, heterologous; Cryopreservation; Tissue engeneering
Effects of n-acetylcysteine on ischemic preconditioning. Study in isolated rat hearts
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
Objective: The aim of this study is to assess if N-Acetylcysteine (NAC) changes the Ischemic Preconditioning (IP) in isolated rat hearts using only one cycle of IP. Methods: Heart Rate (HR), Coronary Flow (CF) and Myocardial Contractility (dP/dt) were registered in 30 Wistar rat's hearts. After anesthesia the hearts were removed and perfused with Krebes-Hensleit equilibrated solution with 95% of O2 and 5% of CO2 according Langendorff's method. GI: Control (n=6); GII: 20 min. ischemia (n=6); GIII: IP (n=6); GIV 50 µg/ml/min NAC before IP (n =6); GV: 100 µg/ml/min NAC before IP (n=6). Parameters were measured after 15 min. of stabilization (T 0) and T3, T5, T10, T15, T20, T25 and T30 min. after reperfusion. Statistical significance was considered when P<0.05. Results: There were changes on HR comparing GI with GII at T20 and T25 and comparing GI with GIII, GIV with GV at T10 and T20 (P<0.05). CF was different comparing GI with GII at T3 and T5, GI with GIV at T10 and GI with GV at T10 and T25 (P<0.05). Myocardial Contractility was similar comparing GIII with GI and GV. GIII had higher dP/dt than GIV but without statistical difference (P>0.05). dP/dt was higher in GV than GIV but with statistically significant difference only at T30. Conclusion: dP/dt was better in preconditioned hearts and was changed if using NAC in GIV. The use of NAC didn't change the effects of preconditioning on myocardial contractility in GV.
Keywords: Ischemic preconditioning; Myocardial infaction; Myocardial contraction; Free radicals; Animal experimentation
Effects of ischemic postconditioning on left ventricular function of isolated rat hearts
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
Objective: To assess the effects of ischemic postconditioning on left ventricular function in isolated rat hearts. Methods: Twenty-four Wistar rats were used. These hearts underwent perfusion by modified LANGERDORFF method and distributed into three groups: GI - control (n=8); GII - three cycles of postconditioning of 10/10s (n=8); GIII - three cycles of postconditioning of 30/30s (n=8). After a 15min stabilization period, all hearts underwent 20min of global ischemia following 20min of reperfusion. In the times 0 (control), 5, 10, 15 and 20min of reperfusion, the heart rate (HR), the coronary flow (CoF), the systolic pressure, the (+dP/dt max) contractility and (-dP/dt max) velocity of relaxation were measured. Data were analyzed by ANOVA method followed by Tukey's test for differences between groups and P < 0.05 was considered significant. Results: The HR (bpm) decreased in all groups after 20min of reperfusion without statistical differences among them (GI 232.5+ 36.8; GII 241.8+ 46.7; GIII 249.4+ 40.4;P>0.05). The same occurred with the systolic pressure (mmHg) (GI 132.6+49.3; GII 140.8+ 43.1; GIII 112.6+33.2; P>0.05), coronary blood flow (GI 18.5+ 4.6; GII 21.4+ 4.4; GIII 22.1+ 9.0; P>0.05) and -dP/dt max (mmHg) (GI 1490.6+ 512.0; GII 1770.4+ 406.6; GIII 1399.1+ 327.4; P>0.05). The + dP/dt max (mmHg) decreased significantly in all groups except in group II (GI 1409.0+ 415.2, GII 1917.3+ 403.1, GIII 1344.8+355.8) (GII vs GI, P= 0.04; GII vs GIII, P= 0.02). Conclusion: The ischemic postconditioning by three cycles of reperfusion/ischemia of 10/10s demonstrated to be effective for preservation of the myocardial contractility in isolated rat hearts which had undergone 20min of ischemia.
