Patients Submitted to Myocardial Revascularization with the Use of Bilateral Internal Thoracic Arteries: Diabetics vs. Non-Diabetics

Abstract Introduction: Use of bilateral internal thoracic artery (BITA) as graft in coronary artery bypass grafting (CABG) is controversial because it is related to higher in-hospital mortality, incidence of sternal wound-related infection, and an increase in surgical time. The primary objective of this study is to evaluate in-hospital mortality and mortality within 30 days from discharge. The secondary objective is to evaluate the occurrence of deep sternal wound infection in a 90-day follow-up. Methods: This is a retrospective review of the medical records of 152 patients undergoing elective CABG with the use of BITA and cardiopulmonary bypass (CPB). These patients were divided into two groups, diabetics and non-diabetics. Patients with acute myocardial infarction and concomitant valvular disease were not included in the sample. Results: Preoperative characteristics did not show significant differences between the groups, which allowed a comparative analysis. The variables electrocardiography time and aortic clamping time were higher in the diabetic group, with a significant statistical difference (P<0.0001). In-hospital mortality occurred in three patients, and there was no mortality up to 30 days in both groups. There was no significant difference in the primary end point between groups (P=0.56). Deep sternal wound infection was present in only one patient and showed no significant difference in the secondary outcome between groups (P=0.40). Conclusion: We did not observe a higher mortality and occurrence of deep sternal wound infection with the use of BITA in diabetic patients compared to non-diabetics, even with greater CPB and aortic clamping times in diabetics.

Patients Submitted to Myocardial Revascularization with the Use of Bilateral Internal Thoracic Arteries: Diabetics vs. Non-Diabetics.

INTRODUCTION: Use of bilateral internal thoracic artery (BITA) as graft in coronary artery bypass grafting (CABG) is controversial because it is related to higher in-hospital mortality, incidence of sternal wound-related infection, and an increase in surgical time. The primary objective of this study is to evaluate in-hospital mortality and mortality within 30 days from discharge. The secondary objective is to evaluate the occurrence of deep sternal wound infection in a 90-day follow-up. METHODS: This is a retrospective review of the medical records of 152 patients undergoing elective CABG with the use of BITA and cardiopulmonary bypass (CPB). These patients were divided into two groups, diabetics and non-diabetics. Patients with acute myocardial infarction and concomitant valvular disease were not included in the sample. RESULTS: Preoperative characteristics did not show significant differences between the groups, which allowed a comparative analysis. The variables electrocardiography time and aortic clamping time were higher in the diabetic group, with a significant statistical difference (P<0.0001). In-hospital mortality occurred in three patients, and there was no mortality up to 30 days in both groups. There was no significant difference in the primary end point between groups (P=0.56). Deep sternal wound infection was present in only one patient and showed no significant difference in the secondary outcome between groups (P=0.40). CONCLUSION: We did not observe a higher mortality and occurrence of deep sternal wound infection with the use of BITA in diabetic patients compared to non-diabetics, even with greater CPB and aortic clamping times in diabetics.

Implantation of transcatheter aortic valve prosthesis through the ascending aorta concomitant with coronary artery bypass grafting without cardiopulmonary bypass / Implante de prótese valvar aórtica transcateter através da aorta ascendente concomitante com revascularização do miocárdio sem circulação extracorpórea

Introdution: The transcatheter aortic valve implantation in the treatment of high-risk symptomatic aortic stenosis has increased the number of implants every year. The learning curve for transcatheter aortic valve implantation has improved since the last 12 years, allowing access alternatives. Objective: The aim of this study is to approach the implantation of transcatheter aortic valve through transaortic via associated with off-pump cardiopulmonary bypass surgery in a 67-year-old man, with chronic obstructive pulmonary disease, arterial hypertension and kidney transplant. Methods: Off-pump coronary artery bypass surgery was performed and the valve in the aortic position was released successfully. Results: There were no complications in the intraoperative and postoperative period. Gradient reduction, effective orifice increasing of the prosthesis and absence of valvular regurgitation after implantation were observed by transesophageal echocardiography. Conclusion: Procedural success demonstrates that implantation of transcatheter aortic valve through the ascending aorta associated with coronary artery bypass surgery without CPB is a new option for these patients. .

