Importance of the Internal Thoracic Artery as the Source of Collateral Circulation in CABG Patients with Leriche Syndrome. / Importância da Artéria Torácica Interna como Fonte de Circulação Colateral em Pacientes com CRM com Síndrome de Leriche.

In coronary artery bypass grafting (CABG) the use of the internal thoracic artery (ITA), is a Class I indication for the left anterior descending (LAD) artery. Atherosclerosis is a systemic disease, and peripheral arterial disease (PAD) is an important complicator of CABG, present in about one-third of the patients with coronary disease. In Leriche Syndrome, ITA can be the source of collateral circulation for arteries below the level of occlusion. Its inadvertent use can lead to serious ischemic complications in the dependent territories.

Na cirurgia de revascularização do miocárdio (CRM), o uso da artéria torácica interna (ATI), é uma indicação de Classe I para a anastomose com a artéria descendente anterior esquerda (ADA). A aterosclerose é uma doença sistêmica, além da doença coronariana, um terço dos pacientes possuem doença arterial obstrutiva periférica (DAOP), que é um complicador da CRM. Na Síndrome de Leriche, a ATI pode ser fonte de circulação colateral para artérias abaixo do nível de oclusão. O seu uso inadvertido pode levar a complicações isquêmicas graves nos territórios dependentes.

Treinamento de Não-Cardiologistas pode Melhorar os Resultados do Tratamento de Infarto Agudo do Miocárdio com Supra de ST / Training Non-Cardiologists Could Improve the Treatment Results of ST Elevation Myocardial Infarction

Resumo Fundamento De acordo com a Organização Mundial da Saúde, países emergentes terão um crescimento considerável no número de ataques cardíacos e mortes relacionadas. Um dos principais problemas médicos no Brasil é a mortalidade causada por infarto agudo do miocárdio com supra de ST (IAMCSST). A Sociedade de Cardiologia do Estado de São Paulo nunca treinou não-cardiologistas para atendimentos de emergência. Os pacientes normalmente buscam ajuda em prontos-socorros, em vez de chamar a ambulância. Objetivo Nosso objetivo foi reduzir as taxas de mortalidade hospitalar causada por infarto agudo do miocárdio ao treinar profissionais da emergência na cidade de São Paulo. Métodos Utilizamos um programa de treinamento para as equipes de cinco hospitais com > 100 pacientes internados com IAMCSST por ano, e pelo menos 15% de mortes hospitalares relacionadas ao IAMCSST. Realizamos treinamentos online, organizamos de dois a quatro eventos para até 400 participantes, fizemos folders e panfletos informativos. A análise estatística utilizou o teste para comparação de duas proporções, com p <0,05. Resultados Quase 200 médicos e 350 enfermeiros participaram de pelo menos um treinamento de maio de 2010 até dezembro de 2013. Inicialmente, muitos médicos da emergência não reconheciam um infarto agudo do miocárdio no eletrocardiograma, mas a tele-ecocardiografia é usada em alguns departamentos da emergência para determinar o diagnóstico. A taxa de mortalidade nos cinco hospitais caiu de 25,6%, em 2009, para 18,2%, em 2010 (p=0,005). Depois da conclusão do período de treinamento, as mortes relacionadas ao IAMCSST em todos os hospitais públicos de São Paulo diminuíram de 14,31%, em 2009, para 11,25%, em 2014 (p<0,0001). Conclusão Mesmo programas simplificados de treinamento de pessoal da emergência pode reduzir muito as taxas de morte por infarto agudo do miocárdio em países em desenvolvimento.

