Reparação da parede abdominal com membranas acelulares de pericárdio bovino - Parte I - Achados clínicos e radiológicos / Abdominal wall repair with acellular bovine pericardial membranes - Part I - Clinical and radiological findings

Introdução: Reduzindo os índices de recidiva de forma impactante, o emprego de biomateriais como "telas de reforço" na reparação de diferentes defeitos da parede abdominal tornou-se rotina quase obrigatória para o sucesso dessas reparações. A partir da década de 1990 houve a introdução de matrizes biológicas acelulares, iniciando-se assim uma nova era na reparação dos defeitos da parede abdominal. O objetivo é avaliar a funcionalidade do pericárdio bovino acelularizado em reparações da parede abdominal. Método: Trinta pacientes foram submetidos a reparação de defeitos da parede abdominal, com biopróteses acelulares de pericárdio bovino, perfazendo um total de 40 implantes anatomicamente individualizados. O seguimento médio foi de 31 meses, sendo os pacientes avaliados clinicamente e radiologicamente. Em três casos foram feitas biópsias das áreas implantadas permitindo análise histológica do material. Resultados: Não se observou recidiva das herniações em nenhum dos casos, tanto clinica como radiologicamente. Também não houve registro de hematomas, infecções ou qualquer fenômeno de natureza reacional local ou sistêmica. Radiologicamente, não foi possível visualizar as matrizes no local de implantação em qualquer dos períodos de pós-operatório analisados. Conclusão: As matrizes mostraram similaridade às demais membranas biológicas descritas na literatura internacional. Representando uma importante atualização e evolução conceitual, as membranas acelulares de pericárdio bovino podem ser incorporadas ao arsenal terapêutico nas reparações de parede abdominal.

Introduction: Reducing recurrence rates significantly, the use of biomaterials as "reinforcement meshes" in the repair of different abdominal wall defects has become an almost mandatory routine for the success of these repairs. From the 1990s onwards, acellular biological matrices were introduced, thus beginning a new era in the repair of abdominal wall defects. The objective is to evaluate the functionality of the acellularized bovine pericardium in abdominal wall repairs. Method: Thirty patients underwent repair of abdominal wall defects using acellular bovine pericardium bioprostheses, making a total of 40 anatomically individualized implants. The average follow-up was 31 months, with patients being evaluated clinically and radiologically. In three cases, biopsies were taken from the implanted areas, allowing histological analysis of the material. Results: No recurrence of herniations was observed in any of the cases, both clinically and radiologically. There were also no records of bruises, infections or any phenomenon of a local or systemic reaction nature. Radiologically, it was not possible to visualize the matrices at the implantation site in any of the postoperative periods analyzed. Conclusion: The matrices showed similarity to other biological membranes described in the international literature. Representing an important update and conceptual evolution, acellular bovine pericardial membranes can be incorporated into the therapeutic arsenal in abdominal wall repairs.

Reparação da parede abdominal com membranas acelulares de pericárdio bovino - Parte II - Análises histológicas e morfométricas / Repair of the abdominal wall with acellular bovine pericardial membranes - Part II - Histological and morphometric analyses

Introdução: Análise histológica é a principal ferramenta de avaliação de biopróteses acelulares, em sua maioria em caráter experimental. O objetivo é analisar histologicamente a matriz acelular de pericárdio bovino em reparações de parede abdominal implantada em humanos. Método: De uma série de 30 reparações com a membrana, 3 pacientes foram submetidas a revisão cirúrgica não relacionada aos implantes, aos 13, 22 e 23 meses de pós-operatório, obtendo-se biópsias das áreas previamente implantadas. Além da avaliação dos aspectos básicos de biocompatibilidade e neoformação tecidual, as lâminas foram digitalizadas e submetidas a análise computadorizada com o software ImageJ para quantificação da cinética de degradação das membranas, associada à análise da dimensão fractal das amostras. Os valores obtidos para porcentagens de membrana residual tiveram suas médias comparadas por análise de variância (ANOVA) e pelo teste T de Student não pareado, também utilizado para os valores da quantificação da dimensão fractal. Resultados: Foi demonstrada a biocompatibilidade do material, com neoformação tecidual, deposição de colágeno e tecido celularizado de aspecto normal, sem reações locais importantes. Fragmentos residuais da membrana foram quantificados em 40%±7% aos 13 meses, em 20%±6% aos 22 meses e em 17%±6% aos 23 meses de pós-operatório, com a análise da dimensão fractal indicando uma progressiva degradação dos implantes, com significância estatística entre 13 meses e as amostras tardias. Conclusão: Os resultados atestaram a funcionalidade do pericárdio bovino acelular sob diferentes níveis de estresse mecânico nas reparações da parede abdominal em humanos.