Introdução: implante de prótese aórtica transcateter no tratamento da estenose aórtica sintomática de alto risco vem aumentando de número a cada ano no mundo. A curva de aprendizado para implante da prótese aórtica transcateter melhorou os resultados ao longo dos últimos 12 anos, o que permitiu o surgimento de outras vias de acesso como alternativas. Objetivo: Este trabalho refere-se ao implante de prótese aórtica transcateter pela via transaórtica associada à revascularização do miocárdio sem em paciente do sexo masculino de 67 anos com doença pulmonar obstrutiva crônica, hipertensão arterial sistêmica e transplante de rim. Métodos: A revascularização miocárdica e o implante da prótese aórtica transcateter foram realizados com sucesso sem o auxílio da circulação extracorpórea. Resultados: No intra e pós-operatório não houve complicações, a redução do gradiente transvalvar, o aumento do orifício efetivo e ausência de regurgitação paravalvar foram observados pelo ecocardiograma transesofágico. Conclusão: O implante da prótese aórtica transcateter pela aorta ascendente associado com revascularização do miocárdio sem circulação extracorpórea é uma nova alternativa para pacientes de alto rico. .

Implantation of transcatheter aortic valve prosthesis through the ascending aorta concomitant with coronary artery bypass grafting without cardiopulmonary bypass.

INTRODUCTION: The transcatheter aortic valve implantation in the treatment of high-risk symptomatic aortic stenosis has increased the number of implants every year. The learning curve for transcatheter aortic valve implantation has improved since the last 12 years, allowing access alternatives. OBJECTIVE: The aim of this study is to approach the implantation of transcatheter aortic valve through transaortic via associated with off-pump cardiopulmonary bypass surgery in a 67-year-old man, with chronic obstructive pulmonary disease, arterial hypertension and kidney transplant. METHODS: Off-pump coronary artery bypass surgery was performed and the valve in the aortic position was released successfully. RESULTS: There were no complications in the intraoperative and postoperative period. Gradient reduction, effective orifice increasing of the prosthesis and absence of valvular regurgitation after implantation were observed by transesophageal echocardiography. CONCLUSION: Procedural success demonstrates that implantation of transcatheter aortic valve through the ascending aorta associated with coronary artery bypass surgery without CPB is a new option for these patients.

Hybrid treatment for correction of pseudoaneurysm after surgical treatment of aortic coarctation.

The need for a new surgical procedure for correction of postoperative pseudoaneurysm of aortic coarctation makes the procedure especially challenging for the surgeon.ta abstract.

Cirurgia de revascularização miocárdica após infarto agudo do miocárdio causado por trombose de aneurisma coronariano / Coronary artery bypass graft surgery after acute myocardial infarction caused by thrombosis of coronary aneurysm

A morfologia do aneurisma coronariano configura um fator predisponente para formação de trombos. Porém, a estase sanguínea causada pela alteração do fluxo pode não ser o suficiente para causar fenômenos tromboembólicos.

The morphology of coronary aneurysm sets a predisposing factor to thrombus formation. However, the blood stasis caused by the change in flow may not be enough to cause thromboembolic events.

Coronary artery bypass graft surgery after acute myocardial infarction caused by thrombosis of coronary aneurysm.

The morphology of coronary aneurysm sets a predisposing factor to thrombus formation. However, the blood stasis caused by the change in flow may not be enough to cause thromboembolic events.

Evaluation of infant membrane oxygenator in sheep.