Abstract Background According to the World Health Organization, emerging countries will have an enormous growth in the number of heart attacks and related deaths. The main medical issue in Brazil is mortality caused by acute ST elevation myocardial infarction (STEMI). The Society of Cardiology in the State of São Paulo has never trained non-cardiologists as emergency personnel. Patients usually seek help from emergency departments instead of calling for an ambulance. Objectives We aimed at reducing in-hospital death rates from acute myocardial infarction by training emergency personnel in the city of Sao Paulo. Methods We used a training program for the personnel of five hospitals with >100 patients admitted with STEMI per year, and at least 15% in-hospital STEMI-associated mortality rate. We performed internet training, biannual-quarterly symposia for up to 400 participants, informative folders and handouts. Statistical analysis used the two proportion comparison test with p <0.05. Results Nearly 200 physicians and 350 nurses attended at least one training from May 2010 to December 2013. Initially, many emergency physicians could not recognize an acute myocardial infarction on the electrocardiogram, but tele-electrocardiography is used in some emergency departments to determine the diagnosis. The death rate in the five hospitals decreased from 25.6%, in 2009, to 18.2%, in 2010 (p=0.005). After the entire period of training, the STEMI-associated death rate in all public hospitals of São Paulo decreased from 14.31%, in 2009, to 11.25%, in 2014 (p<0.0001). Conclusion Even simple training programs for emergency personnel can greatly reduce acute myocardial infarction death rates in undeveloped countries.

Training Non-Cardiologists Could Improve the Treatment Results of ST Elevation Myocardial Infarction. / Treinamento de Não-Cardiologistas pode Melhorar os Resultados do Tratamento de Infarto Agudo do Miocárdio com Supra de ST.

BACKGROUND: According to the World Health Organization, emerging countries will have an enormous growth in the number of heart attacks and related deaths. The main medical issue in Brazil is mortality caused by acute ST elevation myocardial infarction (STEMI). The Society of Cardiology in the State of São Paulo has never trained non-cardiologists as emergency personnel. Patients usually seek help from emergency departments instead of calling for an ambulance. OBJECTIVES: We aimed at reducing in-hospital death rates from acute myocardial infarction by training emergency personnel in the city of Sao Paulo. METHODS: We used a training program for the personnel of five hospitals with >100 patients admitted with STEMI per year, and at least 15% in-hospital STEMI-associated mortality rate. We performed internet training, biannual-quarterly symposia for up to 400 participants, informative folders and handouts. Statistical analysis used the two proportion comparison test with p <0.05. RESULTS: Nearly 200 physicians and 350 nurses attended at least one training from May 2010 to December 2013. Initially, many emergency physicians could not recognize an acute myocardial infarction on the electrocardiogram, but tele-electrocardiography is used in some emergency departments to determine the diagnosis. The death rate in the five hospitals decreased from 25.6%, in 2009, to 18.2%, in 2010 (p=0.005). After the entire period of training, the STEMI-associated death rate in all public hospitals of São Paulo decreased from 14.31%, in 2009, to 11.25%, in 2014 (p<0.0001). CONCLUSION: Even simple training programs for emergency personnel can greatly reduce acute myocardial infarction death rates in undeveloped countries.

FUNDAMENTO: De acordo com a Organização Mundial da Saúde, países emergentes terão um crescimento considerável no número de ataques cardíacos e mortes relacionadas. Um dos principais problemas médicos no Brasil é a mortalidade causada por infarto agudo do miocárdio com supra de ST (IAMCSST). A Sociedade de Cardiologia do Estado de São Paulo nunca treinou não-cardiologistas para atendimentos de emergência. Os pacientes normalmente buscam ajuda em prontos-socorros, em vez de chamar a ambulância. OBJETIVO: Nosso objetivo foi reduzir as taxas de mortalidade hospitalar causada por infarto agudo do miocárdio ao treinar profissionais da emergência na cidade de São Paulo. MÉTODOS: Utilizamos um programa de treinamento para as equipes de cinco hospitais com > 100 pacientes internados com IAMCSST por ano, e pelo menos 15% de mortes hospitalares relacionadas ao IAMCSST. Realizamos treinamentos online, organizamos de dois a quatro eventos para até 400 participantes, fizemos folders e panfletos informativos. A análise estatística utilizou o teste para comparação de duas proporções, com p <0,05. RESULTADOS: Quase 200 médicos e 350 enfermeiros participaram de pelo menos um treinamento de maio de 2010 até dezembro de 2013. Inicialmente, muitos médicos da emergência não reconheciam um infarto agudo do miocárdio no eletrocardiograma, mas a tele-ecocardiografia é usada em alguns departamentos da emergência para determinar o diagnóstico. A taxa de mortalidade nos cinco hospitais caiu de 25,6%, em 2009, para 18,2%, em 2010 (p=0,005). Depois da conclusão do período de treinamento, as mortes relacionadas ao IAMCSST em todos os hospitais públicos de São Paulo diminuíram de 14,31%, em 2009, para 11,25%, em 2014 (p<0,0001). CONCLUSÃO: Mesmo programas simplificados de treinamento de pessoal da emergência pode reduzir muito as taxas de morte por infarto agudo do miocárdio em países em desenvolvimento.

