In vitro assessment of the Apico Aortic Blood Pump: anatomical positioning, hydrodynamic performance, hemolysis studies, and analysis in a hybrid cardiovascular simulator.

The Apico Aortic Blood Pump (AABP) is a centrifugal continuous flow left ventricular assist device (LVAD) with ceramic bearings. The device is in the initial development phase and is being designed to be attached directly to the left ventricular apex by introducing an inlet cannula. This paper reports results from in vitro experiments. In order to evaluate implantation procedures and device dimensioning, in vitro experiments included an anatomic positioning study for the analysis of surgical implantation procedure and device dimensions and positioning that was performed using the body of a pig. The results revealed no damage caused by the device, and the surgical implantation procedure was considered feasible. Hydrodynamic performance curves were obtained to verify the applicability of the device as an LVAD, showing adequate performance. Mechanical blood trauma was analyzed through 6-h hemolysis tests, with total pressure head of 100 mm Hg and flow of 5 L/min. Mean normalized index of hemolysis was 0.009 g/100 L (±0.002 g/100 L). Studies using a hybrid cardiovascular simulator were conducted for three types of circulatory conditions: normal healthy conditions, concentric hypertrophic heart failure (CHHF), and CHHF with AABP assistance. Analysis of cardiovascular parameters under those three conditions demonstrated that when the AABP was assisting the system, parameters under CHHF conditions went back to normal healthy values, indicating the AABP's effectiveness as CHHF therapy. Our preliminary results indicate that it is feasible to use the AABP as a LVAD. The next steps include long-term in vivo experiments.

Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial.

OBJECTIVES: The long-term (five-year) comparative results of treatment of multivessel coronary artery disease with stenting or coronary artery bypass grafting (CABG) is at present unknown. BACKGROUND: The Arterial Revascularization Therapies Study (ARTS) was designed to compare CABG and stenting in patients with multivessel disease. METHODS: A total of 1,205 patients with the potential for equivalent revascularization were randomly assigned to CABG (n = 605) or stent implantation (n = 600). The primary clinical end point was freedom from major adverse cardiac and cerebrovascular events (MACCE) at one year; MACCE at five-year follow-up constituted the final secondary end point. RESULTS: At five years, there were 48 and 46 deaths in the stent and CABG groups, respectively (8.0% vs. 7.6%; p = 0.83; relative risk [RR], 1.05; 95% confidence interval [CI], 0.71 to 1.55). Among 208 diabetic patients, mortality was 13.4% in the stent group and 8.3% in the CABG group (p = 0.27; RR, 1.61; 95% CI, 0.71 to 3.63). Overall freedom from death, stroke, or myocardial infarction was not significantly different between groups (18.2% in the stent group vs. 14.9% in the surgical group; p = 0.14; RR, 1.22; 95% CI, 0.95 to 1.58). The incidence of repeat revascularization was significantly higher in the stent group (30.3%) than in the CABG group (8.8%; p < 0.001; RR, 3.46; 95% CI, 2.61 to 4.60). The composite event-free survival rate was 58.3% in the stent group and 78.2% in the CABG group (p < 0.0001; RR, 1.91; 95% CI, 1.60 to 2.28). CONCLUSIONS: At five years there was no difference in mortality between stenting and surgery for multivessel disease. Furthermore, the incidence of stroke or myocardial infarction was not significantly different between the two groups. However, overall MACCE was higher in the stent group, driven by the increased need for repeat revascularization.

Atrial fibrillation ablation in systolic dysfunction: clinical and echocardiographic outcomes.

BACKGROUND: Heart failure and atrial fibrillation (AF) often coexist in a deleterious cycle. OBJECTIVE: To evaluate the clinical and echocardiographic outcomes of patients with ventricular systolic dysfunction and AF treated with radiofrequency (RF) ablation. METHODS: Patients with ventricular systolic dysfunction [ejection fraction (EF) <50%] and AF refractory to drug therapy underwent stepwise RF ablation in the same session with pulmonary vein isolation, ablation of AF nests and of residual atrial tachycardia, named "background tachycardia". Clinical (NYHA functional class) and echocardiographic (EF, left atrial diameter) data were compared (McNemar test and t test) before and after ablation. RESULTS: 31 patients (6 women, 25 men), aged 37 to 77 years (mean, 59.8 ± 10.6), underwent RF ablation. The etiology was mainly idiopathic (19 p, 61%). During a mean follow-up of 20.3 ± 17 months, 24 patients (77%) were in sinus rhythm, 11 (35%) being on amiodarone. Eight patients (26%) underwent more than one procedure (6 underwent 2 procedures, and 2 underwent 3 procedures). Significant NYHA functional class improvement was observed (pre-ablation: 2.23 ± 0.56; postablation: 1.13 ± 0.35; p < 0.0001). The echocardiographic outcome also showed significant ventricular function improvement (EF pre: 44.68% ± 6.02%, post: 59% ± 13.2%, p = 0.0005) and a significant left atrial diameter reduction (pre: 46.61 ± 7.3 mm; post: 43.59 ± 6.6 mm; p = 0.026). No major complications occurred. CONCLUSION: Our findings suggest that AF ablation in patients with ventricular systolic dysfunction is a safe and highly effective procedure. Arrhythmia control has a great impact on ventricular function recovery and functional class improvement.