Introduction: Histological analysis is the main tool for evaluating acellular bioprostheses, mostly on an experimental basis. The objective is to histologically analyze the acellular matrix of bovine pericardium in abdominal wall repairs implanted in humans. Method: From a series of 30 repairs with the membrane, 3 patients underwent surgical revision unrelated to the implants at 13, 22, and 23 months postoperatively, obtaining biopsies of the previously implanted areas. In addition to evaluating the basic aspects of biocompatibility and tissue neoformation, the slides were digitalized and subjected to computerized analysis with the ImageJ software to quantify the kinetics of membrane degradation associated with the analysis of the fractal dimension of the samples. The values obtained for percentages of residual membrane had their means compared by analysis of variance (ANOVA) and the unpaired Student's T test, also used for the fractal dimension quantification values. Results: The biocompatibility of the material was demonstrated, with tissue neoformation, collagen deposition, and cellularized tissue with a normal appearance without important local reactions. Residual fragments of the membrane were quantified at 40%±7% at 13 months, at 20%±6% at 22 months, and at 17%±6% at 23 months postoperatively, with the analysis of the fractal dimension indicating a progressive degradation of implants, with statistical significance between 13 months and late samples. Conclusion: The results confirmed the functionality of the acellular bovine pericardium under different levels of mechanical stress in abdominal wall repairs in humans.

Endothelial Microparticles: Markers of Inflammatory Response After Sutureless Valve Implantation

ABSTRACT Introduction: Systemic inflammatory response syndrome (SIRS) is related to increased circulating endothelial microparticles (EMP). Objective: The aim of this study was to compare the plasma concentration of EMP between patients undergoing aortic valve replacement with conventional bioprosthesis implantation and Perceval™ S (LivaNova) and to evaluate its impact on the inflammatory response in the short-term follow-up. Methods: This is a randomized clinical trial with 24 patients submitted to isolated aortic valve replacement divided into two groups: Perceval™ S (Group P) and conventional bioprostheses (Group C). Incidence of severe SIRS (three or more criteria) in the first 48 hours postoperatively, EMP release profile, interleukins (IL) 6 and 8, C-reactive protein, and procalcitonin were analyzed preand postoperatively at 24 hours and three months. Results: There were 24 patients (12 in each group), mean age was 69.92±5.17 years, 83.33% were female, the incidence of severe SIRS was 66.7% and 50% in groups C and P, respectively (P=0.68), and EMP showed a significant increase in the 24-hour postoperative period (P≤0.001) and subsequent decrease in the three-month postoperative period (P≤0.001), returning to baseline levels. For IL-6 and IL-8, there was a greater increase in group C at 24 hours postoperatively (P=.0.02 and P<0.001). Conclusion: The incidence of severe SIRS was similar in both groups, with significantly higher levels of IL-6 and IL-8, at the 24-hour postoperative period, in group C, however with higher levels of EMP in group P, and subsequent return to baseline levels at the three-month postoperative period in both groups.

Prognostic Impact of Residual Moderate Mitral Regurgitation Following Valve-in-Valve Transcatheter Aortic Valve Implantation

ABSTRACT Introduction: The impact of mitral regurgitation (MR) on valve-in-valve transcatheter aortic valve implantation (VIV-TAVI) in patients with failed bioprostheses remains unclear. The purpose of this study was to assess the prognostic impact of residual moderate MR following VIV-TAVI. Methods: We retrospectively analyzed 127 patients who underwent VIV-TAVI between March 2010 and November 2021. At least moderate MR was observed in 51.2% of patients before the procedure, and MR improved in 42.1% of all patients. Patients with postoperative severe MR, previous mitral valve intervention, and patients who died before postoperative echocardiography were excluded from further analyses. The remaining 114 subjects were divided into two groups according to the degree of postprocedural MR: none-mild MR (73.7%) or moderate MR (26.3%). Propensity score matching yielded 23 pairs for final comparison. Results: No significant differences were found between groups before and after matching in early results. In the matched cohort, survival probabilities at one, three, and five years were 95.7% vs. 87.0%, 85.0% vs. 64.5%, and 85.0% vs. 29.0% in the none-mild MR group vs. moderate MR-group, respectively (log-rank P=0.035). Among survivors, patients with moderate MR had worse functional status according to New York Heart Association (NYHA) class at follow-up (P=0.006). Conclusion: MR is common in patients with failed aortic bioprostheses, and improvement in MR-status was observed in over 40% of patients following VIV-TAVI. Residual moderate MR after VIV-TAVI is not associated with worse early outcomes, however, it was associated with increased mortality at five years of follow-up and worse NYHA class among survivors.

