Cardiovascular response [corrected] during rehabilitation after coronary artery bypass grafting.

OBJECTIVE: The aim of the present study was to assess the behavior of cardiovascular variables during an in-hospital cardiovascular rehabilitation program in patients following myocardial revascularization surgery. METHODS: A total of 14 patients (mean age: 55.4 ± 6.4 years, 78.6% male) participated in the study, all of whom had a previous diagnosis of coronary insufficiency and indication for elective surgery. The protocol consisted of a group of low-impact (2-3 METs) upper/lower extremity and walking exercises performed both pre and post-operatively (3rd and 4th days). The following variables were evaluated at rest and following the exercise program: heart rate (HR, bpm); systolic arterial pressure (SAP, mmHg); diastolic arterial pressure (DAP, mmHg); mean arterial pressure (MAP, mmHg); double product (DPr, bpm/mmHg); and the Rating of Perceived Exertion (RPE) scale. RESULTS: There was a significant increase in HR and DPr in the individual analysis (P<0.001) as well as in between days (P<0.001 for HR and P<0.05 for DPr), but only attaining maximal values that were ≤ 30% of predicted. Moreover, a negative correlation was found between the RPE scale and both SAP and MAP. CONCLUSION: The exercises proposed proved to be safe with the change in key physiologic variables throughout the experiment below recommended values for the hospitalization phase. Furthermore, the RPE scale appears to have a correlation with some hemodynamic variables and thus may be a useful tool for this group of patients.

Endovascular treatment of type B aortic dissection: the challenge of late success.

BACKGROUND: Thoracic endovascular aortic repair of type B aortic dissection is a therapeutic option for selected patients. However, late outcomes of this intervention are virtually unknown, and the series already published are heterogenous regarding demographics, indications, and type of devices. METHODS: From 1997 to 2004, 106 patients exclusively with classic complicated or symptomatic type B aortic dissection were treated with thoracic endovascular aortic repair, using the same device. We present in-hospital outcomes and late follow-up for 73 patients. RESULTS: Technical success was achieved for 99% of patients, and the clinical success rate was 83% (exclusion of the false lumen, no early death or surgical conversion). In-hospital death occurred in 5 patients, 2 of them after surgical conversion. Three patients required urgent surgical conversion. Neurologic complications occurred in 5 patients (1 case of paraplegia). The average time of follow-up was 35.9 +/- 28.5 months. During follow-up, 37% of patients initially successfully treated reached a failure criterion (new endovascular or surgical intervention in the same aortic segment or death due to aortic or unknown cause). Kaplan-Meier curve showed late survival rates higher than 80% in 2 years. CONCLUSIONS: Patients with both acute and chronic type B aortic dissection had excellent initial results with thoracic endovascular aortic repair. Although event-free survival rates decreased gradually with time owing to the frequent need for new interventions, survival curves were comparable to those for less complex patients undergoing clinical or surgical treatment. Randomized studies are required to establish the actual benefit of this new approach.

Cavectomy for the treatment of Wilms tumor with vascular extension.

PURPOSE: Vascular extension to the vena cava occurs in 4% of Wilms tumor cases and can reach the right atrium in up to 1%. When this happens the thrombus is usually not adherent to the vessel wall, and there is blood flow around it. Preoperative chemotherapy can cause thrombus regression and even resolution. If the thrombus persists after chemotherapy, surgery will be a challenge. On the other hand, if the thrombus invades the vessel wall, its removal may not be feasible. In this situation cavectomy is a good surgical strategy because it provides complete resection. The prerequisite for cavectomy is the absence of blood flow in the vena cava on preoperative Doppler ultrasonography. We report 3 cases of Wilms tumor with vena caval invasion in which cavectomy was performed, and discuss the principles, indications and operative technique. MATERIALS AND METHODS: A total of 171 patients with Wilms tumor were treated at our institution between 1984 and 2004. Of these patients 6 with intravascular extension of thrombus within the right atrium were treated with extracorporeal circulation, cardiac arrest and profound hypothermia, and 3 were treated with cavectomy. RESULTS: There were no instances of surgical complications or postoperative renal failure in our patients who underwent cavectomy. All remain well and free of disease. CONCLUSIONS: Cavectomy is a safe procedure for treating pediatric patients with Wilms tumor when there is extension and invasion of the vena cava wall without blood flow.

Revolutionary treatment of aneurysms and dissections of descending aorta: the endovascular approach.

BACKGROUND: Acute aortic dissection is a life-threatening medical condition. It is associated with high morbidity and mortality. Type B dissections are usually managed clinically during the acute phase. Conventional surgery carries high mortality rates due to the presence of serious complications. We herein present treatment of this condition with a less invasive endovascular approach. Other clinical situations such as penetrating ulcers, intramural hematomas, and true aneurysms of descending aorta were similarly treated. METHODS: From December 1996 to March 2002, 191 patients with type B dissections were treated with self-expandable, polyester-covered stents. There were 120 patients (62.8%) with type B dissections, 61 patients (31.9%) with true aneurysms, 6 patients (3.1%) with penetrating ulcers or intramural hematomas, and 4 patients (2.1%) with trauma. Patients with abdominal aneurysms (44) and stents introduced under direct vision through the aortic arch (70) were excluded. The stent graft was delivered in the catheterization laboratory under general anesthesia, with induced hypotension and heparinization. All stents used were made in Brazil (Braile Biomedics, Sao Jose do Rio Preto, SP). RESULTS: The procedure was performed in 191 consecutive cases. The success rate was 91.1% (174/191). Success was defined as occlusion of the thoracic intimal tear, or exclusion of the aneurysm without leaks. Hospital mortality was 10.4% (20/191 patients), due to preoperative comorbidities. Six patients required conversion to surgery. No case of paraplegia was observed. An actuarial survival curve showed 87.4% +/- 29% survival in the late follow-up period. CONCLUSIONS: Stent grafts are an important development in the treatment of descending aortic aneurysms or dissections. This novel approach may replace conventional surgical treatment of these conditions, with earlier intervention and less morbidity.

Endovascular treatment of thoracic disease: patient selection and a proposal of a risk score.

BACKGROUND: Although selection criteria and subgroup analysis are still in the early developmental stages, endovascular treatment of aortic disease has become an alternative to surgery for many patients. METHODS: From November 1996 to November 1999, 49 patients were treated with a self-expandable endoprosthesis at our institution. Most patients had acute aortic dissections. Thirteen of these patients did not follow the anatomic selection protocol. We retrospectively analyzed these patients to compare our numerical risk score (which includes clinical and anatomic criteria) between groups with or without success and between groups that followed the anatomic protocol (P) or did not follow the anatomic protocol (E [exception]). RESULTS: Success rates were similar in groups P and E, although mortality rates were higher in group E. Patients from group E had longer procedures and required multiple stents more frequently. The proposed risk score was able to differentiate between groups with or without success, as well as between groups P and E. CONCLUSIONS: In order to reduce mortality and morbidity rates, careful selection criteria must be followed when treating patients endovascularly. Although it is time-consuming, using objective criteria can help select patients for endovascular treatment. We propose that patients with a risk score higher than 11 should only undergo percutaneous treatment when they have an unacceptably high surgical risk, and even so only after a detailed discussion of the risks.