Risk factors for acute myocardial infarction during the postoperative period of myocardial revascularization.

OBJECTIVE: To identify risk factors for acute myocardial infarction during the postoperative period after myocardial revascularization. METHODS: This was a case-control study paired for sex, age, number, type of graft used, coronary endarterectomy, type of myocardial protection, and use of extracorporeal circulation. We assessed 178 patients (89 patients in each group) undergoing myocardial revascularization, and the following variables were considered: dyslipidemia, systemic hypertension, smoking, diabetes mellitus, previous myocardial revascularization surgery, previous coronary angioplasty, and acute myocardial infarction. RESULTS: Baseline clinical characteristics did not differ in the groups, except for previous myocardial revascularization surgery, prevalent in the case group (34 patients vs. 12 patients; p = 0.0002). This was the only independent predictor of risk for acute myocardial infarction in the postoperative period, based on a multivariate logistic regression analysis (p = 0.0001). Mortality and the time of hospital stay of the case group were significantly higher (19.1% vs. 1.1%; p < 0.001 and 15.7 days vs. 10.6 days; p < 0.05 respectively) than those of the control. CONCLUSION: Only previous myocardial revascularization was an independent predictor of acute myocardial infarction in the postoperative period, based on multivariate logistic regression analysis.

Sepsis in the postoperative period of cardiac surgery: problem description.

BACKGROUND: In spite of the advances in sepsis diagnosis and treatment in the last years, the morbidity and mortality are still high. OBJECTIVE: To assess the prevalence, in-hospital evolution and prognosis of patients that presented sepsis in the postoperative period of cardiac surgery. METHODS: This is a prospective study that included patients (n = 7,332) submitted to cardiac surgery (valvular or coronary) between January 1995 and December 2007. The classic criteria of sepsis diagnosis were used to identify the patients that developed such condition and the preoperative comorbidities, in-hospital evolution and prognosis were evaluated. RESULTS: Sepsis occurred in 29 patients (prevalence = 0.39%). There was a predominance of the male when compared to the female sex (79% vs. 21%). Mean age was 69 +/- 6.5 years. The main preoperative comorbidities were: systemic arterial hypertension (79%), dyslipidemia (48%) and family history of coronary artery disease (38%). The mean Apache score was 18 +/- 7, whereas the Sofa score was 14.2 +/- 3.8. The primary infectious focus was pulmonary in 19 patients (55%). There were 19 positive cultures and the mean IV hydration during the first 24 hours was 1,016 +/- 803 ml. The main complications were acute renal failure (65%), low cardiac output syndrome (55%) and malignant ventricular arrhythmia (55%). Mortality was 79% (23 patients). CONCLUSION: The occurrence of sepsis after cardiac surgery was a rare event; however, its occurrence showed catastrophic clinical outcomes. The high morbidity and mortality showed the need to improve treatment, aiming at patients' better clinical evolution.

Atrial Fibrillation Ablation in Systolic Dysfunction: Clinical and Echocardiographic Outcomes / Ablação da Fibrilação Atrial na Disfunção Sistólica: Evolução Clínica e Ecocardiográfica

Background: Heart failure and atrial fibrillation (AF) often coexist in a deleterious cycle. Objective: To evaluate the clinical and echocardiographic outcomes of patients with ventricular systolic dysfunction and AF treated with radiofrequency (RF) ablation. Methods: Patients with ventricular systolic dysfunction [ejection fraction (EF) <50%] and AF refractory to drug therapy underwent stepwise RF ablation in the same session with pulmonary vein isolation, ablation of AF nests and of residual atrial tachycardia, named "background tachycardia". Clinical (NYHA functional class) and echocardiographic (EF, left atrial diameter) data were compared (McNemar test and t test) before and after ablation. Results: 31 patients (6 women, 25 men), aged 37 to 77 years (mean, 59.8±10.6), underwent RF ablation. The etiology was mainly idiopathic (19 p, 61%). During a mean follow-up of 20.3±17 months, 24 patients (77%) were in sinus rhythm, 11 (35%) being on amiodarone. Eight patients (26%) underwent more than one procedure (6 underwent 2 procedures, and 2 underwent 3 procedures). Significant NYHA functional class improvement was observed (pre-ablation: 2.23±0.56; postablation: 1.13±0.35; p<0.0001). The echocardiographic outcome also showed significant ventricular function improvement (EF pre: 44.68%±6.02%, post: 59%±13.2%, p=0.0005) and a significant left atrial diameter reduction (pre: 46.61±7.3 mm; post: 43.59±6.6 mm; p=0.026). No major complications occurred. Conclusion: Our findings suggest that AF ablation in patients with ventricular systolic dysfunction is a safe and highly effective procedure. Arrhythmia control has a great impact on ventricular function recovery and functional class improvement. .