Implications of five-year outcomes of PERIGON trial for bioprosthetic aortic valve replacement / 中国胸心血管外科临床杂志

@#For patients with aortic valve disease who require replacement of their native valve, surgical aortic valve replacement (SAVR) has been the standard of care. Due to the hemorrhage and thromboembolic risks of long-term anticoagulation therapy for mechanical prosthesis, bioprosthetic aortic valve replacement (AVR) has a trend to be used in younger patients, which raising the concern for the durability of bioprosthetic valves. The newly published 5-year outcomes of PERIGON trial, with no structural valve deterioration, again demonstrated the favorable durability of the new generation bioprosthetic valves, further providing the evidence of using bioprosthetic AVR in younger patients. At the meantime, the rapid progress of transcatheter aortic valve implantation (TAVI) has brought a new treatment option. For younger patients with low risks, choosing SAVR or TAVI becomes a critical decision. This paper reviews the outcomes of PERIGON trial and its implications to the clinical practice and research of bioprosthetic AVR.

Safety, Effectiveness, and Hemodynamic Performance of the Bovine Pericardium Organic Valvular Bioprosthesis

ABSTRACT Objective: To assess actual data on the safety, effectiveness, and hemodynamic performance of Bovine Pericardium Organic Valvular Bioprosthesis (BVP). Methods: The BIOPRO Trial is an observational, retrospective, non-comparative, non-randomized, and multicenter study. We collected data from 903 patients with symptomatic, moderate, or severe valve disease who underwent BVP implants in the timeframe from 2013 to 2020 at three Brazilian institutions. Death, valve-related adverse events (AEs), functional recovery, and hemodynamic performance were evaluated at the hospital, at discharge, and six months and one year later. Primary analysis compared late (> 30 days after implant) linearized rates of valve-related AEs, such as thromboembolism, valve thrombosis, major hemorrhage, major paravalvular leak, and endocarditis, following objective performance criteria (OPC). Analysis was performed to include at least 400 valve-years for each valve position (aortic and mitral) for complete comparisons to OPC. Kaplan-Meier survival and major adverse cardiovascular and cerebrovascular event analyses were also performed. Results: This retrospective study analyzed follow-up data collected from 903 patients (834.2 late patient-years) who have undergone surgery for 455 isolated aortic valve replacement (50.4%), 382 isolated mitral valve replacement (42.3%), and 66 combined valve replacement or other intervention (7.3%). The linearized rates of valve-related AEs were < 2 × OPC. One-year survival rates were 95.1% and 92.7% for aortic and mitral valve replacement, respectively. This study demonstrated an improvement in the New York Heart Association classification from baseline and hemodynamic performance within an expected range. Conclusion: According to this analysis, BVP meets world standards for safety and clinical efficacy.

Valve in valve en posición tricuspídea: reconociendo opciones de manejo para la válvula «olvidada¼ / Valve in valve in tricuspid position: recognizing management options for the "forgotten" valve

Resumen Presentamos el caso de una paciente con bioprótesis tricuspídea disfuncionante a quien se le realizó un implante valve in valve con una prótesis transcatéter SAPIEN XT, demostrando que esta técnica es una alternativa terapéutica válida frente a la reintervención de la válvula tricúspide.

Abstract We present the case of a patient who was implanted with a transcatheter prosthesis on a dysfunctional bioprosthesis, demonstrating that it is a valid therapeutic alternative to reoperation in those patients with high surgical risk.

A Surgical Technique to Preserve the Subvalvular Apparatus in Patients Undergoing Mitral Valve Replacement for Severe Ischemic Regurgitation

ABSTRACT Severe functional mitral valve regurgitation should be treated in patients undergoing myocardial revascularization. When replacement is considered the best therapeutic option, preservation of the mitral subvalvular apparatus is crucial, especially in the emergency setting, because of its primary role in preserving geometry and function of left and right ventricles. Here we present a simple and quick technique, where subvalvular apparatus is preserved in toto in patients undergoing mitral valve replacement with a bioprosthesis.

