A randomized, double-blind, and placebo-controlled study with tranexamic acid of bleeding and fibrinolytic activity after primary coronary artery bypass grafting.

Cardiopulmonary bypass is frequently associated with excessive blood loss. Platelet dysfunction is the main cause of non-surgical bleeding after open-heart surgery. We randomized 65 patients in a double-blind fashion to receive tranexamic acid or placebo in order to determine whether antifibrinolytic therapy reduces chest tube drainage. The tranexamic acid group received an intravenous loading dose of 10 mg/kg, before the skin incision, followed by a continuous infusion of 1 mg kg(-1) h(-1) for 5 h. The placebo group received a bolus of normal saline solution and continuous infusion of normal saline for 5 h. Postoperative bleeding and fibrinolytic activity were assessed. Hematologic data, convulsive seizures, allogeneic transfusion, occurrence of myocardial infarction, mortality, allergic reactions, postoperative renal insufficiency, and reopening rate were also evaluated. The placebo group had a greater postoperative blood loss (median (25th to 75th percentile) 12 h after surgery (540 (350-750) vs 300 (250-455) mL, P = 0.001). The placebo group also had greater blood loss 24 h after surgery (800 (520-1050) vs 500 (415-725) mL, P = 0.008). There was a significant increase in plasma D-dimer levels after coronary artery bypass grafting only in patients of the placebo group, whereas no significant changes were observed in the group treated with tranexamic acid. The D-dimer levels were 1057 (1025-1100) microg/L in the placebo group and 520 (435-837) microg/L in the tranexamic acid group (P = 0.01). We conclude that tranexamic acid effectively reduces postoperative bleeding and fibrinolysis in patients undergoing first-time coronary artery bypass grafting compared to placebo.

Late outcome of unsupported annuloplasty for rheumatic mitral regurgitation.

OBJECTIVES: The aim of this study was to evaluate medium- and long-term (range 4 months to 17 years) clinical results in a series of patients treated surgically by unsupported mitral annuloplasty. BACKGROUND: Mitral valve regurgitation has usually been treated by valve replacement or ring annuloplasty. A few series have reported plastic repair procedures without annular support or remodeling. Furthermore, in rheumatic lesions the results have been inferior to those in degenerative mitral insufficiency, and the majority of previous reports have provided information on short- or medium-term follow-up. METHODS: One hundred fifty-four patients were operated on (55 male [36%] and 99 female [64%]). The mean age +/- SD was 36 +/- 16 years (range 5 to 73). Associated lesions comprised 47 aortic and 21 tricuspid valve lesions and 2 atrial septal defects. Patients with concomitant mitral stenosis were not included. Preoperative functional class was I or II in 19% and III or IV in 81%. The cardiothoracic ratio was 0.61 +/- 0.10. All patients underwent an unsupported mitral annuloplasty procedure in which the mural portion of the annulus was reduced by applying two buttressed mattress sutures at the commissures without compromising the width of the septal leaflet. When necessary, additional chordal procedures were performed. No patients received ring or posterior annular support. RESULTS: The early mortality rate was 1.9% (three patients; one of the three died of myocardial failure and two of pulmonary thromboembolism). The late mortality rate was 5.8% (nine patients; three of the nine died of myocardial failure, one each of septicemia, pulmonary thromboembolism and sudden arrhythmic death and three of unknown causes). Twenty-eight patients (18.2%) were reoperated on because of mitral valve dysfunction and 2 (1.3%) because of prosthetic aortic valve dysfunction. A residual late systolic murmur was present in 48% of patients. Late complications were systemic thromboembolism in 5.8% (one third with an aortic valve prosthesis), infective endocarditis in 1.3% and pulmonary thromboembolism in 0.6%. Postoperative functional class was I or II in 84% and III or IV in 16%. Cardiothoracic ratio was 0.58 +/- 0.10. Actuarial probability of late survival was 79.5 +/- 5.3% at 10 years and 71.0 +/- 7.4% at 14 years. Event-free survival was 67.9 +/- 8.9% at 10 years and 56.1 +/- 11.7% at 14 years. CONCLUSIONS: Rheumatic mitral regurgitation can be effectively treated by annuloplasty without prosthetic annular support, with late results comparable to those obtained with more complicated procedures. This observation is particularly important for treatment of children and young adult patients.

A new technique for repair of aortic coarctation. Subclavian flap aortoplasty with preservation of arterial blood flow to the left arm.