Fundamento: Insuficiência cardíaca e fibrilação atrial (FA) frequentemente coexistem em um ciclo deletério. Objetivo: Avaliar a evolução clínica e ecocardiográfica de portadores de disfunção ventricular e FA tratados com ablação por radiofrequência (RF). Métodos: Portadores de disfunção sistólica [fração de ejeção (FE) < 50%] e FA rebelde a tratamento clínico foram submetidos à ablação por RF escalonada em três etapas na mesma sessão com isolamento das veias pulmonares, ablação dos ninhos de FA, pesquisa e ablação de taquicardias atriais e "taquicardia de background". Os dados clínicos (classe funcional da NYHA) e ecocardiográficos (FE; diâmetro do átrio esquerdo) pré- e pós-procedimento foram comparados (teste de McNemar e teste t, respectivamente). Resultados: 31 pacientes (6 mulheres, 25 homens) de 37 a 77 anos (média, 59,8 ± 11 anos) foram submetidos à ablação por RF. A cardiopatia foi predominantemente idiopática (19 p; 61%). Na evolução média de 20,3 ± 17 meses, 24 pacientes (77%) estavam em ritmo sinusal, sendo 11 (35%) com amiodarona. Oito pacientes (26%) foram submetidos a mais de um procedimento (6 submetidos a 2 procedimentos e 2 a 3 procedimentos). Observou-se melhora expressiva da classe funcional da NYHA (pré-ablação: 2,23 ± 0,56; pós: 1,13 ± 0,35; p < 0,0001). A avaliação ecocardiográfica evolutiva também mostrou melhora significativa da função ventricular (FE pré: 44,68% ± 6,02%; pós: 59% ± 13,2%; p = 0,0005) e redução significativa no diâmetro do átrio esquerdo (pré: 46,61 ± 7,3 mm; pós: 43,59 ± 6,6 mm; p = 0,026). Não ocorreram complicações maiores. Conclusão: Os resultados deste estudo sugerem que ablação de FA em portadores de disfunção ventricular seja um procedimento seguro e com eficácia elevada a médio prazo. O controle da arritmia tem grande impacto na recuperação da função ventricular e na melhora clínica avaliada pela classe funcional. .

Prevalence and surgical approach of supravalvular pulmonary stenosis after Jatene operation for transposition of great arteries.

BACKGROUND: The Transposition of the Great Arteries is the most frequent congenital cyanogenic cardiopathy in the neonatal period, corresponding to 7% of all congenital cardiopathies. Among the operations for surgical treatment, the Jatene operation, with arterial correction, is the treatment of choice. During the late postoperative evolution, some problems were observed, with the most common being the occurrence of supravalvular stenosis at the neopulmonary, regardless of the type of surgical technique used. OBJECTIVE: To study and analyze the prevalence of stenosis, as well as describe the surgical treatment and propose technical maneuvers to prevent its onset. METHODS: Of the 553 patients that underwent surgery, 409 were discharged from the hospital and 281 had late follow-up; 59 (20.9%) presented different degrees of supravalvular pulmonary stenosis and 21 had a mean gradient > 60 mmHg, needing surgical treatment. Depending on the location and anatomy of the stenosis, the surgical treatment consisted of the use of different techniques, such as the enlargement of stenosis areas with bovine pericardium patches, resection of stenotic areas and termino-terminal anastomosis, replacement of retracted patches and synthetic tubes. RESULTS: Twenty patients presented good evolution and only one patient died. CONCLUSION: It can be concluded that the supravalvular pulmonary stenosis, post-Jatene operation for Transposition of Great Arteries, had a prevalence of 20.9%; once identified and with indication for treatment, it can be treated surgically with low mortality levels, through different surgical techniques; to prevent the occurrence of stenosis, ample dissection and release of the pulmonary branches, double anastomoses, large patches of autologous pericardium and careful reconstruction of the aorta are proposed, which prevents the compression of the neopulmonary.

Risk factors for stroke after coronary artery bypass grafting.

BACKGROUND: Stroke is a feared complication after coronary artery bypass grafting surgery (CABG), with an incidence between 1.3 and 4.3%. OBJECTIVE: To identify predictive factors for stroke after CABG in the modern era of cardiac surgery. METHODS: This is a case-control study of 65 pairs of patients, paired by sex, age (+ 3 years) and date of CABG (+ 3 months). The cases were patients submitted to elective CABG with extracorporeal circulation (ECC) that presented stroke (defined as clinical neurological deficit up to 24 hours post-operatively and confirmed by imaging assessment) and the controls were those individuals submitted to elective CABG with ECC, but without stroke. RESULTS: The univariate analysis demonstrated that the number of revascularized vessels was associated with the occurrence of stroke after the CABG (3 +/- 0.8 vs. 2.76 +/- 0.8, p = 0.01). The multivariate analysis by conditional logistic regression showed that systemic arterial hypertension (SAH) [OR: 6.1 (1.5 - 24), p = 0.009] and diabetes mellitus (DM) [OR: 3.1 (1.09 - 11), p= 0.03] were the determinants of the highest chance of stroke after CABG, whereas acute myocardial infarction (AMI) > 1 month, was the determinant of the lowest chance of stroke [OR: 0.1 (0.03 - 0.36), p = 0.003]. CONCLUSION: Hypertension and diabetes mellitus were identified as independent predictors of stroke within the first 24 postoperative hours after CABG. In patients with such risk factors, it is possible that the knowledge of the causal mechanisms of brain injury represents a strategy capable of decreasing the incidence of stroke after CABG.