Dysregulation of microRNAs and target genes networks in human abdominal aortic aneurysm tissues.

BACKGROUND: Abdominal aortic aneurysm (AAA) is a pathological enlargement of infrarenal aorta close to the aortic bifurcation, and it is an important cause of mortality in the elderly. Therefore, the biomarker identification for early diagnosis is of great interest for clinical benefit. It is known that microRNAs (miRNAs) have important roles via target genes regulation in many diseases. This study aimed to identify miRNAs and their target genes involved in the pathogenesis of AAA. METHODS: Tissue samples were obtained from patients who underwent AAA surgery and from organ donors (control group). Quantitative PCR Array was applied to assess 84 genes and 384 miRNAs aiming to identify differentially expressed targets (AAA n = 6, control n = 6), followed by validation in a new cohort (AAA n = 18, control n = 6) by regular qPCR. The functional interaction between validated miRNAs and target genes was performed by the Ingenuity Pathway Analysis (IPA) software. RESULTS: The screening cohort assessed by PCR array identified 10 genes and 59 miRNAs differentially expressed (≥2-fold change, p<0.05). Among these, IPA identified 5 genes and 9 miRNAs with paired interaction. ALOX5, PTGIS, CX3CL1 genes, and miR-193a-3p, 125b-5p, 150-5p maintained a statistical significance in the validation cohort. IPA analysis based on the validated genes and miRNAs revealed that eicosanoid and metalloproteinase/TIMP synthesis are potentially involved in AAA. CONCLUSION: Paired interactions of differentially expressed ALOX5, PTGIS, CX3CL1 genes, and miR-193b-3p, 125b-5p, 150-5p revealed a potentially significant role of the eicosanoid synthesis and metalloproteinase/TIMP pathways in the AAA pathogenesis.

Use of Quality of Life in Cardiovascular Surgery in Coronary Artery Bypass Grafting: Validation, Reproducibility, and Quality of Life in One Year of Follow-Up.

BACKGROUND: The objectives of this study are to validate the Quality of Life in Cardiovascular Surgery (QLCS) questionnaire and to observe the evolution of quality of life in the first year of postoperative follow-up of patients who underwent coronary artery bypass grafting (CABG). METHODS: This was a prospective observational study of patients undergoing CABG from July 2016 to June 2017 who survived and answered the QLCS with 1, 6, and 12 months of follow-up. Validation was evaluated for internal consistency by Cronbach's alpha, test-retest reproducibility by correlation coefficient of concordance, and accuracy for interrater reliability by the kappa statistic. The nonparametric analysis of variance test was used for analysis of repeated measures, during follow-up, of the QLCS was considered significant at p < 0.05. RESULTS: Included were 360 patients, with a mean age of 63 years; 72% were men. Cronbach's alpha was 0.82, demonstrating adequate internal consistency. The correlation coefficient of concordance was 0.93 and accuracy 0.99, showing good precision and accuracy. The kappa statistic for questions ranged from 0.58 to 0.78, which ensures a moderate reproducibility. Scores of the QLCS in patients undergoing CABG of 17.69, 18.82, and 19.52 were found at 1, 6, and 12 months, respectively. Thus there was a progressive improvement in quality of life over the first year of follow-up (p < 0.0001). CONCLUSIONS: The QLCS proved to be a good questionnaire in this population, with adequate internal consistency and moderate reproducibility. Its use revealed a progressive and significant improvement in the quality of life of patients undergoing CABG.

Quality of Life in Cardiovascular Surgery: Elaboration and Initial Internal Validation of a Quality of Life Questionnaire.