From February 1984 to March 1986, 28 patients underwent a new technique of coarctation repair. This technique consists of a complete mobilization of the left subclavian artery extended to the origin of its first branches. The aorta need not be extensively mobilized and the intercostal arteries are individually controlled with snares. After all the proper clamping, the left subclavian artery is detached from the aorta at its origin and is opened longitudinally on its posterior aspect. The anterior wall of the aorta is then incised, beginning with the opening at the origin of the left subclavian artery and extending distally to the descending aorta 12 to 15 mm past the coarctation. The coarctation membrane is excised and the ductus is ligated and divided. The opened left subclavian artery, now forming a flap, is pulled down and sutured to the edges of the aorta, widening the coarctation site and also preserving the blood flow to the left arm. The ages of the patients ranged from 2 months to 25 years (mean 4.24 +/- 4.9 years) and their weights ranged from 2.8 to 52 kg (mean: 14.8 +/- 10.0 kg). There were no hospital deaths and the mean follow-up was 9.6 months (+/- 4.9 months). Recatheterization of four patients from 4 to 12 months postoperatively showed adequate correction and strongly suggested normal growth of the aorta at the site of coarctation, as well as preservation of the blood flow through the left subclavian artery. Doppler measurements showed normal flow to the left arm and no gradients through the isthmic area. Our experience indicates that this technique is not only feasible but is the procedure of choice in most cases of discrete isthmic coarctation and in some cases of long narrowing of the isthmus in patients with a wide range of ages and weights.

Aprotinin in children undergoing correction of congenital heart defects. A double-blind pilot study.

Thirty children undergoing surgical repair for congenital heart defects were randomly selected for a double-blind study on the anti-hemorrhagic and blood-saving properties of aprotinin. The treatment group comprised 14 patients who received aprotinin 7 mg/kg of body weight until the end of perfusion. The placebo group (n = 16) received an infusion of the corresponding volumes of saline. Patients treated with aprotinin bled less during the operation (12.6 ml/kg versus 18.1 ml/kg, p = 0.25) and in the first 24 postoperative hours (chest drainage 12.1 ml/kg versus 17.7 ml/kg, p = 0.07). Hemoglobin loss into chest drainage was reduced in the treated group by half (0.66 versus 1.21 gm in 24 hours, p = 0.07). Fewer blood donors were needed during hospitalization by patients receiving aprotinin (1.07 versus 2.75 donors per patient, p = 0.04). Postoperative transfusion was unnecessary in 64.2% of patients receiving aprotinin compared with only 25% of the placebo group (p = 0.03). Aprotinin increased diuresis significantly during perfusion (4.3 ml/kg versus 1.0 ml/kg, p = 0.005). Other parameters are evaluated, and considerations are made regarding adequacy of the dosage regimen. The drug seems to be safe and easy to handle in children.

Subannular aortic aneurysms in whites. Report of two cases and review of literature.

Subannular aortic aneurysms are a rare entity occurring predominantly in young black men. Five white patients have been reported who underwent surgical correction, but long-term survival occurred in only two. We report two white men, 36 and 45 years old, who survived aortic valve replacement and direct suture of subannular aneurysms, with no symptoms at 29 and 42 postoperative months.

A new valve retractor for mitral valve procedures.

Optimal exposure greatly facilitates reconstructive mitral valve procedures. We describe an effective method for exposing this valve using a specially designed mitral valve retractor. This technique proved useful in 321 patients who underwent operation on the mitral valve.

Cardiac tamponade due to chylopericardium after cardiac surgery.

Chylopericardium as an isolated complication after open-heart surgery is a rare event. We present here a case of postoperative chylopericardium with cardiac tamponade and comment on the clinical course and treatment.

Side-to-side carotid-subclavian anastomosis for interrupted aortic arch.

A simple technique is proposed for restoring aortic flow in an interrupted aortic arch simulating a type B interruption that does not require aortic cross-clamping, circulatory arrest, or the ligation of major aortic branches. Side-to-side anastomosis between the left carotid and subclavian arteries together with division of the ductus arteriosus and pulmonary artery banding proved effective for relieving aortic arch stricture in that location.

Surgical treatment of annuloaortic ectasia with composite grafts including homologous dura mater valves.