Coronary artery bypass grafting using both internal mammary arteries in patients with diabetes mellitus.

OBJECTIVE: We sought to describe the use of both internal mammary arteries (IMA) in patients with diabetes mellitus (DM) submitted to coronary artery bypass grafting (CABG). METHOD: Between January of 1995 to August of 2005, 4.569 patients received isolated CABG in our institution, of these, 1.298 had DM. Mean sample age was 62 years, and total mortality was 2.18% (100 patients). We have used both IMA's in 700 patients, that here are split in two groups, with DM (group I, 148 patients), and without DM (group II, 552 patients). Patient selection for double IMA grafting was based on coronary artery anatomy and sternal bone quality, the later was evaluated during sternal transsection. When these two factors were considered favorable, we harvested both IMA's, not mattering if the patient had or had not DM. During IMA's harvest, care was taken not to open the pleural spaces. RESULTS: There was small difference between the two groups in terms of morbidity and mortality. CONCLUSION: Our data suggest that patients with DM can benefit of double IMA's grafting, with little increase in risk for complications if its application is carefully indicated.

Prevalence and risk factors for combined coronary artery disease and aortic aneurysm.

OBJECTIVE: To evaluate CAD prevalence in patients with aortic aneurysm, as well as differences related to aneurysm topographies. To describe the primary risk factors for CAD related to this association and their occasional differences according to AA topographies. METHODS: This was an open, prospective, nonrandomized study that evaluated 95 patients (66 men and 33 women, mean age 63 +/- 11.8). All patients, asymptomatic for CAD, had undergone aortic CT and coronary angiography. According to the AA topography, they were classified into three groups: 1) patients with thoracic aortic aneurysm (TAA); 2) thoracoabdominal aortic aneurysm (TAAA); and 3) abdominal aortic aneurysm (AAA). A database was created to store information from clinical data and complementary examinations. Statistical analysis was performed using the Students t test or analysis of variance (ANOVA) for continuous variables and chi-square test for categorical variables. P values < 0.05 were considered statistically significant. RESULTS: CAD prevalence was 63.1%, and AAA was more prevalent than TAA and TAAA (76% vs. 70% vs. 30%, p = 0.001). The comparative analysis of CAD risk factors based on the aortic aneurysm topography revealed that smoking and dyslipidemia were more prevalent among AAA patients (74.5% vs. 42.3% vs. 60%, p = 0.01 and (54.2% vs. 19.9% vs. 60%, p = 0.007, respectively). As for coronary lesion severity in the population of AA patients, 12 (20%) had at least one lesion > or = 70% and 19 (31.6%), > or = 50%. Fifteen patients (25%) had single-vessel disease, 11 (18%) had two-vessel disease, and 34 (57%) had three-vessel disease. CONCLUSION: Asymptomatic CAD is highly prevalent in AA patients, particularly among those with AAA. Study results suggest the need for diagnostic stratification for CAD in patients with AA, especially those with AAA.

Postoperative atrial fibrillation following coronary artery bypass graft: clinical factors associated with in-hospital death.

OBJECTIVE: To identify factors associated with a higher likelihood of in-hospital death in patients submitted to coronary artery bypass graft surgery (CABG) who developed atrial fibrillation (AF) postoperatively. METHODS: The authors analyzed data from 397 consecutive patients submitted to CABG that developed AF postoperatively between 2000 and 2003. The patients were divided into 2 groups: group 1 (G1) comprised patients who survived (n=369); and group 2 (G2) comprised patients who died during hospital stay (n=28). Statistical analysis was performed using Student's t test and chi-square test, and p values < 0.05 were considered significant. RESULTS: A comparative analysis between G1 and G2 showed that there was no difference between the groups as regards age (67.3 +/- 8.4 versus 69.3 +/- 9.6; p = 0.4), male gender (75.9% versus 64.3%; p = 0.1), systemic arterial hypertension (75.3% versus 85.7%; p = 0.2) and congestive heart failure (17% versus 17%; p = 1). Group 2 presented higher rates for previous acute myocardial infarction (14.6% versus 28.6%; p = 0.05), left ventricular ejection fraction < 40% (12.2% versus 32.1%; p = 0.003), previous cerebrovascular accident (0.8% versus 17.9%; p = 0.03), previous percutaneous coronary intervention (19.5% versus 39.3%; p = 0.01) and previous CABG (19.3% versus 35.7%; p = 0.03). CONCLUSION: Clinical history of acute myocardial infarction, CABG, percutaneous coronary intervention, cerebrovascular accident and severe ventricular dysfunction were significantly more frequent in the group that died during hospital stay, which suggests a possible association of these factors with a higher likelihood of death following CABG.

Radiofrequency catheter ablation of atrial fibrillation guided by spectral mapping of atrial fibrillation nests in sinus rhythm.