High Residual Gradient Following a Self-Expandable Transcatheter Aortic Valve-in-Valve Implantation — Risk Factor Analysis, Outcomes, and Survival

Abstract Introduction: Transcatheter aortic valve-in-valve implantation (TAVI-ViV) can be associated with unfavorable hemodynamic outcomes. This study aimed to estimate the prevalence, identify the risk factors, and evaluate the outcomes and survival of patients with high residual gradients after TAVI-ViV. Methods: A total of 85 patients were included in the study. The cohort was divided into group A, with postprocedural mean pressure gradient (PG) ≥ 20 mmHg, and group B, with mean PG < 20 mmHg. Results: Postprocedural PG ≥ 20 mmHg was observed in 24.7% of the patients. In a univariate analysis, preoperative gradient, pre-existing patient-prosthesis mismatch (PPM), deep valve implantation, small degenerated valves, and an older generation of transcatheter aortic valves were found to be risk factors for high residual gradient. Multivariate analysis showed that preexisting maxPG > 60 mmHg, implantation level of 4 mm below neo-annulus, and degenerated valve size ≤ 23 mm were independent predictors of high residual gradient. There were no differences in early morbidity (myocardial infarction, pacemaker implantation, stroke, acute renal insufficiency) between groups. Kaplan-Meier estimated that the survival rate was comparable at one and five years regardless of postoperative gradient. Survivors with high residual mean gradient were significantly affected by a high New York Heart Association (NYHA) class. Conclusion: High residual transvalvular gradient after TAVI-ViV is not rare, but it does not significantly affect mortality. High residual mean gradient has a negative impact on NYHA functional class improvement after the procedure. High preoperative gradient, implantation level, and small failed bioprosthesis may predispose to increased residual gradient.

Comparison of Postoperative Outcomes of Sutureless versus Stented Bioprosthetic Aortic Valve Replacement

Abstract Objective: Sutureless aortic valve replacement (Su-AVR) offers an alternative to supra-annular stented biological aortic prostheses. This single-center study aimed to compare early outcomes after aortic valve replacement with sutureless and conventional stented bioprostheses. Methods: In this retrospective study, we analyzed 52 patients who underwent aortic valve replacement with sutureless and stented bioprostheses between January 2013 and October 2017. Sorin Perceval S sutureless valves were implanted in group 1 and Sorin Mitroflow stented bioprosthetic valves were used in group 2. Postoperative outcomes, including demographics, cardiopulmonary bypass (CPB) times, cross-clamp times, morbidity and mortality, as well as echocardiography in the first month, were compared. Results: Mortality occurred in 1 (3.6%) patient in group 1, and in 2 (8.3%) patients in group 2 (P=0.186). Group 1 had significantly shorter CPB (61.6±26.1 min vs. 106.3±32.7 min, P=0.001) and cross-clamp (30.9±13.6 min vs. 73.3±17.3 min, P=0.001) times. The length of stay in the intensive care unit (1.9±1.3 days vs. 2.4±4.9 days, P=0.598) and hospital stay (7.6±2.7 days vs. 7.3±2.6 days, P=0.66) were similar. Postoperatively, there was no statistically significant difference between the two groups in echocardiography results, and morbidities. The mean aortic valve gradient was 13.5±5.8 mmHg in group 1 and 14.5±8.0 mmHg in group 2 (P=0.634). Paravalvular regurgitation was diagnosed in 3 (10.7%) patients in group 1 and in 1 (4.2%) patient in group 2 (P=0.220). Conclusions: Su-AVR resulted in shorter cross-clamp and CPB times. However, early mortality, postoperative morbidity, and echocardiography results were similar between groups.

Ring Fracture of Brazilian Aortic Valve Bioprostheses Using Non-Compliant High-Pressure Transcatheter Balloon, an Ex Vivo Test