We describe 3 patients in whom a composite dura mater valve-Dacron tube graft was used for replacement of the entire ascending aorta and aortic valve. Two patients had Marfan's syndrome and 1, a chronic aortic dissection, type II. All had severe aortic regurgitation. There were no early or late deaths in a follow-up period of 2, 7, and 12 months, respectively. All 3 patients were asymptomatic when last seen. Two underwent postoperative aortography that disclosed well-functioning valves and good filling of the coronary arteries. It is concluded that annuloaortic ectasia is best treated by the technique of total replacement of the ascending aorta and aortic valve by a composite valve-tube graft, and that the homologous dura mater valve, for its characteristics of central flow, lack of need for anticoagulants, and durability, represents a reasonable alternative for use in this situation.

New needle for catheter introduction in left atrium.

We describe a new needle for left atrial catheter introduction. It allows catheter introduction through the right superior pulmonary vein or through the interatrial septum. Used in 32 patients (adults and children), the device proved to be highly efficient, simple, and safe.

Surgical repair of ventricular aneurysms. Early results with Cooley's technique.

Using bovine pericardium instead of Dacron for grafting, we performed ventricular endoaneurysmorrhaphy (Cooley's technique) in 13 patients with postmyocardial infarction left ventricular aneurysm. Twelve patients were men and 1 was a woman; their ages ranged from 38 to 67 years (mean, 51.2 +/- 11.4 years). Eight patients had large anterolateral aneurysms, 4 had apical aneurysms, and 1 had a false inferior aneurysm. Postoperatively, the mean cardiac index increased from 2.07 +/- 0.50 to 3.09 +/- 0.99 L/min/m2 (p < 0.05), with a mean percentage increase of 50.17% +/- 37.03%. No patient required postoperative mechanical circulatory assistance, and pharmacologic support could be withdrawn soon after surgery. All patients had uncomplicated recoveries and were asymptomatic upon discharge, at a mean time of 9.0 +/- 2.3 days after surgery. We conclude that ventricular endoaneurysmorrhaphy provides excellent initial results, and we believe, through subjective analysis of ventriculograms, that the use of bovine pericardium for grafting produces better functional results than does the use of Dacron.

[The use of a rate-responsive pacemaker after heart transplantation]. / Uso de marcapasso com resposta de freqüência após transplante cardíaco.

PURPOSE: The indications and the results of pacemaker implant following orthotopic cardiac transplantation. METHODS: Four patients implanted a cardiac pacemaker (PM) in the early post-operative period (PO) of orthotopic cardiac transplantation (from 10th to 16th PO day). The patients were 33 to 55 year-old and the indications to PM were supraventricular arrhythmia (atrial fibrillation or flutter) associated with atrioventricular block in three, and complete atrioventricular block in one patient. Previous to PM implant, patients were submitted to endomyocardial biopsy, which was normal in two patients, evidenced mild rejection in one and moderate rejection in the remaining. A ventricular rate responsive pacemaker was implanted in all patients, with sensors responsive to muscular activity in one patient, and to minute ventilation in three. RESULTS: One patient died in the 20th PO due to acute allograft rejection not controlled by immunosuppressive drugs. Three other patients had satisfactory evolution and the pacemakers were programmed during exercise testing, previous to hospital discharge. Recent evaluation revealed that these patients are in good clinical condition at the 6th, 14th and 24th PO months. Adequate pacemaker function was insured by exercise testing and ambulatory electrocardiographic recording. CONCLUSION: A ventricular rate responsive pacemaker represented a satisfactory mode of pacing, in patients with severe bradycardia, following heart transplantation.

[Modified Cooley technique for surgical repair of left ventricular aneurysms]. / Técnica de Cooley modificada para a correção cirúrgica de aneurismas do ventrículo esquerdo.

PURPOSE: To evaluate early postoperative results of modified Cooley's technique of ventricular endoaneurysmorrhaphy. PATIENTS AND METHODS: Eight patients, seven males, with ages ranging 38.0 to 67.0 years (m = 51.2 +/- 11.4 years) and with postinfarction left ventricular aneurysms were submitted to surgical repair by a modified Cooley's technique of ventricular endoaneurysmorrhaphy. RESULTS: No postoperative complication occurred and all patients were discharged from the hospital asymptomatic on a mean time of 9.0 +/- 2.3 days after surgery. The mean cardiac index increased from 2.1 +/- 0.5 to 3.3 +/- 1.1 l/min (p less than 0.05) with a mean percentual increase of 53.0%. No patient required mechanical circulatory assistance after surgery and the pharmacological support could be interrupted soon. CONCLUSION: Ventricular endoaneurysmorrhaphy searchs to restore shape, contour and volume to the left ventricle and has shown excellent initial results.