BACKGROUND: Two types of myocardia can be observed through the endocardial spectral mapping (SM) in sinus rhythm: the compact type with a smooth spectrum and the fibrillar type with a segmented spectrum (atrial fibrillation nests). During the atrial fibrillation (AF), the compact type has an organized activation and low frequency (passive), whereas the fibrillar type has a rather disorganized activation and high frequency (active/resonant), with both being activated by high-frequency sustained tachycardia--the background tachycardia (BT). OBJECTIVE: To describe the treatment of AF by the ablation of the AF nests and BT. METHODS: 1) Catheter ablation of the AF nests with RF [4/8 mm-60 masculine/30-40 J/30s] guided by SM in sinus rhythm, outside the pulmonary vein; 2) atrial stimulation -300 ppm; 3) Additional ablation of the AF nests if AF is induced; 4) Focal ablation if BT and/or Flutter is induced; 5) Clinical follow-up+ ECG+ Holter. RESULTS: A total of 50+/-18 AF nests/patient were treated. After 11.3+/-8 m, 81 patients (88%) did not present AF (28.3% with antiarrhythmic drugs). After the ablation of the AF nests, AF was not reinduced in 61 patients (71%) and BT was induced and treated in 24 patients (26%). There were two episodes of pericardial bleeding (1 treated clinically and 1 surgically), caused by sheaths that are no longer used CONCLUSION: The SM in sinus rhythm can be used in the ablation of AF nests. During the AF, the AF nests present a reactive-resonant pattern and the compact myocardium is passive, stimulated by the high frequency of the BT. After the ablation of the AF nests and the BT, it was not possible to reinduce the sustained AF. The Ablation of AF nests outside the pulmonary veins showed to be safe and highly effective in the cure and/or clinical control of the AF.

Late outcome of sirolimus-eluting stents: comparison of multidetector computed tomography with quantitative coronary angiography and intravascular ultrasound.

OBJECTIVE: To assess the performance of multidetector computed tomography in determining late clinical outcomes of patients undergoing sirolimus-eluting stent implantation. METHODS: Thirty patients, successfully submitted to sirolimus-eluting stent implantation for more than six months, were selected to participate in the study. All underwent invasive angiography and intravascular ultrasound following CT angiography using iodinated contrast medium at a dose of 1.5 ml/kg. RESULTS: Mean proximal reference diameter was 3.01 +/- 0.31 mm by tomography and 3.14 +/- 0.31 mm by angiography (p = 0.04). When the left circumflex artery was excluded from the analysis, the difference between both examinations was no longer significant (tomography = 3.01 +/- 0.32 mm; angiography = 3.10 +/- 0.30 mm, p = 0.65). Mean distal reference diameter was 2.86 +/- 0.30 mm by tomography and 2.92 +/- 0.32 by angiography (p = 0.25). Mean in-stent minimal lumen diameter was 2.85 +/- 0.25 mm by tomography and 2.85 +/- 0.29 mm by angiography (p = 0.27). Mean minimal in-stent cross-sectional area was 7.19 +/- 1.47 mm(2) by tomography and 6.90 +/- 1.52 mm(2) by intravascular ultrasound (p = 0.36), but there was only a weak correlation between these measurements (r = 0.33). CONCLUSION: Computed tomography allows the qualitative assessment of sirolimus-eluting stents, accurate estimate of proximal and distal reference diameters of the target vessel, and in-stent minimal lumen diameter. Its correlation with measurements performed using intravascular ultrasound, however, is less strong.

Syncopal high-degree AV block treated with catheter RF ablation without pacemaker implantation.

A 23-year-old-female patient had undergone a very successful gastric banding surgery to treat obesity. Six months later she began to present recurrent syncope due to very frequent, intermittent high-degree AV block referred to as pacemaker implantation. The electrophysiological study showed impaired AV nodal conduction but the His-Purkinje conduction was preserved. Partial catheter radiofrequency ablation of the cardiac autonomic nervous system guided by spectral endocardial mapping (cardioneuroablation) was performed. The electrophysiological parameters were normalized. Holter recordings were normal and the patient was asymptomatic with normal life without pacemaker implantation in a follow-up 21 months later.

"Cardioneuroablation"--new treatment for neurocardiogenic syncope, functional AV block and sinus dysfunction using catheter RF-ablation.

Cardiac neuroablation is a new technique for management of patients with dominantly adverse parasympathetic autonomic influence. The technique is based on radiofrequency (RF) ablation of autonomic connections in the three main ganglia around the heart. Their connections are identified by Fast-Fourier Transforms (FFTs) of endocardial signals: sites of autonomic nervous connections show fractionated signals with FFTs shifted to the right. In contrast, normal myocardium without these connections does not show these features. RF-ablation is thought to inflict permanent damage on the parasympathetic autonomic influence because its cells are adjacent to the heart whereas sympathetic cells are remote. Twenty-one patients with a mean age of 48 years, neurally mediated reflex syncope in six, functional high grade atrioventricular block in seven and sinus node dysfunction in 13 (there is overlap between the second and third groups) were treated. Follow-up for a mean of 9.2 months demonstrated success in all cases with relief of symptoms. No complications occurred.