OBJECTIVE: Elaboration and internal validation of the Quality of Life in Cardiovascular Surgery (QLCS) questionnaire adapted to the reality of Brazilian cardiovascular surgery. METHODS: Cross-sectional pilot study of a prospective cohort included in the Documentation and Surgical Registry Center (CEDREC) for internal validation of the QLCS questionnaire. Four hundred forty-five patients submitted to cardiovascular surgery and who answered a QLCS questionnaire 30 days after hospital discharge were included. It was applied via telephone. To verify the questions' internal consistency, Cronbach's alpha was used. The total QLCS score was calculated as the sum of 5 questions, ranging from 5 to 25 points. Mann-U-Whitney test was used to relate the symptoms with the quality of life (QoL). Level of significance was 5%. RESULTS: After 30 days of surgery, about 95% of the patients had already returned to normal routine and 19% of them were already performing physical activity. In the evaluation of the QLCS's internal consistency, a Cronbach's alpha of 0.74 was found, suggesting that this was probably an adequate questionnaire to evaluate QoL in this population. In the comparison between the presence and absence of symptoms and the median of QoL, the presence of pain at the incision (P=0.002), chest pain (P<0.001), shortness of breath (P<0.001), and return to physical activity (P<0.001) were statistically significant. CONCLUSION: The process of elaboration and validation of questionnaires includes a series of steps. The QLCS questionnaire is probably an adequate tool for the evaluation of QoL in the postoperative patient of cardiovascular surgery, in this first stage of internal validation.

Quality of life in cardiovascular surgery: elaboration and initial internal validation of a quality of life questionnaire

Abstract Objective: Elaboration and internal validation of the Quality of Life in Cardiovascular Surgery (QLCS) questionnaire adapted to the reality of Brazilian cardiovascular surgery. Methods: Cross-sectional pilot study of a prospective cohort included in the Documentation and Surgical Registry Center (CEDREC) for internal validation of the QLCS questionnaire. Four hundred forty-five patients submitted to cardiovascular surgery and who answered a QLCS questionnaire 30 days after hospital discharge were included. It was applied via telephone. To verify the questions' internal consistency, Cronbach's alpha was used. The total QLCS score was calculated as the sum of 5 questions, ranging from 5 to 25 points. Mann-U-Whitney test was used to relate the symptoms with the quality of life (QoL). Level of significance was 5%. Results: After 30 days of surgery, about 95% of the patients had already returned to normal routine and 19% of them were already performing physical activity. In the evaluation of the QLCS's internal consistency, a Cronbach's alpha of 0.74 was found, suggesting that this was probably an adequate questionnaire to evaluate QoL in this population. In the comparison between the presence and absence of symptoms and the median of QoL, the presence of pain at the incision (P=0.002), chest pain (P<0.001), shortness of breath (P<0.001), and return to physical activity (P<0.001) were statistically significant. Conclusion: The process of elaboration and validation of questionnaires includes a series of steps. The QLCS questionnaire is probably an adequate tool for the evaluation of QoL in the postoperative patient of cardiovascular surgery, in this first stage of internal validation.

Persistent Inflammatory Activity in Blood Cells and Artery Tissue from Patients with Previous Bare Metal Stent.

BACKGROUND: Studies have pointed out a higher mortality after coronary artery bypass surgery (CABG) in patients with stent. OBJECTIVE: To evaluate inflammatory markers in peripheral blood cells and in coronary artery tissue samples obtained during CABG in patients with stent compared to controls. METHODS: The case series consisted of two groups, one with previous stent implantation (n = 41) and one control (n = 26). The expression of the LIGHT, IL-6, ICAM, VCAM, CD40, NFKB, TNF, IFNG genes was analyzed in peripheral blood cells collected preoperatively. The coronary artery was evaluated for: interleukin-6, ICAM, VCAM, CD40, NFKB, TNF-alpha and IFN-gamma by immunohistochemistry. A total of 176 tissue samples were grouped for analysis in: A1- arteries with stent (n = 38); A2- native arteries from patients with stent in another artery (n = 68); and A3- arteries without stent from controls undergoing routinely CABG surgery (n = 70). A significance level of 0.05 was adopted. RESULTS: Patients with stent showed higher TNF (p = 0.03) and lower CD40 gene expression (p = 0.01) in peripheral blood cells than controls without stent. In coronary artery samples, the TNF-alpha protein staining was higher in the group A1, not only in the intima-media layer (5.16 ± 5.05 vs 1.90 ± 2.27; p = 0.02), but also in the adipose tissue (6.69 ± 3.87 vs 2.27 ± 4.00; p < 0.001). Furthermore, group A1 had a higher interleukin-6 protein staining in adipose tissue than group A3 (p = 0.04). CONCLUSION: We observed a persistently higher systemic TNF expression associated with exacerbated TNF-alpha and interleukin-6 local production in patients with stents. This finding may contribute to a worse clinical outcome.