[Hospital risk factors in subclavian-pulmonary anastomosis with polytetrafluoroethylene graft]. / Fatores de risco hospitalar na anastomose subclávia-pulmonar com enxerto de politetrafluoretileno.

PURPOSE: Identification of risk factors for mortality in subclavian-pulmonary anastomosis using polytetrafluorethylene (PTFE). PATIENT AND METHODS: Immediate surgical results (30 days) were analyzed in 180 cyanotic patients consecutively operated on from september 1979 to march 1989. RESULTS: The hospital mortality was 12.7% (23 patients) and age at surgery, low weight (less than 3 kg) and preoperative diagnosis were considered risk factors for mortality. Pulmonary artery diameter at echocardiography, date of surgery and diameter of the conduits were associated with increased risk, but this association lacked statistical significance. Sex and previous palliative surgery have not increased hospital mortality. CONCLUSION: We believe that identification of risk factors to PTFE conduit implant plays an important role in the preoperative management of those patients in order to obtain better results in this life saving procedure.

[Late evaluation with spiral computed tomography of smooth bovine pericardium grafts]. / Avaliação tardia por tomografia computadorizada espiral de enxertos de pericárdio bovino liso como substitutos aórticos.

PURPOSE: To evaluate morphologically by spiral computed tomography (SCT) bovine pericardial grafts as aortic substitutes. METHODS: Ten patients were submitted to aortic graft evaluation with SCT. There were 8 ascending and 2 descending grafts. Examination was done after 2 to 7 years post operative. Ages ranged from 49 to 67 years, with 6 male and 4 female patients. All had implanted smooth surface naked pericardial grafts. RESULTS: Surgical result was good in all. Distal dissection persisted in some cases. One had a peri-graft hematoma, 5 had no structural changes and 4 presented mild graft dilatation. There were no graft calcification or pseudoaneurysm. CONCLUSION: Glutaraldehyde preserved naked smooth surface bovine pericardial aortic grafts present satisfactory structural aspect, as seen by SCT, at medium term follow-up. Mild dilatation may be seen in some cases.

Results of the surgical treatment of chronic atrial fibrillation.

OBJECTIVE: Report clinical experience in surgical treatment of atrial fibrillation (AF) by Cox-maze procedure. METHODS: 61 patients underwent surgical treatment for AF. Two had primary AF and 59 AF secondary to heart disease (2 atrial septal defects, 57 mitral). Ages ranged from 20 to 74 years (mean = 49). There were 44 females (72%). The surgical technique employed was Cox 3 without cryoablation. The patients were follow-up in specific at patient clinics and underwent periodical ECG, exercise tests, echocardiogram and Holter monitoring. RESULTS: In-hospital mortality was 4.9% and late mortality 1.6%. A temporary pacemaker was used in 28 (46%) and a definitive in 7 patients (11.4%). On hospital discharge, AF remained in 17%; 63.9% had sinus rhythm, 6.9% atrial rhythm, 1.7% junctional rhythm, and 10.3% had pacemaker rhythm. In the last evaluation, AF was present in 19.5%; (70.5% sinus rhythm, 4% atrial rhythm, 2% atrial tachycardia, and 4% pacemaker rhythm). There was no report of thromboembolic episodes. Chronotropic response was considered adequate in 19%, intermediate in 29%, and inadequate in 42%. In Holter monitoring, the mean heart rate was 82 +/- 8 bpm, with a minimum of 57 +/- 7 bpm and maximum of 126 +/- 23 bpm, with supraventricular extrasystoles in 2.3 +/- 5.5% of the total heartbeats and ventricular extrasystoles in 0.8 +/- 0.5%. In the echocardiogram, the A wave was present in the left atrium in 87.5%. CONCLUSION: Maze procedure is effective and has acceptable surgical risk. Atrial or sinus rhythms remain stable with a small but remarkable frequency of atrial and ventricular arrhythmias. Left atrial contraction is present, although attenuated, as well as the chronotropic response to exercise.

Ventricular evoked response in patients with hypertrophic obstructive cardiomyopathy treated with DDD pacing.