ABSTRACT Introduction: Aortic valve bioprostheses ring fracture in valve-in-valve procedures has shown low complication rates and presents as an option in the treatment of patients at high risk for conventional surgery, avoiding high transvalvular gradients, which are associated with increased mortality. Some prostheses available in the market cannot be fractured. In an ex vivo test, the possibility of ring fracture of aortic valve bioprostheses produced in Brazil when submitted to radial force application using a high-pressure non-compliant balloon was evaluated. Methods: One unit of each aortic valve bioprosthesis model, sizes 19 and 21 mm, produced by Brazilian companies (Braile Biomédica, Cardioprótese, and Labcor), was used. In the experiment, a non-compliant high-pressure balloon (Atlas®-Gold), 1 mm larger than the external diameter of the prosthesis, was positioned inside the valve annulus and inflated gradually aiming to fracture the prosthesis. Fracture pressures and photographic and radiological images of the prostheses before and after test were recorded. Results: All prostheses were fractured. In the models with metal ring, the fracture pressures were between 23 and 25 atm. In the other prostheses, the rupture occurred between 10 and 13 atm. No deformations in the structure were observed, which could potentially damage the aortic root. Conclusion: All the Brazilian prostheses evaluated were fractured, although the presence of a metal ring in the prosthesis framework increases the pressure required for fracture. The information obtained helps in the planning of valve-in-valve procedures in patients with aortic valve bioprostheses.

Outcomes Following Supracoronary Ascending Aortic Replacement with Aortic Valve Resuspension versus Modified Bentall's Operation for Acute Type A Aortic Dissection

Abstract Introduction: Type A acute aortic dissection (AAD) remains a challenging cardiac emergency despite the availability of various management strategies. This study compared the outcomes of supracoronary ascending aortic replacement (SCAAR) with aortic valve (AV) resuspension with those of modified Bentall's operation for type A AAD and the progression of aortic regurgitation (AR), long-term dilatation of aortic root and proximal arch, and long-term mortality in SCAAR patients. Methods: Sixty patients underwent surgery for type A AAD (January 2005 to December 2015). Forty-three patients underwent SCAAR with AV resuspension and 17 underwent modified Bentall's operation. All patients were followed up. Results: Upon follow-up of SCAAR patients (n=40), there was significant reduction in aortic root size (preoperative 39.3 mm [9.4] vs. postoperative 33.1 mm [9.1]; P<0.001). Three of these patients worsened to severe AR while others had similar or lesser degree of AR. On comparison between preoperative and postoperative dimensions of all patients (n=53), there was no significant difference in distal ascending aorta size (35.7 mm [8.1] vs. 34.4 mm [8.9]; P=0.52). However, an increase in descending thoracic aorta size (28.8 mm [7.8] vs. 33.7 mm [9.9]; P<0.001) was observed. In-hospital and late mortalities for SCAAR vs. modified Bentall's procedure were 11.7% (seven patients) (7% [3] vs. 23.5% [4]) and 28% (15 patients) (15% [6] vs. 69% [9]), respectively. Conclusion: SCAAR with AV resuspension is a safe surgical option for type A AAD. Preservation of AV is associated with better long-term outcomes and reduced mortality. Modified Bentall's operation may be associated with long-term mortality.

Bioprosthetic Aortic Valve Degeneration: a Review from a Basic Science Perspective

Abstract Introduction: The increase in the prevalence of aortic stenosis due to an aging population has led to an increasing number of surgical aortic valve replacements. Over the past 20 years, there has been a major shift in preference from mechanical to bioprosthetic valves. However, despite efforts, there is still no "ideal" bioprosthesis. It is crucial to understand the structure, biology, and function of native heart valves to design more intelligent, strong, durable, and physiological heart valve tissues. Methods: A comprehensive review of the literature was performed to identify articles reporting the basic mechanisms of bioprosthetic valve dysfunction and the biology of native valve cells. Searches were run in PubMed, MEDLINE® (the Medical Literature Analysis and Retrieval System Online), and Google Scholar. Terms for subject heading and keywords search included "biological heart valve dysfunction", "bioprosthesis dysfunction", "bioprosthesis degeneration", and "tissue heart valves". Results: All the relevant findings are summarized in the appropriate subsections. Structural dysfunction is a logical and expected consequence of the chemical, mechanical, and immunological processes that occur during fixation, manufacture, and implantation. Conclusion: Biological prosthesis valve dysfunction is a clinically significant process. It has become a major issue considering the growing rate of bioprosthesis implantation and improved long-term patient survival. Understanding bioprosthetic aortic valve degeneration from a basic science perspective is a key point to improve technologic advances and specifications that lead to a new generation of bioprostheses.

Aortic Valve Reconstruction with Ozaki Technique

Abstract Modern bioprostheses offer a complete and definitive solution to elderly patients who need aortic valve surgery. Nonetheless, the scenario is more demanding when dealing with younger and less fragile patients. In this setting, any prosthetic aortic valve replacement can provide only a suboptimal solution and its related issues have not been fixed yet. The answer to the needs of this special population is the enhancement and refinement of the surgical technique. The Ozaki technique relies on custom-tailored autologous aortic cusps individually sutured in the aortic position. This approach has been showing optimal results if performed after a dedicated training period.