OBJECTIVE: To analyze the security and efficacy of a new membrane oxygenator, the so-called OXM - 1500. METHODS: From May 2005 to September 2006, six sheep of Santa Inês breed (five male and one female, respectively) were studied. The average body weight was 14.1 (+/-5) kg, body surface 0.6 (+/-0.2) m(2) and a mean age 3.8 (+/-1.5) months. All of them were submitted to extracorporeal circulation (CEC) with evaluation at 10, 30, 60, 120, 180 and 240 minutes. The following values were obtained: values of oxygen transference (TTO2) and carbon dioxide transference (TTCO2), haemoglobin (HBS) and free haemoglobin (HBL), the score of platelets and of leucocytes, and heat transference rate. RESULTS: TTO2 and TTCO2 were adequate. Lesion of the majority formed blood elements was insignificant; there no modifications in HBS, HBL levels; platelets and leucocytes decreased over time. Heat exchange was effective (p < 0.05). CONCLUSIONS: The membrane OXM--1500 infant oxygenator, tested in sheep, showed adequate oxygenation capacity, CO2 removal capacity, and small alteration of haemoglobin and platelets without significant decrease of leucocytes, as expected. Heat exchanger connected to the oxygenator was efficient in temperature changes.

Avaliação de oxigenador de membrana infantil em ovinos / Evaluation of infant membrane oxygenator in sheep

OBJETIVO: Analisar a segurança e a eficácia de um novo oxigenador de membrana denominado OXM -1500. MÉTODOS: No período de maio de 2005 a setembro de 2006, foram estudados seis ovinos da raça Santa Inês, sendo cinco machos e uma fêmea, com peso corpóreo médio de 14,1 (±5) kg, superfície corpórea de 0,6 (±0,2) m² e idade média de 3,8 (±1,5) meses. Todos foram submetidos a circulação extracorpórea (CEC) com avaliação nos tempos 10, 30, 60, 120, 180 e 240 minutos, obtendo-se os valores de taxa de transferência de oxigênio (TTO2) e de taxa de transferência de gás carbônico (TTCO2), hemoglobina sérica (HBS) e livre (HBL), plaquetometria, leucometria e taxa de transferência de calor. RESULTADOS: Houve adequadas TTO2 e TTCO2. A lesão da maioria dos elementos figurados do sangue foi insignificante, sem alterações dos níveis de HBS, HBL, plaquetas e o número de leucócitos diminuíram com o tempo. A troca de calor foi efetiva (p < 0,05). CONCLUSÃO: O oxigenador de membrana infantil OXM1500, testado em ovinos, mostrou-se com capacidade adequada de oxigenação, remoção de gás carbônico e pequena alteração da hemoglobina e plaquetas, com diminuição do número de leucócitos de forma esperada. O trocador de calor acoplado ao oxigenador foi eficaz nas variações de temperatura.

OBJECTIVE: To analyze the security and efficacy of a new membrane oxygenator, the so-called OXM - 1500. METHODS: From May 2005 to September 2006, six sheep of Santa Inês breed (five male and one female, respectively) were studied. The average body weight was 14.1 (±5) kg, body surface 0.6 (±0.2) m² and a mean age 3.8 (±1.5) months. All of them were submitted to extracorporeal circulation (CEC) with evaluation at 10, 30, 60, 120, 180 and 240 minutes. The following values were obtained: values of oxygen transference (TTO2) and carbon dioxide transference (TTCO2), haemoglobin (HBS) and free haemoglobin (HBL), the score of platelets and of leucocytes, and heat transference rate. RESULTS: TTO2 and TTCO2 were adequate. Lesion of the majority formed blood elements was insignificant; there no modifications in HBS, HBL levels; platelets and leucocytes decreased over time. Heat exchange was effective (p < 0.05). CONCLUSIONS: The membrane OXM - 1500 infant oxygenator, tested in sheep, showed adequate oxygenation capacity, CO2 removal capacity, and small alteration of haemoglobin and platelets without significant decrease of leucocytes, as expected. Heat exchanger connected to the oxygenator was efficient in temperature changes.

[Blood mesenchymal stem cell culture from the umbilical cord with and without Ficoll-Paque density gradient method]. / Cultivo de células mesenquimais do sangue de cordão umbilical com e sem uso do gradiente de densidade Ficoll-Paque.