Five year clinical effect of coronary stenting and coronary artery bypass grafting in renal insufficient patients with multivessel coronary artery disease: insights from ARTS trial.

AIMS: To compare coronary stent implantation and bypass surgery for multivessel coronary disease in patients with renal insufficiency. METHODS AND RESULTS: In the ARTS trial, 142 moderate renal insufficient patients (Ccr<60 mL/min) with multivessel coronary disease were randomly assigned to stent implantation (n=69) or CABG (n=73). At 5 years, there was no significant difference between the two groups in terms of mortality (14.5% in the stent group vs. 12.3% in the CABG group, P=0.81), or combined endpoint of death, cerebrovascular accident (CVA), or myocardial infarction (MI) (30.4% in the stent group vs. 23.3% in the CABG group, P=0.35). Among patients who survived without CVA or MI, 18.8% in the stent group underwent a second revascularization procedure when compared with 8.2% in the surgery group (P=0.08). The event-free survival at 5 years was 50.7% in the stent group and 68.5% in the surgery group (P=0.04). CONCLUSION: At 5 years, the differences in mortality and combined incidence of death, CVA, and MI between coronary stenting and surgery did not reach statistically significant level. However, the occurrence of MACCE in the stent group was higher than in the CABG group, mainly driven by the higher incidence of repeat revascularization in the stent group.

Sepse no pós-operatório de cirurgia cardíaca: descrição do problema / Sepsis in the postoperative period of cardiac surgery: problem description

FUNDAMENTOS: A despeito do avanço no diagnóstico e na terapêutica da sepse nos últimos anos, a morbidade e mortalidade são elevadas. OBJETIVO: Avaliar a prevalência, a evolução hospitalar e o prognóstico de pacientes que apresentaram sepse no pós- operatório de cirurgia cardíaca. MÉTODOS: Trata-se de um registro prospectivo que incluiu pacientes (n = 7.332) submetidos à cirurgia cardíaca (valvar ou coronariana) entre janeiro de 1995 e dezembro de 2007. Utilizamos os critérios clássicos de diagnóstico de sepse para identificar os pacientes que evoluíram com tal enfermidade e avaliamos as comorbidades pré-operatórias, a evolução hospitalar e o prognóstico. RESULTADOS: A sepse ocorreu em 29 pacientes (prevalência = 0,39 por cento). O sexo masculino predominou sobre o feminino (79 por cento vs. 21 por cento). A idade média foi de 69 ± 6,5 anos. As principais comorbidades pré-operatórias eram: hipertensão arterial sistêmica (79 por cento), dislipidemia (48 por cento) e antecedente familiar de doença arterial coronariana (38 por cento). O índice Apache médio foi de 18 ± 7, enquanto o Sofa indicou 14,2 ± 3,8. O foco infeccioso primário foi pulmonar em 19 pacientes (55 por cento). Houve 19 culturas positivas, e a média de hidratação endovenosa nas primeiras 24 horas foi de 1.016 ± 803 ml. As principais complicações foram: insuficiência renal aguda (65 por cento), síndrome de baixo débito cardíaco (55 por cento) e arritmia ventricular maligna (55 por cento). A mortalidade foi de 79 por cento (23 pacientes). CONCLUSÃO: A sepse após cirurgia cardíaca foi um evento raro, porém com desfechos clínicos catastróficos. O índice elevado de morbidade e mortalidade revelou a necessidade de um aprimoramento no tratamento, visando melhorar a evolução clínica dos pacientes.

BACKGROUND: In spite of the advances in sepsis diagnosis and treatment in the last years, the morbidity and mortality are still high. OBJECTIVE: To assess the prevalence, in-hospital evolution and prognosis of patients that presented sepsis in the postoperative period of cardiac surgery. METHODS: This is a prospective study that included patients (n = 7,332) submitted to cardiac surgery (valvular or coronary) between January 1995 and December 2007. The classic criteria of sepsis diagnosis were used to identify the patients that developed such condition and the preoperative comorbidities, in-hospital evolution and prognosis were evaluated. RESULTS: Sepsis occurred in 29 patients (prevalence = 0.39 percent). There was a predominance of the male when compared to the female sex (79 percent vs. 21 percent). Mean age was 69 ± 6.5 years. The main preoperative comorbidities were: systemic arterial hypertension (79 percent), dyslipidemia (48 percent) and family history of coronary artery disease (38 percent). The mean Apache score was 18 ± 7, whereas the Sofa score was 14.2 ± 3.8. The primary infectious focus was pulmonary in 19 patients (55 percent). There were 19 positive cultures and the mean IV hydration during the first 24 hours was 1,016 ± 803 ml. The main complications were acute renal failure (65 percent), low cardiac output syndrome (55 percent) and malignant ventricular arrhythmia (55 percent). Mortality was 79 percent (23 patients). CONCLUSION: The occurrence of sepsis after cardiac surgery was a rare event; however, its occurrence showed catastrophic clinical outcomes. The high morbidity and mortality showed the need to improve treatment, aiming at patients' better clinical evolution.