Transcatheter valve-in-valve implantation using the J-Valve for bioprosthetic degeneration at different anatomic positions: A single-center experience / 中国胸心血管外科临床杂志

@#Objective     To summarize the early results and clinical experience of using the J-Valve for transcatheter valve-in-valve implantation in patients with degenerated bioprosthesis at different anatomic positions. Methods     A retrospective analysis was conducted to evaluate the short-term outcomes of 39 consecutive patients who underwent transcatheter valve-in-valve implantation using the J-Valve System in the Department of Cardiac Surgery of Guangdong Provincial People’s Hospital from April 2020 to August 2021 due to bioprosthetic degeneration at different  anatomic positions. Among them, 35 patients underwent transcatheter mitral valve-in-valve (TMViV) implantation, 1 transcatheter aortic valve-in-valve (TAViV) implantation, 1 transcatheter tricuspid valve-in-valve (TTViV) implantation, 1 TMViV implantation with simultaneous TAViV implantation, and another one TMViV implantation with simultaneous transcatheter aortic valve replacement (TAVR) and perivalvular leakage (PVL) closure. Results     Among the 35 patients who underwent isolated TMViV implantation, 17 were male and 18 were female with a mean age of 72.6±10.8 years. Mean duration between two operations was 10.5±2.7 years. The mean Society of Thoracic Surgeons and EuroSCORE Ⅱ scores were 12.95%±9.61% and 13.91%±8.94%, respectively. The device success rate was 97.1% and no death occured during the operation. One patient was transferred to thoracotomy due to device displacement, 1 was re-opened for uncontrolled bleeding, and 1 presented left ventricular outflow tract obstruction. One patient underwent craniotomy due to intracranial hemorrhage within 30 days after surgery, and no other complications occurred including death, stroke, permanent pacemaker implantation, cardiac tamponade, or re-hospitalization. The mean follow-up time was 6.0±4.4 months, the mean mitral valve gradient was significantly improved (10.4±2.0 mm Hg vs. 5.5±1.2 mm Hg, P<0.05), and the New York Heart Association class≤Ⅱ in all the patients at the last follow-up. Among the other 4 patients who did not undergo isolated TMViV implantation, the transapical TAViV implantation and the trans-right atrium TTViV implantation were successful without intra- or post-operative complications. The patient who underwent TMViV and TAViV implantation simultaneously via transapical approach died of severe pulmonary hemorrhage and multiple organ failure 16 days after surgery. The other patient who underwent transapical TMViV combined with TAVR and PVL closure died of septic shock 10 days after the surgery. Conclusion     Transcatheter valve-in-valve implantation using the J-Valve system is shown to be a safe and effective procedure to treat mitral, aortic and tricuspid bioprosthetic valve dysfunction in high-risk patients, providing a new alternative to surgical surgery for degenerated bioprosthesis at different anatomic positions. However, simultaneous different valves intervention should be very cautious.

A importância do uso de pericárdio bovino para reconstruções cirúrgicas: uma revisão sistemática / The importance of the use of bovine pericardium for surgical reconstructions: a systematic review

Introdução: O uso de pericárdio bovino teve início em 1972 nas cirurgias cardiovasculares. A partir da evolução da engenharia de tecidos com os cuidados na preparação do material, minimizando os riscos de rejeição e facilitando a utilização para diversos tipos de cirurgias, o pericárdio bovino tornou-se ferramenta importante em procedimentos cirúrgicos reconstrutivos. Objetivos: Nessa casuística, o presente estudo propõe avaliar o atual cenário da utilização do pericárdio bovino em procedimentos cirúrgicos de diversas especialidades e os resultados pósoperatórios encontrados. Métodos: Assim, foi realizada uma revisão sistemática da literatura e a base de dados consultada foi a MEDLINE, utilizando a palavra-chave "bovine pericardium", elencando estudos publicados nos últimos cinco anos em inglês e português, e que não utilizavam outro tipo de "patch". Resultados: Foram selecionados 14 artigos que totalizam 507 pacientes, submetidos a cirurgias em diversas áreas, tais quais, cardiologia, neurologia, vascular, pediatria, urologia e oftalmologia. Conclusão: Depreende-se que o uso de pericárdio bovino como remendo cirúrgico é seguro, tendo em vista que existem poucos casos de rejeição do hospedeiro, além de fácil e rápido de ser manuseado, possuindo benefícios frente a próteses mecânicas. Faz-se relevante, portanto, ampliar o número de estudos sobre o tema, visando o grande potencial que esse tipo de material possui para a medicina regenerativa.

