Twenty years of vasoplegic syndrome treatment in heart surgery. Methylene blue revised.

OBJECTIVE: This study was conducted to reassess the concepts established over the past 20 years, in particular in the last 5 years, about the use of methylene blue in the treatment of vasoplegic syndrome in cardiac surgery. METHODS: A wide literature review was carried out using the data extracted from: MEDLINE, SCOPUS and ISI WEB OF SCIENCE. RESULTS: The reassessed and reaffirmed concepts were 1) MB is safe in the recommended doses (the lethal dose is 40 mg/kg); 2) MB does not cause endothelial dysfunction; 3) The MB effect appears in cases of NO up-regulation; 4) MB is not a vasoconstrictor, by blocking the cGMP pathway it releases the cAMP pathway, facilitating the norepinephrine vasoconstrictor effect; 5) The most used dosage is 2 mg/kg as IV bolus, followed by the same continuous infusion because plasma concentrations sharply decrease in the first 40 minutes; and 6) There is a possible "window of opportunity" for MB's effectiveness. In the last five years, major challenges were: 1) Observations about side effects; 2) The need for prophylactic and therapeutic guidelines, and; 3) The need for the establishment of the MB therapeutic window in humans. CONCLUSION: MB action to treat vasoplegic syndrome is time-dependent. Therefore, the great challenge is the need, for the establishment the MB therapeutic window in humans. This would be the first step towards a systematic guideline to be followed by possible multicenter studies.

Twenty years of vasoplegic syndrome treatment in heart surgery. Methylene blue revised / Vinte anos de tratamento da síndrome vasoplégica em cirurgia cardíaca. Azul de metileno revisado

Objective: This study was conducted to reassess the concepts established over the past 20 years, in particular in the last 5 years, about the use of methylene blue in the treatment of vasoplegic syndrome in cardiac surgery. Methods: A wide literature review was carried out using the data extracted from: MEDLINE, SCOPUS and ISI WEB OF SCIENCE. Results: The reassessed and reaffirmed concepts were 1) MB is safe in the recommended doses (the lethal dose is 40 mg/kg); 2) MB does not cause endothelial dysfunction; 3) The MB effect appears in cases of NO up-regulation; 4) MB is not a vasoconstrictor, by blocking the cGMP pathway it releases the cAMP pathway, facilitating the norepinephrine vasoconstrictor effect; 5) The most used dosage is 2 mg/kg as IV bolus, followed by the same continuous infusion because plasma concentrations sharply decrease in the first 40 minutes; and 6) There is a possible "window of opportunity" for MB's effectiveness. In the last five years, major challenges were: 1) Observations about side effects; 2) The need for prophylactic and therapeutic guidelines, and; 3) The need for the establishment of the MB therapeutic window in humans. Conclusion: MB action to treat vasoplegic syndrome is time-dependent. Therefore, the great challenge is the need, for the establishment the MB therapeutic window in humans. This would be the first step towards a systematic guideline to be followed by possible multicenter studies. .

Objetivo: O presente estudo foi realizado com a finalidade de reavaliar conceitos estabelecidos em 20 anos, com ênfase nos últimos 5 anos, sobre a utilização do azul de metileno no tratamento da síndrome vasoplégica em cirurgia cardíaca. Métodos: Foram considerados dados da literatura utilizando-se três bases de dados (MEDLINE, SCOPUS e ISI Web of Science). Resultados: Os conceitos reavaliados e reafirmados foram: 1) Nas doses recomendadas o AM é seguro (a dose letal é de 40 mg/kg); 2) O AM não causa disfunção endotelial; 3) O efeito do AM só aparece em caso de supra nivelamento do NO; 4) O AM não é um vasoconstritor, pelo bloqueio da via GMPc ele libera a via do AMPc, facilitando o efeito vasoconstritor da norepinefrina; 5) A dosagem mais utilizada é de 2 mg/kg, como bolus EV, seguida de infusão contínua porque as concentrações plasmáticas decaem fortemente nos primeiros 40 minutos, e; 6) Existe uma "janela de oportunidade" precoce para efetividade do AM. Nos últimos cinco anos, os principais desafios foram: 1) Observações de efeitos colaterais; 2) A necessidade de diretrizes, e; 3) A necessidade da determinação de uma janela terapêutica para o uso do AM em humanos. Conclusão: O efeito do AM no tratamento da SV é dependente do tempo, portanto, o grande desafio atual é a necessidade do estabelecimento da janela terapêutica do AM em humanos. Esse seria o primeiro passo para a sistematização de uma diretriz a ser seguida por possíveis estudos multicêntricos. .

A variant technique for the surgical treatment of left ventricular aneurysms.

OBJECTIVE: To present a surgical variant technique to repair left ventricular aneurysms. METHODS: After anesthesia, cardiopulmonary bypass, and myocardial protection with hyperkalemic tepic blood cardioplegia: 1) The left ventricle is opened through the infarct and an endocardial encircling suture is placed at the transitional zone between the scarred and normal tissue; 2) Next, the scar tissue is circumferentially plicated with deep stitches using the same suture thread, taking care to eliminate the entire septal scar; 3) Then, a second encircling suture is placed, completing the occlusion of the aneurysm, and; 4) Finally, the remaining scar tissue is oversewn with an invaginating suture, to ensure hemostasis. Myocardium revascularization is performed after correction of the left ventricle aneurysm. The same surgeon performed all the operations. RESULTS: Regarding the post-surgical outcome 4 patients (40%) had surgery 8 eight years ago, 2 patients (20%) were operated on over 6 years ago, and 1 patient (10%) was operated on more than 5 years ago. Three patients (30%) were in functional class I, class II in 2 patients (20%) and 2 patients (20%) with severe comorbidities remains in class III of the NYHA. There were three deaths (at four days, 15 days and eight months) in septuagenarians with acute myocardial infarction, diabetes and pulmonary emphysema. CONCLUSION: The technique is easy to perform, safe and it can be an option for the correction of left ventricle aneurysms.