Keywords: Heart Arrest, induced; Myocardial reperfusion; Myocardial ischemia; Cardiovascular physiology
Coronary artery bypass grafting using the radial artery: influence of proximal anastomosis site in mid-term and long-term graft patency
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
Objective: To determine whether the proximal anastomosis interferes or not in mid- and long-term patency of these grafts. Methods: One hundred twenty-three out of 481 patients who had undergone surgery using radial artery (RA) were restudied. The mean age was 58.8 + 10.4 years. In 96 (78.05%) patients the cardiopulmonary bypass (CPB) was used. Considering all surgical grafts, 382 coronary branches were grafted (mean, 3.1 + 0.8 arteries per patient). 150 of them used radial artery (RA), and the left marginal branches (LOM) were the most prevalent (48.67%). The proximal anastomosis was performed in the aorta in 50 (40.65%) patients and as an artificial "Y" composite graft with the left or right internal thoracic artery (LIMA/RITA) in 73 (59.35%). Postoperatively, coronary angiography studies were performed within a mean period of 5.36 + 3.21 years. The obtained data was divided into two categories: proximal anastomosis (aorta/composite) and patency (occluded/patent). A chi-square test was used to compare both proportions, within a 95% confidence interval (CI). Results: From the 50 aorta-anastomosed grafts, 42 (84%) were patent and eight (16%) occluded. Regarding the 73 "Y" composite grafts, 59 (80.82%) were patent and 14 (19.18%) occluded. Comparing these proportions in both techniques, there was no statistically significant difference between them (P=0.651, CI=95%). Conclusion: The site of proximal anastomosis of the RA coronary grafts does not interfere in mid- and long-term graft occlusion and patency.
Keywords: Myocardial revascularization/methods; Treatment outcome; Radial artery; Anastomosis, surgical
Video-thoracoscopic pericardial drainage in the treatment of pericardial effusions
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
OBJECTIVES: To assess efficacy and safety of videothoracoscopic pericardial drainage in the treatment and diagnostic of pericardial effusion through 26 cases review. METHODS: From April 2005 to December 2007, 26 patients with pericardial effusion underwent a video-thoracoscopic pericardial window. Median age was 48.2 years old. Dyspnea was the most frequent symptom followed by thoracic pain. The procedure was performed in lateral decubitus, under general anesthesia and selective intubation with the aid of three trocars. RESULTS: Procedure accomplish was feasible in 25 cases. One conversion occurred. In 61.53% of the cases the procedure was able to modify the initial diagnosis. Microbiology and tissue culture were negative in all cases. Neoplasia was present in nine cases, tuberculosis in two, aspergillosis in one, postoperative heart surgeries in three; lupus in two, uremia in one and idiopathy in eight. Associated pleuropulmonary procedures were performed in four cases. No deaths related to the procedure occurred. One late recurrence was recorded. CONCLUSION: The procedure is feasible, safe, reproducible and allowed an etiologic diagnostic. Specific treatment could be initiated in some cases. The intervention could possibly be the new gold standard treatment of pericardial effusion in selected patients.
Keywords: Thoracic surgery, video-assisted; Pericardial effusion/surgery; Pericardium
Quality of life in heart transplant candidates
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
Objective: To assess the quality of life of patients with refractory heart failure disease as candidates for heart transplant. Methods: A transversal, descriptive and prospective study with 18 adult patients, with mean age of 52 years under pre-transplantation outpatient follow-up at educational and public hospital in São Paulo town. The quality of life was assessed by reference to "The Medical Outcomes Study 36-item Short-Form Health Survey" (SF-36) generic questionnaire in order to assess the aspects in relation to the function, dysfunction, physical and emotional uneasiness. Results: According to this group, 14 (77.8%) of these patients were male and four (22.2%) female; 14 (77.8%) of them were classified as functional class IV and four (22.2%) as functional class III (New York Heart Association); 17 (94.4%) of them were at stage D and one (5.6%) at stage C (American Heart Association/American College of Cardiology). The mean results obtained from the assessment of SF-36 scales were: functional capacity 38%, pain 49%, health general condition 49%, vitality 39%, social aspects 53%, emotional aspects 43% and mental health 54%. Conclusion: The quality of life of patients presenting terminal heart failure is considered to be very bad; it is likely to be worse than in many other more common morbid entities. Both mental and social aspects are least affected, on the other hand the vitality and functional capacity are the most affected.