Introduction: The use of bovine pericardium started in 1972 in cardiovascular surgeries. From the evolution of tissue engineering with care in the preparation of the material, minimizing the risk of rejection and facilitating the use for various types of surgeries, the bovine pericardium has become an important tool in reconstructive surgical procedures. Purpose: In this series, the present study proposes to evaluate the current scenario of the use of bovine pericardium in surgical procedures of different specialties, and the postoperative results found. Methods: Thus, a systematic literature review was carried out and the database consulted was MEDLINE, using the keywords "bovine pericardium", listing studies published in the last five years in English and Portuguese and that did not use another type of patch. Results: 14 articles were selected, totaling 507 patients, who underwent surgery in several areas, such as cardiology, neurology, vascular, pediatrics, urology, and ophthalmology. Conclusion: It appears that the use of bovine pericardium as a surgical patch is safe, given that there are few cases of host rejection, in addition to being easy and quick to handle, with benefits compared to mechanical prostheses. It is relevant, therefore, to expand the number of studies on the subject, aiming at the great potential that this type of material has for regenerative medicine.

Degeneración valvular en pacientes con bioprótesis aórtica porcina evaluada mediante PET con 18Ffluoruro de sodio / Valve degeneration in patients with aortic porcine bioprosthesis evaluated through 18Fsodium fluoride PET / Degeneração valvular em pacientes com bioprótese aórtica suína avaliada mediante PET com fluoreto18F

Introducción: la degeneración valvular protésica es un problema clínico; los métodos de imagen convencionales permiten diagnosticarla en las últimas etapas. La tomografía por emisión de positrones (PET) con 18Ffluoruro puede detectar de manera precoz la degeneración subclínica. Objetivo: correlacionar parámetros de deterioro estructural protésico por PET con parámetros hemodinámicos ecocardiográficos al año de la sustitución valvular aórtica (SVA) por bioprótesis porcina. Métodos: estudio prospectivo ad hoc de un ensayo clínico. Se reclutaron pacientes sometidos a SVA por bioprótesis porcina en dos centros nacionales entre el 01/01/2019 y el 13/02/2020. Se realizaron controles clínicos y ecocardiográficos. Se seleccionaron aleatoriamente 19 sujetos a los que se les realizó PET 18Ffluoruro de sodio con angiotomografía al año de la SVA. Se midió la captación del trazador en la válvula (SUVavV) y aurícula derecha (SUVavA), calculando el índice SUVavV/SUVavA, que se comparó con los gradientes ecocardiográficos medio y máximo al año, mediante análisis de correlación de Spearman. Resultados: de 140 sujetos sometidos a SVA se realizó PET a 19, a los 16,3 meses (15,9-16,9) luego de la SVA. La mediana del índice SUVavV/SUVavA fue de 1,17 (1,11-1,27). Se encontró una correlación negativa moderada entre la captación de 18Ffluoruro y el gradiente medio (coeficiente de correlación -0,516, p = 0,028) y máximo (coeficiente -0,589, p = 0,010) al año. Conclusiones: en el seguimiento de los pacientes en los que se le realizó una sustitución valvular aórtica con bioprótesis, encontramos valores bajos de captación en el PET y gradientes ecocardiográficos normales con una correlación negativa moderada entre estos hallazgos

Introduction: prosthetic valve degeneration is a relevant clinical disorder; conventional imaging methods allow diagnosis in the later stages. 18Ffluoride positron emission tomography (PET) can detect subclinical degeneration earlier. Objective: correlate parameters of prosthetic structural deterioration by PET with echocardiographic hemodynamic parameters one year after aortic valve replacement (AVR) by porcine bioprosthesis. Methods: prospective ad hoc study of a clinical trial. Patients undergoing AVR by porcine bioprosthesis were recruited in two national centers between 01/01/2019 and 02/13/2020. Clinical and echocardiographic controls were carried out. 19 subjects were randomly selected and underwent 18Fsodium fluoride PET with CT angiography one year after AVR. Tracer uptake in the valve (SUVavV) and right atrium (SUVavA) was measured, creating the SUVavV/SUVavA index, which was compared with the mean and maximum gradients at one year, using Spearman's correlation analysis. Results: of a total of 140 subjects, PET was performed on 19 at 16.3 months (15.9-16.9) after the AVR. The median SUVavV/SUVavA ratio was 1.17 (1.11-1.27). A moderate negative correlation was found between. 18Ffluoride uptake and the mean gradient (correlation coefficient -0.516, p = 0.028) and maximum (coefficient of -0.589, p = 0.010) at one year. Conclusions: we found low uptake values in PET, echocardiographic gradients in normal range and no positive correlation between both parameters. It is the first national report with these imaging techniques