OBJECTIVES: Implantation of cell separation and mesenchymal stem cell culture techniques from human umbilical cord blood with and without using the Ficoll-Paque gradient density method (d=1.077 g/ml). METHODS: Ten samples of the umbilical cord blood obtained from full-term deliveries were submitted to two different procedures of mesenchymal stem cell culture: a) Method without the Ficoll-Paque density gradient, which concentrates all nucleated cells; b) Method with the Ficoll-Paque density gradient, which selects only low-density mononuclear cells. Cells were initially plated into 25 cm(2) cultures flasks at a density of 1 x 10(7) nucleated cells/cm(2) and 1 x 10(6) mononuclear cells/cm(2). RESULTS: It was obtained 2-13 x 10(7) (median = 2.35 x 10(7)) nucleated cells/cm(2) by the method without the Ficoll-Paque gradient density, and 3.7-15.7 x 10(6) (median = 7.2 x 10(6)) mononuclear cells/cm(2) by the method with the Ficoll-Paque gradient density. In all cultures adherent cells were observed 24 hours after being cultured. Cells presented fibroblastoid and epithelioid morphology. In most of the cultures, cell proliferation occurred in the first week, but after the second week only some cultures - derived from the method without the Ficoll-Paque gradient density-maintained the growth rate reaching confluence. Those cultures were submitted to trypsinization with 0.25% trypsin/EDTA solution and cultured for two to three months. CONCLUSION: In the samples analyzed, cell separation and mesenchymal stem cell culture techniques from human umbilical cord blood by the method without the Ficoll-Paque density gradient was more efficient than the method with the Ficoll-Paque density gradient.

Cultivo de células mesenquimais do sangue de cordão umbilical com e sem uso do gradiente de densidade Ficoll-Paque / Blood mesenchymal stem cell culture from the umbilical cord with and without Ficoll-Paque density gradient method

OBJETIVOS: Implantação de técnicas de isolamento e cultivo de células-tronco mesenquimais do sangue de cordão umbilical humano, com e sem uso de gradiente de densidade Ficoll-Paque (d=1,077g/ml). MÉTODOS: Dez amostras de sangue de cordão umbilical humano de gestação a termo foram submetidas a dois procedimentos de cultivo de células-tronco mesenquimais: sem gradiente de densidade Ficoll-Paque e com gradiente de densidade. As células foram semeadas em frascos de 25cm² a uma densidade de 1x10(7)células nucleadas/cm² (sem Ficoll) e 1,0x10(6) células mononucleares/cm² (com Ficoll). As células aderentes foram submetidas a marcação citoquímica com fosfatase ácida e reativo de Schiff. RESULTADOS: No procedimento sem gradiente de densidade Ficoll, foram obtidas 2,0-13,0x10(7) células nucleadas (mediana=2,35x10(7)) e, no procedimento com gradiente de densidade Ficoll, foram obtidas 3,7-15,7x10(6) células mononucleares (mediana=7,2x10(6)). Em todas as culturas foram observadas células aderentes 24 horas após o início de cultivo. As células apresentaram morfologias fibroblastóides ou epitelióides. Na maioria das culturas houve proliferação celular nas primeiras semanas de cultivo, mas após a segunda semana, somente três culturas provenientes do método sem gradiente de densidade Ficoll-Paque mantiveram crescimento celular, formando focos confluentes de células. Essas culturas foram submetidas a várias etapas de tripsinização para espalhamento ou subdivisão e permaneceram em cultivo por períodos que variaram de dois a três meses. CONCLUSÃO: Nas amostras estudadas, o isolamento e cultivo de células-tronco mesenquimais do sangue de cordão umbilical humano pelo método sem gradiente de densidade Ficoll-Paque foi mais eficiente do que o método com gradiente de densidade Ficoll-Paque.