Keywords: Heart transplantation; Sickness impact profile; Quality of Life; Cardiac failure
One-stage management of infected sternotomy wounds using bilateral pectoralis major myocutaneous advancement flap
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
OBJECTIVE: To assess the results of single-stage treatment of infected sternotomy wounds using bilateral pectorals major myocutaneous advancement flaps. METHODS: Between January 2000 and July 2007, 1972 heart surgeries with median transesternal thoracotomy were performed. Thirteen (0.65%) patients presented wound infections and dehiscence after sternotomy. To treat those patients we adopted exclusively single-stage management, drainage, early intervention and immediate wounds closure using bilateral pectoralis major myocutaneous advancement flaps to the medium line of the sternum. Two patients with superficial wounds infection and other two who underwent torsion adjustment of the steel wire were not included in this study. RESULTS: There was one death in the 30-day postoperative period. There was no intraoperative death. Four patients needed additional surgical intervention to drain residual seroma or local infection. There was total resolution of the sternal infection in 12 patients. CONCLUSION: The authors recommend the single-stage early management of sternotomy infected wounds with debridement, drainage and immediate closure of the wound using bilateral pectoralis major myocutaneous advancement flaps to the medium line of the sternum. The procedure is effective and may contribute to decrease the morbidity.
Keywords: Infection; Cardiac surgical procedures; Surgical wound infection; Surgical wound dehiscence
Development and assessment of sterility of a closed-system pediatric peritoneal dialysis
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
Objective: To develop an easy-handling totally closed pediatric peritoneal dialysis system and assess the sterility assurance level. Methods: From February to December 2008 was designed and developed a closed-system pediatric peritoneal dialysis at the Bioengineering Division of Braile Biomédica Indústria, Comércio e Representações S/A®. Twenty systems were manufactured and submitted to sterility assurance level testing, and were divided into Group A (10) - using the sterility test - and B (10) - ethylene oxide gas penetration. Results: In Group A, the sterility test was negative for bacteria and fungi proliferation within 14 days in all systems. In Group B, the gas penetration test showed that there was gas penetration in all points assessed. Conclusions: It was possible to develop a new easy-handling closed-system pediatric peritoneal dialysis and ensure its sterility.
Keywords: Peritoneal dialysis; Sterilization; Child
Clinical complications of limb undergone harvesting of great saphenous vein for coronary artery bypass grafting using bridge technique
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
Objective: The aim of this study was to assess clinical complications of limbs undergone harvesting of the great saphenous vein for venous coronary artery bypass graft surgery using bridge technique. Methods: Fourty-four patients who had undergone CABG using the great saphenous vein harvested by the bridge technique over more than 3 months ago were randomly selected. The exclusion criteria were the harvesting of both saphenous veins, prior saphenectomy of the contralateral limb, edema caused by a systemic etiology, such as heart, renal, thyroid or hepatic diseases and venous insufficiency of the lower limbs as characterized by swollen varicose veins both with and without trophic changes. The age, gender, diabetes, time of surgery and occurrence of complications, such as edema, paresthesia, infection, lymphorrhea, erysipelas and deep venous thrombosis, were assessed. The assessment was clinic and diagnosis of the diabetes was performed by the preoperative exams. The chi-square, Fisher and Student's t tests were used for statistical analysis with an alpha error of 5%. Results: The time between surgery and assessment ranged between 3 and 187 months with a mean of 47.3±42.5 months. Infections of the saphenous harvest site were detected in 25% of the cases, edema in 52.3%, paresthesia in 29.5%, erysipelas in 9.1%, lymphorrhea in 4.5% and deep venous thrombosis in 2.3%. There was no association between diabetes and complications. Conclusion: The saphenous vein harvesting using bridge technique for coronary artery bypass grafting does not eliminate clinical complications, such as paresthesia, infection and edema of the saphenous vein harvesting site.
