ABSTRACT
Resumo Fundamento A intervenção percutânea em pacientes com disfunção de prótese biológica mitral apresenta-se como uma alternativa ao tratamento cirúrgico convencional. Objetivo Relatar a primeira experiência brasileira de implante transcateter de bioprótese valve-in-valve mitral via transeptal (TMVIV-via transeptal). Métodos Foram incluídos pacientes portadores de disfunção de bioprótese cirúrgica submetidos ao TMVIV-transeptal em 12 hospitais brasileiros. Foram considerados estatisticamente significativos valores de p<0,05. Resultados Entre junho/2016 e fevereiro/2019, 17 pacientes foram submetidos ao TMVIV-via transeptal. A mediana de idade foi 77 anos (IIQ,70-82), a mediana do escore STS-PROM foi 8,7% (IIQ,7,2-17,8). Todos os pacientes tinham sintomas limitantes de insuficiência cardíaca (CF≥III), tendo 5 (29,4%) sido submetidos a mais de uma toracotomia prévia. Obteve-se sucesso do TMVIV-via transeptal em todos os pacientes. A avaliação ecocardiográfica demonstrou redução significativa do gradiente médio (pré-intervenção, 12±3,8 mmHg; pós-intervenção, 5,3±2,6 mmHg; p<0,001), assim como aumento da área valvar mitral (pré-intervenção, 1,06±0,59 cm2; pós-intervenção, 2,18±0,36 cm2; p<0,001) sustentados em 30 dias. Houve redução significativa e imediata da pressão sistólica de artéria pulmonar, com redução adicional em 30 dias (pré-intervenção, 68,9±16,4 mmHg; pós-intervenção, 57,7±16,5 mmHg; 30 dias, 50,9±18,7 mmHg; p<0,001). Durante o seguimento, com mediana de 162 dias (IIQ, 102-411), observou-se marcada melhora clínica (CF≤II) em 87,5%. Um paciente (5,9%) apresentou obstrução de via de saída de ventrículo esquerdo (VSVE), evoluindo para óbito logo após o procedimento, e outro morreu aos 161 dias de seguimento.Conclusão: A primeira experiência brasileira de TMVIV-transeptal demonstra a segurança e a efetividade dessa nova técnica. A obstrução da VSVE é uma complicação potencialmente fatal, reforçando a importância da seleção dos pacientes e do planejamento do procedimento. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)
Abstract Background Percutaneous intervention in patients with bioprosthetic mitral valve dysfunction is an alternative to conventional surgical treatment. Objectives To report the first Brazilian experience with transseptal transcatheter bioprosthetic mitral valve-in-valve implantation (transseptal-TMVIV). Methods Patients with surgical bioprosthetic dysfunction submitted to transseptal-TMVIV in 12 Brazilian hospitals were included. The significance level adopted was p<0.05. Results From June/2016 to February/2019, 17 patients underwent transseptal-TMVIV. Their median age was 77 years (IQR,70-82) and median Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) score was 8.7% (IQR,7.2-17.8). All patients had limiting symptoms of heart failure (FC≥III) and 5 (29.4%) had undergone more than one previous thoracotomy. Transseptal-TMVIV was successful in all patients. Echocardiographic assessment showed a significant reduction in mean mitral valve gradient (pre-intervention, 12±3.8 mmHg; post-intervention, 5.3±2.6 mmHg; p<0.001), in addition to an increase in mitral valve area (pre-intervention, 1.06±0.59 cm2; post-intervention, 2.18±0.36 cm2; p<0.001) sustained for 30 days. There was a significant and immediate reduction in the pulmonary artery systolic pressure, with an additional reduction in 30 days (pre-intervention, 68.9±16.4 mmHg; post-intervention, 57.7±16.5 mmHg; 30 days, 50.9±18.7 mmHg; p<0.001). During follow-up (median, 162 days; IQR, 102-411), significant clinical improvement (FC≤II) was observed in 87.5% of the patients. One patient (5.9%) had left ventricular outflow tract (LVOT) obstruction and died right after the procedure, and another died at 161 days of follow-up. Conclusion The first Brazilian experience with transseptal-TMVIV shows the safety and effectivity of the new technique. The LVOT obstruction is a potentially fatal complication, reinforcing the importance of patients' selection and of procedural planning. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)
Subject(s)
Humans , Aged , Aged, 80 and over , Heart Valve Prosthesis , Heart Valve Prosthesis Implantation , Mitral Valve Insufficiency/surgery , Prosthesis Design , Brazil , Cardiac Catheterization , Treatment Outcome , Mitral Valve/surgery , Mitral Valve/diagnostic imagingABSTRACT
Abstract Introduction: Advances in modern medicine have led to people living longer and healthier lives. Frailty is an emerging concept in medicine yet to be explored as a risk factor in cardiac surgery. When it comes to CABG surgery, randomized controlled clinical trials have primarily focused on low-risk (ROOBY, CORONARY), elevated-risk (GOPCABE) or high-risk patients (BBS), but not on frail patients. Therefore, we believe that off-pump CABG could be an important technique in patients with limited functional capacity to respond to surgical stress. In this study, the authors introduce the new national, multicenter, randomized, controlled trial "FRAGILE", to be developed in the main cardiac surgery centers of Brazil, to clarify the potential benefit of off-pump CABG in frail patients. Methods: FRAGILE is a two-arm, parallel-group, multicentre, individually