Incidência e preditores de revascularização da lesão-alvo no seguimento clínico de longo prazo: análise crítica do registro DESIRE / Incidence and predictors of target lesion revascularization during the long-term clinical follow-up: a critical analysis of the DESIRE registry

Introdução: Reportamos a incidência e preditores de nova revascularização da lesão-alvo (RLA) numa coorte de pacientes do mundo real tratados com stents farmacológicos (SF). Método: Entre maio de 2002 e fevereiro de 2010, 3.320 pacientes de único centro foram submetidos a intervenção percutânea (ICP), eletiva ou de urgência, com implante de 5.320 SF (Cypher, 83%; Taxus, 9%; Xience V/Promus, 3%; Endeavor, 4%; BioMatrix, 1%). O seguimento clínico de até oito anos (mediana, 3,4 anos) foi completo em 98% do grupo e 129 pacientes (3,88%) foram submetidos a RLA. Resultados: Entre os pacientes com RLA, 33% tinham diabetes, 10% eram portadores de insuficiência renal e 61%, de doença em múltiplos vasos. A artéria descendente anterior foi o vaso mais frequentemente tratado (33%), e 72,3% das lesões eram de alta complexidade (tipo B2/C). Nesse grupo, foram implantados 214 SF em 191 lesões e 45% dos pacientes receberam múltiplos stents. Na análise univariada, os preditores de RLA foram: diabetes melito [razão de risco (RR) 1,88, intervalo de confiança (IC) de 95% 1,08-3,27; P = 0,025), uso do stent Taxus (RR 1,73, IC 95% 1,20-2,50; P = 0,003), lesão ostial (RR 1,82, IC 95% 1,1-2,98; P = 0,018), ponte de safena (RR 2,36; IC 95% 1,55-3,50; p = 0,0001), e lesões reestenóticas (RR 1,95, IC 95% 1,17-3,24; P = 0,009). Após análise multivariada, permaneceram como preditores independentes: diabetes melito, uso do stent Taxus e tratamento de lesões em pontes de safena (RR 1,64, IC 95% 1,14-2,35; P = 0,008). Conclusão: No registro DESIRE, a RLA em pacientes complexos tratados com SF foi baixa, e o diabetes melito, o tratamento de lesões em ponte de safena e o uso de SF Taxus foram os únicos preditores de RLA no acompanhamento clínico de até oito anos.

Background: We report the incidence and predictors of target lesion revascularization (TLR) in a cohort of realworld patients treated with drug eluting stents (DES). Method: From May 2002 to February 2010, 3,320 patients were treated with elective or emergency percutaneous coronaryintervention (PCI) and 5,320 DES (Cypher, 83%; Taxus, 9%; Xience V/Promus, 3%; Endeavor, 4%; BioMatrix, 1%) were implanted in a single center. The clinical follow-up of upto eight years (median time 3.4 years) was concluded in 98% patients of the group and 129 patients (3.88%) weresubmitted to TLR. Results: Of the patients with TLR, 33% had diabetes, 10% had chronic kidney disease and 61% had multivessel disease. The left anterior descending artery was the most frequent target vessel (33%) and 72.3% of the lesions were complex lesions (type B2/C). In this group,214 DES were implanted in 191 lesions and 45% of the patients received multiple stents. In the univariate analysis, TLR predictors were: diabetes mellitus [relative risk (RR) 1.88, 95% confidence interval (CI) 1.08-3.27; P = 0.025], use of Taxus stents (RR 1.73, 95% CI 1.20-2.50; P = 0.003), ostial lesion (RR 1.82, 95% CI 1.1-2.98; P = 0.018), saphenous bypass graft (RR 2.36, 95% CI 1.55-3.50; P = 0.0001), and restenotic lesions (RR 1.95, 95% CI 1.17-3.24; P = 0.009). After the multivariate analysis, the independent predictors were: diabetes mellitus, use of Taxus stents and treatment of lesions in saphenous bypass grafts (RR 1.64, 95% CI, 1.14-2.35; P = 0.008). Conclusion: In the DESIRE registry,TLR in complex patients treated with DES was low and diabetes mellitus, treatment of lesions in saphenous bypass grafts and the use of Taxus stents were the only TLR predictors in the clinical follow-up of up to 8 years.

Fibrilação atrial no pós-operatório de cirurgia de revascularização do miocárdio: da prevenção à morbimortalidade: registro de mundo real / Atrial fibrillation in the postoperative period of coronary artery bypass grafting: from prevention to morbidity and mortality: real world registry