OBJECTIVES: Implantation of cell separation and mesenchymal stem cell culture techniques from human umbilical cord blood with and without using the Ficoll-Paque gradient density method (d=1.077g/ml). METHODS: Ten samples of the umbilical cord blood obtained from full-term deliveries were submitted to two different procedures of mesenchymal stem cell culture: a) Method without the Ficoll-Paque density gradient, which concentrates all nucleated cells; b) Method with the Ficoll-Paque density gradient, which selects only low-density mononuclear cells. Cells were initially plated into 25 cm² cultures flasks at a density of 1x10(7) nucleated cells/cm² and 1x10(6) mononuclear cells/cm². RESULTS: It was obtained 2-13x10(7) (median = 2.35x10(7)) nucleated cells/cm² by the method without the Ficoll-Paque gradient density, and 3.7-15.7x10(6) (median = 7.2x10(6)) mononuclear cells/cm² by the method with the Ficoll-Paque gradient density. In all cultures adherent cells were observed 24 hours after being cultured. Cells presented fibroblastoid and epithelioid morphology. In most of the cultures, cell proliferation occurred in the first week, but after the second week only some cultures - derived from the method without the Ficoll-Paque gradient density - maintained the growth rate reaching confluence. Those cultures were submitted to trypsinization with 0.25 percent trypsin/EDTA solution and cultured for two to three months. CONCLUSION: In the samples analyzed, cell separation and mesenchymal stem cell culture techniques from human umbilical cord blood by the method without the Ficoll-Paque density gradient was more efficient than the method with the Ficoll-Paque density gradient.

Impacto dos níveis séricos da troponina I cardíaca na evolução tardia de pacientes submetidos a ressincronização com estimulação biventricular / Impact of serum levels of cardiac troponin I in later evolution of patients submited to resynchronization with biventricular simulation

Objetivo: Analisar evolução e a influência dos níveis séricos da troponina I cardíaca no prognóstico de pacientes com insuficiência cardíaca congestiva (ICC) submetidos a ressincronização biventricular. Método: 33 pacientes com miocardiopatia dilatada idiopática , classe funcional III/IV da NYHA, submetdios a ressincronização com estímulo biventricular, foram acompanhados por até 59 meses. A qualidade de vida (QV) foi avaliada no pré e pós-operatórios, utilizando-se o Minnesota Code, e a função ventricular foi analisada por meio de ecocardigrafia. Em 23 pacientes, os níveis séricos de troponina I foram dosados para verificar sua relação com o óbito (teste exato de Fisher) e analisar a taxa de sobrevivência (curva de Kaplan-Meier). Resultados: A QV mostrou-se significativamente melhor após a RV, com mediana de 73 pontos no pré e 36 pontos no pós-operatório (p menor que 0,0001). O diâmetro diastólico do VE(DDVE) reduziu-se de 65 mm para 60 mm após o implante (p igual a 0,0014) e a fração de ejeção (FEVE) aumentou de 37 por cento para 47 por cento (p igual a 0,0004). Não ocorreram óbitos entre os 15 pacientes com valores normais de troponina. Já entre os oito com valores elevados, seis vieram a falecer (p igual a 0,0003). A curva mostrou uma taxa de sobrevivência de 47,1 maior ou menor que 13,3 por cento ao final de 59 meses. Conclusões: Em pacientes com ICC, a ressincronização biventricular melhora os parâmetro ecocardiográficos (FEVE e DEVE) e a QV. Constitui uma boa alternativa para pacientes em classe funcional III/IV NYHA. Os níveis séricos elevados da troponina I cardíaca são preditores de risco para óbito.

Risk stratification with troponin I in patients undergoing myocardial revascularization surgery.

OBJECTIVE: To determine the immediate behavior and the prognostic value in terms of late survival of serum troponin I measurement in patients undergoing myocardial revascularization surgery with extracorporeal circulation. METHODS: We studied 88 random patients, 65 (73.8%) of the male sex, who underwent myocardial revascularization surgery with extracorporeal circulation. Troponin measurements were performed as follows: in the preoperative period, right after intensive care unit admission, and on the first and second postoperative days. Values below 0.1 nanogram per milliliter (ng/mL) were considered normal. The cut points for late prognostic assessment were 0.5 ng/mL; 1 ng/mL; 2.5 ng/mL; and 5 ng/mL. RESULTS: The serum troponin I levels were elevated on the first postoperative day, suggesting the occurrence of specific myocardial damage. Patients with a poor prognosis could be identified, because the serum levels above 2.5 ng/mL and 5 ng/mL in the postoperative period resulted, respectively, in mortality rates of 33% and 50% in a maximum 6-month follow-up. CONCLUSION: Troponin I values around 2.5 ng/mL in the postoperative period should call attention to the need for more aggressive diagnostic or therapeutical measures.