randomized (1:1) controlled trial which will enroll 630 patients with blinded outcome assessment (at 30 days, 6 months, 1 year, 2 years and 3 years), which aims to compare adverse cardiac and cerebrovascular events after off-pump versus on-pump CABG in pre-frail and frail patients. Primary outcomes will be all-cause mortality, acute myocardial infarction, cardiac arrest with successful resuscitation, low cardiac output syndrome/cardiogenic shock, stroke, and coronary reintervention. Secondary outcomes will be major adverse cardiac and cerebrovascular events, operative time, mechanical ventilation time, hyperdynamic shock, new onset of atrial fibrillation, renal replacement therapy, reoperation for bleeding, pneumonia, length of stay in intensive care unit, length of stay in hospital, number of units of blood transfused, graft patency, rate of complete revascularization, neurobehavioral outcomes after cardiac surgery, quality of life after cardiac surgery and costs. Discussion: FRAGILE trial will determine whether off-pump CABG is superior to conventional on-pump CABG in the surgical treatment of pre-frail and frail patients. Trial registration: ClinicalTrials.gov, ID: NCT02338947. Registered on August 29th 2014; last updated on March 21st 2016.
Subject(s)
Humans , Aged , Coronary Artery Bypass/methods , Coronary Artery Bypass, Off-Pump/methods , Coronary Artery Bypass/adverse effects , Coronary Artery Bypass/mortality , Follow-Up Studies , Frail Elderly , Treatment Outcome , Risk Assessment , Coronary Artery Bypass, Off-Pump/adverse effects , Coronary Artery Bypass, Off-Pump/mortalityABSTRACT
Objetivo: Analisar a perviedade da artéria torácica interna direita pediculada, anteroaórtica em anastomose para o ramo interventricular anterior na revascularização do miocárdio, em relação à artéria torácica interna esquerda, com o uso de angiotomografia coronária, no 6º mês de pós-operatório. Métodos: No período de dezembro de 2008 a dezembro de 2011, 100 pacientes foram selecionados, prospectivamente, para cirurgia de revascularização do miocárdio sem circulação extracorpórea. Foram agrupados em Grupo-1 (G-1) e Grupo-2 (G-2), com 50 pacientes cada, randomização por computador e conhecimento da técnica no início da cirurgia. No G-1, os pacientes receberam artéria torácica interna esquerda para o ramo interventricular anterior e complementação da revascularização do miocárdio com a artéria torácica interna direita livre para ramos da circunflexa. Os pacientes do G-2 receberam artéria torácica interna direita pediculada para o ramo interventricular anterior e complementação da revascularização do miocárdio com artéria torácica interna esquerda, pediculada, para ramos da circunflexa. Resultados: Os grupos eram semelhantes quanto aos dados clínicos de pré-operatório. Houve predominância do sexo masculino, 75,6% e 88% nos grupos 1 e 2 respectivamente. Cinco pacientes migraram do G-1 para o G-2 devido à doença ateromatosa na aorta ascendente. A média de anastomoses distais no G-1 foi de 3,48 (DP=0,72), e no G-2 foi de 3,20 (DP=0,76). Os resultados das angiotomografias coronarianas em 96 pacientes reestudados mostraram que todas as artérias torácicas internas, direita ou esquerda, utilizadas pediculadas para a região anterior do coração encontravam-se ...
Objective: To assess the patency of the pedicled right internal thoracic artery with an anteroaortic course and compare it to the patency of the left internal thoracic artery , in anastomosis to the left anterior descending artery in coronary artery bypass grafting by using coronary CT angiography at 6 months postoperatively. Methods: Between December 2008 and December 2011, 100 patients were selected to undergo a prospective coronary artery bypass grafting procedure without cardiopulmonary bypass. The patients were randomly divided by a computer-generated list into Group-1 (G-1) and Group-2 (G-2), comprising 50 patients each, the technique used was known at the beginning of the surgery. In G-1, coronary artery bypass grafting was performed using the left internal thoracic artery for the left anterior descending and the free right internal thoracic artery for the circumflex, and in G-2, coronary artery bypass grafting was performed using the right internal thoracic artery pedicled to the left anterior descending and the left internal thoracic artery pedicled to the circumflex territory. Results: The groups were similar with regard to the preoperative clinical data. A male predominance of 75.6% and 88% was observed in G-1 and G-2, respectively. Five patients migrated from G-1 to G-2 because of atheromatous disease in the ascending aorta. The average number of distal anastomoses was 3.48 (SD=0.72) in G-1 and 3.20 (SD=0.76) in G-2. Coronary CT angiography in 96 re-evaluated patients showed that all ITAs, right or left, used in situ for the left anterior descending were patent. There were no deaths in either group. Conclusion: Coronary artery bypass grafting surgery involving anastomosis of the anteroaortic right internal thoracic artery to the left anterior descending artery has an outcome similar to that obtained using the left internal thoracic artery for the same coronary site. .