JUSTIFICATIVA E OBJETIVOS: A prevalência de fibrilação atrial (FA) no pós-operatório de cirurgia de revascularização do miocárdio (CRM) varia de 20% a 40%. O objetivo deste estudo foi avaliar a prevalência de FA sintomática após CRM e descrever o perfil clínico e a evolução hospitalar dos pacientes com essa arritmia.MÉTODO: Estudo de coorte, longitudinal, observacional, retrospectivo, descritivo realizado a partir de informações de um registro de mundo real de 5.330 pacientes, submetidos à CRM eletiva no período de janeiro de 1995 a abril de 2009. Avaliaram-se a prevalência de FA sintomática no pós-operatório de CRM, o perfil clínico e a evolução hospitalar dos pacientes.RESULTADOS: A prevalência de FA sintomática no pós-operatório foi 6,3% (493), sendo 78% do sexo masculino, e 22% do sexo feminino. A idade média foi 68 ± 9 anos. As principais comorbidades pré-operatórias foram: hipertensão arterial sistêmica (76%), dislipidemia (51%), infarto do miocárdio prévio (40%), tabagismo (35%), diabetes mellitus (32%), CRM prévia (18%), intervenção coronariana percutânea prévia (12%). As principais complicações hospitalares observadas foram: insuficiência cardíaca (13%), ventilação mecânica prolongada (12%), insuficiência renal aguda (11%), acidente vascular encefálico (9,3%), infarto agudo do miocárdio (5,5%), sangramento aumentado (4%). O tempo de permanência na unidade de terapia intensiva foi 16 ± 15 dias e a mortalidade hospitalar de 6%.CONCLUSÃO: Na população estudada a prevalência de FA foi menor do que a referida classicamente na literatura. Os pacientes com FA eram idosos, a maioria do sexo masculino, hipertensos e dislipidêmicos. A mortalidade hospitalar foi elevada, sugerindo ser esse um subgrupo de maior risco.(AU)

BACKGROUND AND OBJECTIVES: The prevalence of atrial fibrillation (AF) in postoperative period of coronary artery bypass graft (CABG) ranges between 20% and 40%. AF increases morbidity and mortality after CABG. This objective of study to evaluate the prevalence of symptomatic AF in postoperative period of CABG, and describe the demographic data, morbidity and mortality of patients who presented this type of arrhythmia.METHOD: This is observational cohort study, which was made from information of our institutional registry of AF after CABG. This registry have enrolled 5,330 patients underwent CABG between January 1995 and April 2009. We evaluate the in-hospitalar prevalence of symptomatic AF, demographic data, morbidity and mortality of the patients.RESULTS: The inhospital prevalence of symptomatic atrial fibrillation was 6.3% (493 patients). There were more men (78%) than women (22%) and the mean age was 68 ± 9 years. The analysis of demographic data showed: high blood pressure (76%), dyslipidemia (51%), previous myocardium infarction (40%), smoking (35%), diabetes mellitus (32%), previous CABG (18%), previous percutaneous coronary intervention (12%). The most common adverse events were: heart failure (13%), prolonged mechanical ventilation (12%), acute renal failure (11%), stroke (9.3%), acute myocardial infarction (5.5%), and increased bleeding (4%). The mean time at intensive care unit was 16 ± 15 days. The inhospital mortality was 6%.CONCLUSION: The prevalence of atrial fibrillation inhospital period of CABG was low and less than the classical data of literature. Patients who presented AF were male, older, with systemic arterial hypertension and dyslipidemia.(AU)

A new treatment for atrial fibrillation based on spectral analysis to guide the catheter RF-ablation.

BACKGROUND: By studying the spectrum of atrial potentials by fast Fourier transform (FFT) we have found two types of atrial muscle: the compact (CM) and the fibrillar (FM) myocardium. The former presents normal in-phase conduction inferring a great number of cellular connections, long-lasting refractoriness and leftward FFT-shift. The latter shows anisotropic out-of-phase conduction, fewer cellular connections, short refractoriness and a segmented right-FFT-shift. The compact is the normal predominant muscle and the fibrillar is different and may be neural input, vein insertion, interatrial (1A) septum, left atrial (LA) roof, etc. or pathological tissue, being so by loss of cellular connections this is a possible mechanism for conversion of compact into fibrillar-like myocardium. During atrial fibrillation (AF), clusters of FM (AF nests) present higher frequencies than any surrounding tissue. PURPOSE: The purpose was to describe a new method for paroxysmal AF RF-ablation targeting AF nests. METHOD: Forty patients, six control and 34 having idiopathic drug-refractory paroxysmal or persistent AF were studied and treated. Two catheters were placed in the LA by transseptal approach. RF (30-40 J/60-70 degrees C) was applied to all sites outside the pulmonary veins (PV) presenting right-FFT-shift (AF nests). RESULTS: Numerous AF nests were found in 34/34 AF patients and only in 1/6 controls (only in this case it was possible to induce AF despite an absence of AF history). The main FM sites were: LA roof, LA septum, close to the insertion of the superior PV, near the insertion of the inferior PV, LA posterior wall, RA near the superior vena cava insertion, RA lateral and anterior wall and the right IA septum. Ablation of all AF nests near PV insertions resulted in 35 PV isolations. After 9.9 +/- 5 months only two AF patients presented relapse of a different AF form (coarse AF) which was very well controlled with medication previously ineffective. The AF was more frequent as the ratio FM/CM increased. CONCLUSIONS: The RF-ablation of AF nests decreasing the fibrillar/compact myocardium ratio eliminated 94% of the paroxysmal AF in patients in the FU of 9.9 +/- 5 months. The AF nests may be easily identified by spectral analysis and seem to be the real AF substrate. Paroxysmal AF may be cured or controlled by applying RF in several places outside the PV and, thereby, avoiding PV stenosis.