Keywords: Saphenous vein; Postoperative complications/etiology; Coronary artery bypass/methods; Myocardial revascularization
Early cyanosis after bidirectional glenn operation by venovenous connection via hemiazygos vein
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
SPECIAL ARTICLE
Reflexions about formulation of politics for attention to cardiovascular pediatrics in Brazil
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
The authors discuss the different moments of the National Policy of High-complexity Cardiovascular Care, focusing on the attention to Cardiovascular Pediatrics. This process begun with the attempt to meet the local needs, but, very soon, became a national matter due to the verification of a significant shortage in the attention given to patients with congenital cardiovascular diseases. In 2002 the shortage of procedures in these cases was around 65%. The participation of different agents from the civil society and the Government will be demonstrated regarding the formulation of the politics directed to the attention to cardiovascular pediatrics. Some authors are cited during the discussion to base each moment of the process. The National Policy of High-complexity Cardiovascular Care was regulated on June 15th, 2004, through the Ministerial Directive No 1169/GM as well as the Pediatric Cardiovascular Surgery, on the same date, through the Ministerial Directive No 210 SAS/MS. The importance of the civil society participation in the elaboration of the public social politics is emphasized. The intervention of agents who experience the day-to-day difficulties is of the utmost importance to the better knowledge of questions involving the social area
Keywords: Child; Adolescent; Public policies; Cardiac surgical procedures/history; Heart Defects, Congenital
CASE REPORT
Complete repair of total anomalous pulmonary venous connection in adult patient
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
A 22 year-old male patient was admitted with supracardiac, nonobstructive, total anomalous pulmonary venous connection and large atrial septal defect. Cardiac catheterization revealed severe pulmonary hypertension due to pulmonary overflow (Qp/Qs 6, pulmonary vascular resistance = 1.6 Woods/m2). Complete repair was performed through median sternotomy and cardiopulmonary bypass. The patient was discharged from hospital on the sixth postoperative day with no complications, using converting enzyme inhibitor and aspirin. At six-month follow-up he is currently asymptomatic, with preserved biventricular function and no echocardiographic signs of pulmonary hypertension.
Keywords: Heart defects, congenital; Hypertension, pulmonary; Pulmonary veins/abnormalities
Mobile intrapericardial bullet
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
Patients with bullets in the pericardial sac without myocardial injuries are rare, and most commonly are associated with significant trauma. The diagnosis of an intrapericardial foreign body can be difficult. Its removal is always indicated because it prevents pericarditis, either sterile or infectious, with potential for other significant complications. The authors present two cases of a meandering bullet in the pericardial sac and propose approach and perform review of the literature.
Keywords: Pericarditis; Pericardial effusion; Pericardium/injuries; Wounds, gunshot
Low level laser therapy in acute dehiscence saphenectomy: therapeutic proposal
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
Dehiscence is a feared complication after major surgeries. Patient who had undergone coronary artery bypass grafting developed saphenectomy's dehiscence on lower limb with edema and pain on the 15th postoperative day. Conventional treatment had been initially performed without clinical improvement. On the 30th postoperative day only Low Level Laser Therapy (LLLT) was applied punctually around surgical wounds edge. The results revealed granulated tissue, reduction of inflammatory process and analgesic effect since the first application. In this pilot study, LLLT has shown a considerable role as a wound healing agent, through a new proposal for efficient, safe and noninvasive therapy.
Keywords: Laser therapy, low-level; Surgical wound dehiscence; Wound healing
MULTIMEDIA
Technical option for redirection of flow in the partial anomalous pulmonary veins connection
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
CLINICAL-SURGICAL CORRELATION
Implantable cardioverter-defibrillator in a child with isolated noncompacted myocardium
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
NEWS
Tomas Salerno receives the 2009 Robert Zeppa, M.D. Award of Excellence
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025
LETTERS TO THE EDITOR
Letters to the Editor
Braz J Cardiovasc Surg 24;
Publish in: 8/2/2025