Subject(s)
Female , Humans , Male , Coronary Artery Disease/surgery , Internal Mammary-Coronary Artery Anastomosis/methods , Mammary Arteries/physiopathology , Vascular Patency/physiology , Anastomosis, Surgical , Coronary Angiography/methods , Coronary Artery Disease , Coronary Vessels/physiopathology , Coronary Vessels , Medical Illustration , Mammary Arteries , Postoperative Period , Prospective Studies , Risk Factors , Treatment Outcome , Tomography, X-Ray Computed/methodsSubject(s)
Humans , Male , Coronary Disease/surgery , Myocardial Revascularization/standards , Anesthesia , Extracorporeal Circulation/standards , Multicenter Studies as Topic , Myocardial Infarction/complications , Myocardial Infarction/surgery , Postoperative Care , Postoperative Complications , Preoperative Care , Minimally Invasive Surgical Procedures/standardsABSTRACT
Realizamos análise retrospectiva de todos os pacientes com idade igual ou superior a 70 anos, submetidos à operação de revascularização do miocárdio isolada, no período de janeiro de 1992 a dezembro de 1997, objetivando avaliar a morbimortalidade. Do total de 144 pacientes, 92 (63,9 por cento) eram do sexo masculino, idade entre 70 e 84 anos, média de 73,51 anos e desvio padrão de 2,82. A grande maioria encontrava-se com angina classe funcional III ou IV (79,16 por cento). Tiveram relação com a ocorrência de maior mortalidade, a presença no período pré-operatório de: obesidade (p = 0,004), insuficiência cardíaca congestiva (classe III/IV - p = 0,03) e/ou infarto agudo do miocárdio (<21 dias - p = 0,01). Houve amplo predomínio de pacientes com lesões em três ou mais vasos, com média de 3,48 anastomoses/paciente. Utilizamos a artéria torácica interna pediculada em 126 (87,5 por cento) pacientes; nos últimos 2 anos este índice atingiu 98,9 por cento. As principais complicações presentes no período pós-operatório, mais relacionadas com o óbito, foram: insuficiência renal com diálise (p<0,0001), infecção (p<0,0001), com sepse, suporte respiratório prolongado (p<0,0001), e baixo débito cardíaco (p = 0,003). Para a análise estatística utilizamos o teste T de Student, teste do Qui-quadrado e teste exato de Fisher. A mortalidade cirúrgica global, considerando-se os primeiros 30 dias do período pós-operatório, foi de 5,5 por cento (8/144), caindo para 1,53 por cento (1/65) nos últimos 2 anos. A operação de revascularização do miocárdio no idoso pode ser realizada com baixa morbimortalidade, avaliando-se cuidadosamente o paciente e seus sistemas orgânicos.
Subject(s)
Humans , Male , Female , Aged , Myocardial Revascularization , Aged, 80 and over , Morbidity , Retrospective Studies , Myocardial Revascularization/mortalityABSTRACT
Purpose To assess this initial clinical experience with heart-lung transplantation in Brazil. Methods Four patients underwent heartlung transplantation from December 1988 to March 1990, one patient with cardiomyopathy and high pulmonary resistance, two patiens with primary pulmonary hypertension and another with pulmonry silicosis. The heart lung blocks were harvestedfrom the donor using cardiopulmonary bypass and deep hypotermia. They were transplanted to the recipient by anastomosing the tracheae, right atrium or venae cavae, and the ascending aorta. Results The second patient died on the 5th postoperative day due to respiratory insuffciency with consequent brain lesions. The first and third patients had survived nine manths and 42 days respectively. The 4th patients is assymptomatic eight months after the operation. The main complications were bleeding in two patients, acute pulmonary rejection in three of them and obliterans bronchiolitis in one patients. Conclusion The heart lung transplantation is a challenging procedure which results are progressively improving with the development of better surgical technique and clinical concepts.
Subject(s)
Heart-Lung Transplantation , Time Factors , Brazil , Cardiomyopathies/surgery , Postoperative Complications , Hypertension, Pulmonary/surgeryABSTRACT
Homem de 31 anos de idade, portador de mixoma de átrio direito, com manifestaçöes de tortura, mal-estar geral e dispnéia aos grandes esforços, apresentava ao exame físico sopros holossistólico e telediastólico de média intensidade em área trícuspide. Os sinais radiológicos e eletrocardiográficos foram de sobrecarga atrial e ventricular diretas e o diagnóstico de mixoma de átrio direito foi feito com auxílio do ecocardiograma bidimensional. A ressecçäo cirúrgica da massa tumoral confirmou o diagnóstico, através do estudo histopatológico da peça, que media 75x50x40mm. Houve remissäo das manifestaçöes clínicas, radiológicas e eletrocardiográficas