Introdução: a degeneração da válvula protética é um problema clínico; os métodos convencionais de imagem permitem o diagnóstico nas fases posteriores. A tomografia por emissão de pósitrons (PET) com fluoreto18F pode detectar a degeneração subclínica precocemente. Objetivo: correlacionar parâmetros de deterioração estrutural protética por PET com parâmetros hemodinâmicos ecocardiográficos após um ano da troca valvar aórtica (SVA) por bioprótese suína. Métodos: estudo ad hoc prospectivo de um ensaio clínico. Pacientes submetidos a SVA por bioprótese suína foram recrutados em dois centros nacionais entre 01/01/2019 e 13/02/2020. Foram realizados controles clínicos e ecocardiográficos. 19 indivíduos foram selecionados aleatoriamente que foram submetidos a PET com fluoreto de sódio 18F com angiotomografia um ano após AVS. A captação do traçador na válvula (SUVavV) e átrio direito (SUVavA) foi medida, criando o índice SUVavV/SUVavA, que foi comparado com os gradientes médio e máximo em um ano, usando a análise de correlação de Spearman. Resultados: de um total de 140 indivíduos submetidos a SVA, PET foi realizado em 19, em 16,3 meses (15,9-16,9) após a SVA. A proporção média de SUVavV/SUVavA foi de 1,17 (1,11-1,27). Uma correlação negativa moderada foi encontrada entre a captação de fluoreto18F e o gradiente médio (coeficiente de correlação -0,516, p = 0,028) e máximo (coeficiente de -0,589, p = 0,010) em um ano. Conclusões: encontramos valores baixos de captação na PET, gradientes ecocardiográficos dentro da normalidade, sem correlação positiva entre os dois parâmetros. É o primeiro trabalho nacional com essas técnicas de imagem

Endoscopic transposition with the hernial sac (eTHS) in ventral hernia repair - technical description / Transposição endoscópica do saco herniário (TeSH) no tratamento da hérnia ventral - descrição da técnica

ABSTRACT Incisional hernia is a late complication of the most frequent after abdominal surgeries, with resulting morbidity that can worsen the condition. The treatment has been done both by open techniques, using screens or not, and by laparoscopic and robotic methods, which use them systematically. However, introducing a permanent foreign body into the tissues requires more surgical time, despite not closing the parietal defect in most cases and a higher risk of infections. New technologies have been trying to improve these results, with absorbable prostheses (biological or synthetic), but their high cost and recurrences remain a severe problem. Even so, standard repair establishes reinforcement with screens, routine, and whether the approach is traditional or mini-invasive. The authors report their first case of endoscopic repair of incisional hernia, which occurred two years ago, with a Brazilian technique already fifty years old: the transposition with the hernia sac proposed by Prof. Alcino Lázaro da Silva in 1971.

RESUMO A hérnia incisional é uma das complicações tardias mais frequentes, após operações abdominais, resultando em alta morbidade. O tratamento tem sido feito tanto por técnicas abertas, com telas ou sem, quanto por métodos laparoscópicos e robóticos, que utilizam próteses de forma sistemática. No entanto, a introdução de um corpo estranho permanente entre os tecidos requer mais tempo cirúrgico, não fecha o defeito parietal na maioria dos casos e está associado a maior risco de infecções. Novas tecnologias têm sido utilizadas para melhorar esses resultados, empregando próteses absorvíveis (biológicas ou sintéticas), mas o alto custo e as recidivas continuam sendo um grave problema. No entanto, a reparação padrão rotineiramente estabelece reforço com telas, seja na abordagem tradicional ou minimamente invasiva. Os autores relatam o primeiro caso do reparo endoscópico de hérnia incisional, usando técnica brasileira com 50 anos de idade: a transposição com o saco herniário, conforme proposta pelo Prof. Alcino Lázaro da Silva, em 1971.