Estratificaçäo de risco com troponina-I em pacientes submetidos à revascularizaçäo cirúrgica do miocárdio / Risk stratification with troponin I in patients undergoing myocardial revascularization surgery

OBJECTIVE: To determine the immediate behavior and the prognostic value in terms of late survival of serum troponin I measurement in patients undergoing myocardial revascularization surgery with extracorporeal circulation. METHODS: We studied 88 random patients, 65 (73.8 percent) of the male sex, who underwent myocardial revascularization surgery with extracorporeal circulation. Troponin measurements were performed as follows: in the preoperative period, right after intensive care unit admission, and on the first and second postoperative days. Values below 0.1 nanogram per milliliter (ng/mL) were considered normal. The cut points for late prognostic assessment were 0.5 ng/mL; 1 ng/mL; 2.5 ng/mL; and 5 ng/mL. RESULTS: The serum troponin I levels were elevated on the first postoperative day, suggesting the occurrence of specific myocardial damage. Patients with a poor prognosis could be identified, because the serum levels above 2.5 ng/mL and 5 ng/mL in the postoperative period resulted, respectively, in mortality rates of 33 percent and 50 percent in a maximum 6-month follow-up. CONCLUSION: Troponin I values around 2.5 ng/mL in the postoperative period should call attention to the need for more aggressive diagnostic or therapeutical measures

Cirurgia de revascularizaçäo em coronariopatas hipertensos / Myocardial revascularization in coronary hypertensive patients

Nesta revisão os autores analisam os aspectos gerais da hipertensão como fator de risco na revascularização do miocárdio. Demonstram que a hipertensão em si, como fator isolado, não aumenta a morbidade e a mortalidade nesses procedimentos, corroborada pela experiência pessoal em que a mortalidade hospitalar no grupo hipertenso foi de 3 por cento e no grupo não-hipertenso, de 2,5 por cento (RR=1,2; IC 95 por cento = 0,57 a 2,5; p>0,05). São comentadas as medidas anestésicas, operatórias e de proteção miocárdica empregadas nesse grupo especial de pacientes.

Revascularizaçäo do miocárdio com cirurgia minimamente invasiva (MIDCAB): resultados em 46 pacientes / Myocardial revascularization with minimally invasive direct coronary artery bypass graft (MIDCAB): results in 46 patients

Objetivo: Apresentar a experiência com a realizaçao de revascularizaçao do miocárdio com técnica minimamente invasiva, via minitoratocotomia anterior esquerda sem circulaçao extracorpórea (MIDCAB). Casuística e Métodos: 46 pacientes foram submetidos a MIDCAB de fevereiro de 1997 a janeiro de 1998. Todos eram portadores de doença obstrutiva na porçao proximal do ramo interventricular anterior (RIA). A técnica consistiu em pequena incisao, de cerca de 8,0 cm, transversal, na regiao inframamária esquerda, obtendo-se fácil acesso para dissecçao da artéria torácica interna (ATI) e posterior anastomose com o RIA. A avaliaçao dos resultados foi feita com controle clínico, laboratorial e angiográfico. Resultados. O tempo médio de operaçao foi de 2 horas, com cerca de 18 horas de internaçao na UTI e permanência hospitalar máxima de 5 dias. Nao ocorreram óbitos intra-operatórios. Houve 1 caso de morte súbita após alta (15º PO). Os pacientes acompanhados ambulatorialmente nao referiram dor anginosa. Documentou-se 4 casos de oclusao da ATI e 2 estenoses do RIA após anastomose, provavelmente decorrentes da bandagem desse vaso durante o procedimento. Nao houve correlaçao entre níveis de troponina-I e oclusao do enxerto. Verificou-se, porém, que os níveis de troponina I dos pacientes submetidos à MIDCAB foram significativamente menores que nos procedimento convencional. Nao ocorreram complicaçoes clínicas de significância. Conclusao: A MIDCAB demonstrou ser procedimento útil e de baixa morbidade e mortalidade, com possibilidade de menor permanência hospitalar e conseqüente menor custo. Os baixos níveis snagüíneos de troponina I indicam menor sofrimento miocárdico com o procedimento.