OBJECTIVE: To assess the changes in ventricular evoked responses (VER) produced by the decrease in left ventricular outflow tract gradient (LVOTG) in patients with hypertrophic obstructive cardiomyopathy (HOCM) treated with dual-chamber (DDD) pacing. METHODS: A pulse generator Physios CTM (Biotronik, Germany) was implanted in 9 patients with severe drug-refractory HOCM. After implantation, the following conditions were assessed: 1) Baseline evaluation: different AV delay (ranging from 150 ms to 50 ms) were sequentially programmed during 5 to 10 minutes, and the LVOTG (as determined by Doppler echocardiography) and VER recorded; 2) standard evaluation, when the best AV delay (resulting in the lowest LVOTG) programmed at the initial evaluation was maintained so that its effect on VER and LVOTG could be assessed during each chronic pacing evaluation. RESULTS: LVOTG decreased after DDD pacing, with a mean value of 59 +/- 24 mmHg after dual chamber pacemaker, which was significantly less than the gradient before pacing (98 + 22 mmHg). An AV delay > 100 ms produced a significantly lower decrease in VER depolarization duration (VERDD) when compared to an AV delay < or = 100 ms. Linear regression analyses showed a significant correlation between the LVOTG values and the magnitude of VER (r = 0.69; p < 0.05) in the 9 studied patients. CONCLUSION: The telemetry obtained intramyocardial electrogram is a sensitive means to assess left ventricular dynamics in patients with HOCM treated with DDD pacing.

Unsupported valvuloplasty in children with congenital mitral valve anomalies. Late clinical results.

OBJECTIVE: To analyze late clinical evolution after surgical treatment of children, with reparative and reconstructive techniques without annular support. METHODS: We evaluated 21 patients operated upon between 1975 and 1998. Age 4.67+/-3.44 years; 47.6% girls; mitral insufficiency 57.1% (12 cases), stenosis 28.6% (6 cases), and double lesion 14.3% (3 cases). The perfusion 43.10+/-9.50 min, and ischemia time were 29.40+/-10.50 min. The average clinical follow-up in mitral insufficiency was 41.52+/-53.61 months. In the stenosis group (4 patients) was 46.39+/-32.02 months, and in the double lesion group (3 patients), 39.41+/-37.5 months. The echocardiographic follow-up was in mitral insufficiency 37.17+/-39.51 months, stenosis 42.61+/-30.59 months, and in the double lesion 39.41+/-37.51 months. RESULTS: Operative mortality was 9.5% (2 cases). No late deaths occurred. In the group with mitral insufficiency, 10 (83.3%) patients were asymptomatic (p=0.04). The majority with mild reflux (p=0.002). In the follow-up of the stenosis group, all were in functional class I (NYHA); and the mean transvalve gradient varied between 8 and 12 mmHg, average of 10.7 mmHg. In the double lesion group, 1 patient was reoperated at 43 months. No endocarditis or thromboembolism were reported. CONCLUSION: Mitral stenosis repair has worse late results, related to the valve abnormalities and associated lesions. The correction of mitral insufficiency without annular support showed good long-term results.

[Surgical myocardial revascularization in young patients]. / Cirurgia de revascularização miocárdica em pacientes jovens.

PURPOSE: To determine early and late results of surgical myocardial revascularization (SMR) in young patients. METHODS: We studied retrospectively 73 patients aging less than 40 years and submitted to SMR between 1975 and 1989. The method used was patient card review and thelephone contact with the patient or his physician. RESULTS: Follow-up was obtained in all cases in a period of 2 to 185 (59.9 +/- 41.0) months. Of the coronary risk factors smoking was the most frequent. One vessel coronary artery disease was observed in 16 (21.9%) patients, 2 and 3 vessel coronary artery disease in 26 (35.6%) and 32 (43.8%) patients respectively. SMR was considered complete in 68 (93.2%) patients. An associated procedure was performed on 10 cases: Left ventricular aneurysm repair in 9 (12.3%) and mitral valve replacement in one (1.4%). Perioperative myocardial infarction occurred in 7 (9.5%) patients and one of them died (operative mortality: 1.4%). During follow-up, 6 (8.3%) patients died with an actuarial survival rate of 89.1% at 15 years. An event free survival rate of 68.3% was observed at 10 years. From 66 survivors, 53 (80.3%) were asymptomatic at late follow-up and 48 (72.7%) patients returned to work. CONCLUSION: Surgical myocardial revascularization in young patients associated with medical treatment, has good early and late results with a high percentage of patients asymptomatic and reemployed at a late follow-up.