Terapia de antiagregação plaquetária: prevenção primária e secundária / Platelet antiaggregation therapy: primary and secondary prevention, peculiarities in anticoagulation of the patient with DM

O diabetes mellitus (DM) é um importante e crescente problema de saúde, sendo que a doença aterosclerótica é uma importante comorbidade. Além do uso de fármacos, a prevenção da aterosclerose envolve mudança do estilo de vida como exercícios, nutrição, controle do peso e interrupção do tabagismo. O uso da aspirina possui papel bem estabelecido na prevenção secundária da doença cardiovascular (DCV) em pacientes com DM2, porém, o seu uso na prevenção primária permanece controverso e ainda com estudos em andamento. O objetivo desse estudo consistia em realizar uma revisão na literatura sobre as principais indicações para o uso da terapia de antiagregação plaquetária nos pacientes diabéticos. Já na prevenção secundária, o uso da aspirina é um consenso e a dupla terapia é indicada após síndromes coronárias agudas. As diretrizes não trazem informações específicas aos pacientes diabéticos, assim como, suas indicações clássicas na anticoagulação.

A new classification of post-sternotomy dehiscence.

The dehiscence after median transesternal sternotomy used as surgical access for cardiac surgery is one of its complications and it increases the patient's morbidity and mortality. A variety of surgical techniques were recently described resulting to the need of a classification bringing a measure of objectivity to the management of these complex and dangerous wounds. The different related classifications are based in the primary causal infection, but recently the anatomical description of the wound including the deepness and the vertical extension showed to be more useful. We propose a new classification based only on the anatomical changes following sternotomy dehiscence and chronic wound formation separating it in four types according to the deepness and in two sub-groups according to the vertical extension based on the inferior insertion of the pectoralis major muscle.

A new classification of post-sternotomy dehiscence / Uma nova classificação das deiscências após esternotomias

The dehiscence after median transesternal sternotomy used as surgical access for cardiac surgery is one of its complications and it increases the patient's morbidity and mortality. A variety of surgical techniques were recently described resulting to the need of a classification bringing a measure of objectivity to the management of these complex and dangerous wounds. The different related classifications are based in the primary causal infection, but recently the anatomical description of the wound including the deepness and the vertical extension showed to be more useful. We propose a new classification based only on the anatomical changes following sternotomy dehiscence and chronic wound formation separating it in four types according to the deepness and in two sub-groups according to the vertical extension based on the inferior insertion of the pectoralis major muscle.

A deiscência após a esternotomia transesternal mediana utilizada em cirurgia cardíaca é uma de suas complicações e provoca o aumento da morbidade e mortalidade dos pacientes. Várias técnicas cirúrgicas têm sido descritas para o seu tratamento, o que contribuiu para aumentar a importância da classificação destas deiscências. Os métodos de classificação inicialmente descritos se baseavam na infecção do sítio cirúrgico, entretanto, é cada vez mais clara a relevância da descrição exata da localização e a extensão da área cruenta resultante como parâmetros para definição da técnica cirúrgica a ser escolhida. Neste relato é sugerida uma nova classificação baseada somente nas alterações anatômicas das feridas que as classifica em quatro tipos, de acordo com a profundidade, e em dois subgrupos, de acordo com a sua extensão vertical, tendo como referência a inserção da margem inferior do músculo peitoral maior.

Clinical evolution of mediastinitis in patients undergoing adjuvant hyperbaric oxygen therapy after coronary artery bypass surgery.

OBJECTIVE: To evaluate the use of hyperbaric oxygen therapy as an adjunctive treatment in mediastinitis after coronary artery bypass surgery. METHODS: This is a retrospective descriptive study, performed between October 2010 and February 2012. Hyperbaric oxygen therapy was indicated in difficult clinical management cases despite antibiotic therapy. RESULTS: We identified 18 patients with mediastinitis during the study period. Thirty three microorganisms were isolated, and polymicrobial infection was present in 11 cases. Enterobacteriaceae were the most prevalent pathogens and six were multi-resistant agents. There was only 1 hospital death, 7 months after the oxygen therapy caused by sepsis, unrelated to hyperbaric oxygen therapy. This treatment was well-tolerated. CONCLUSION: The initial data showed favorable clinical outcomes.

Influência da lesão carotídea no pós-operatório de revascularização miocárdica e sua evolução tardia / Influence of carotid injury in post-myocardial revascularization surgery and its late evolution

FUNDAMENTO: Cerca de 30% dos AVE perioperatórios da cirurgia de revascularização do miocárdio (CRM) são decorrentes de lesões carotídeas, sem redução de risco confirmada por intervenção perioperatória. OBJETIVOS: Avaliar o impacto da doença carotídea e a intervenção perioperatória nos pacientes submetidos à CRM. MÉTODOS: Estudo retrospectivo observacional, avaliando 1.169 pacientes com idade > 65 anos submetidos à CRM entre janeiro de 2006 e dezembro de 2010, acompanhados, em média, por 49 meses. Todos foram submetidos à ultrassonografia de carótidas prévia à CRM. Definiu-se doença carotídea quando lesão > 50%. O desfecho primário foi composto pela incidência de AVE, acidente isquêmico transitório (AIT) e óbito por AVE. RESULTADOS: A prevalência da doença carotídea foi de 19,9% dos pacientes. A incidência do desfecho primário entre portadores e não portadores foi de 6,5% e 3,7%, respectivamente (p = 0,0018). Nos primeiros 30 dias, ocorreram 18,2% dos eventos. Relacionaram-se a doença carotídea: disfunção renal (OR 2,03, IC95% 1,34-3,07; p < 0,01), doença arterial periférica (OR 1,80, IC95% 1,22-2,65; p < 0,01) e infarto do miocárdio prévio (OR 0,47, IC95% 0,35-0,65; p < 0,01). Quanto ao desfecho primário, foram associados AIT prévio (OR 5,66, IC95% 1,67-6,35; p < 0,01) e disfunção renal (OR 3,28, IC95% 1,67-6,45; p < 0,01). Nos pacientes com lesão > 70%, a intervenção carotídea perioperatória apresentou incidência de 17% no desfecho primário contra 4,3% na conduta conservadora (p = 0,056) sem diferença entre abordagens percutânea e cirúrgica (p = 0,516). CONCLUSÃO: A doença carotídea aumenta o risco para AVE, AIT ou morte por AVE na CRM. Entretanto, a intervenção carotídea não foi relacionada à redução do desfecho primário.

BACKGROUND: Approximately 30% of perioperative CVA of myocardial revascularization surgery (MRS) are a result of carotid injuries, without reduction of risk confirmed by perioperative intervention. OBJECTIVES: Evaluate the impact of carotid disease and perioperative intervention in patients subjected to MRS. METHODS: Observational, retrospective study, evaluating 1169 patients aged > 69 years undergoing MRS from January, 2006 and December, 2010, monitored, on average, for 49 months. All patients were subjected to ultrasonography of carotids before MRS. It was defined as carotid disease when lesion > 50%. The primary outcome was composed of CVA incidence, transitory ischemic accident (TIA) and death due CVA. RESULTS: Prevalence of carotid disease was of 19.9% of patients. The incidence of primary outcome between unhealthy and healthy patients was of 6.5% and 3.7%, respectively (p = 0.0018). In the first 30 days, there were 18.2% of events. Were related to carotid disease: renal dysfunction (OR 2.03, IC95% 1.34-3.07; p < 0.01), peripheral arterial disease (OR 1.80, IC95% 1.22-2.65; p < 0.01) and previous myocardial infarction (OR 0.47, IC95% 0.35-0.65; p < 0.01). Regarding the primary outcome, were associated the previous TIA (OR 5.66, IC95% 1.67-6.35; p < 0.01) and renal dysfunction (OR 3.28, IC95% 1.67-6.45; p < 0.01). In patients with lesion >70%, perioperative carotid intervention demonstrated an incidence of 16% in primary outcome compared to 4.3% in conservatory treatment (p = 0.056) with no difference between percutaneous and surgical approaches (p = 0.516). CONCLUSION: Carotid disease increases the risk of CVA, TIA or death due to CVA in MRS. However, the carotid intervention was not related to reduction of primary outcome.