Retrograde autologous priming in cardiopulmonary bypass in adult patients: effects on blood transfusion and hemodilution / Perfusato autólogo retrógrado no circuito de circulação extracorpórea em pacientes adultos: efeitos sobre a hemodiluição e transfusão de sangue

INTRODUCTION: Retrograde autologous priming (RAP) is a cardiopulmonary bypass (CPB) method, at low cost. Previous studies have shown that this method reduces hemodilution and blood transfusions needs through increased intra-operative hematocrit. OBJECTIVE: To evaluate RAP method, in relation to standard CPB (crystalloid priming), in adult patients. METHODS: Sixty-two patients were randomly allocated to two groups: 1) Group RAP (n = 27) of patients operated using the RAP and; 2) Control group of patients operated using CPB standard crystalloid method (n = 35). The RAP was performed by draining crystalloid prime from the arterial and venous lines, before CPB, into a collect recycling bag. The main parameters analyzed were: 1) CPB hemodynamic data; 2) Hematocrit and hemoglobin values; 3) The need for blood transfusions. RESULTS: It was observed statistically significant fewer transfusions during surgery and reduced CPB hemodilution using RAP. The CPB hemodynamic values were similar, observing a tendency to use lower CPB flows in the RAP group patients. CONCLUSION: This investigation was designed to be a small-scale pilot study to evaluate the effects of RAP, which were demonstrated concerning the CPB hemodilution and blood transfusions.

INTRODUÇÃO: Perfusato autólogo retrógrado (PAR) é uma técnica de circulação extracorpórea (CEC) com baixos custos. Estudos anteriores demonstraram que esta técnica reduz a hemodiluição e a necessidade de transfusões de sangue por meio do aumento do hematócrito intraoperatório. OBJETIVO: Avaliar técnica de PAR em relação à CEC técnica padrão (perfusato cristaloide) em pacientes adultos. MÉTODOS: Sessenta e dois pacientes foram aleatoriamente alocados em dois grupos: 1) Grupo PAR (n = 27), constituído por pacientes operados utilizando a técnica de PAR e; 2) Grupo Controle, constituído por pacientes operados utilizando técnica padrão de CEC com cristaloides (n = 35). A PAR foi realizada drenando-se o perfusato cristaloide das linhas arterial e venosa, antes da CEC, para uma bolsa coletora de recirculação. Os principais parâmetros analisados foram: 1) parâmetros hemodinâmicos da CEC; 2) valores de hematócrito e hemoglobina; e; 3) necessidade de transfusões de sangue. RESULTADOS: Observaram-se diferenças estatisticamente significativas de transfusão no intraoperatório e diminuição da hemodiluição em CEC utilizando PAR. Os valores hemodinâmicos durante a CEC foram semelhantes, observando-se tendência de utilização de fluxos menores na CEC dos pacientes do grupo PAR. CONCLUSÃO: O presente estudo foi projetado em pequena escala para avaliar os efeitos do PAR, o que foi demonstrado em relação aos já conhecidos efeitos na diminuição da hemodiluição em CEC e transfusão sanguínea, porém não mostrou vantagens hemodinâmicas em relação à técnica padrão com perfusato cristaloide.

Reflections on the 24 years durability of an isolate tricuspid bovine pericardium IMC/Braile bioprosthesis / Reflexões sobre a durabilidade de 24 anos de uma bioprótese IMC/Braile de pericárdio bovino em posição tricúspide isolada

We were challenged by the experience of one patient reoperation for a bioprosthetic bovine pericardium degenerative stenosis, 24 years after implantation. This bioprosthesis was implanted due to tricuspid valve bacterial staphylococcal endocarditis after septic abortion.

Vivenciamos a experiência de reoperar uma paciente por estenose degenerativa de uma prótese biológica de pericárdio bovino, após 24 anos de implante. Essa prótese degenerada havia sido implantada devido à destruição da valva tricúspide por endocardite bacteriana estafilocócica após aborto séptico.

Retrograde autologous priming in cardiopulmonary bypass in adult patients: effects on blood transfusion and hemodilution.

INTRODUCTION: Retrograde autologous priming (RAP) is a cardiopulmonary bypass (CPB) method, at low cost. Previous studies have shown that this method reduces hemodilution and blood transfusions needs through increased intra-operative hematocrit. OBJECTIVE: To evaluate RAP method, in relation to standard CPB (crystalloid priming), in adult patients. METHODS: Sixty-two patients were randomly allocated to two groups: 1) Group RAP (n = 27) of patients operated using the RAP and; 2) Control group of patients operated using CPB standard crystalloid method (n = 35). The RAP was performed by draining crystalloid prime from the arterial and venous lines, before CPB, into a collect recycling bag. The main parameters analyzed were: 1) CPB hemodynamic data; 2) Hematocrit and hemoglobin values; 3) The need for blood transfusions. RESULTS: It was observed statistically significant fewer transfusions during surgery and reduced CPB hemodilution using RAP. The CPB hemodynamic values were similar, observing a tendency to use lower CPB flows in the RAP group patients. CONCLUSION: This investigation was designed to be a small-scale pilot study to evaluate the effects of RAP, which were demonstrated concerning the CPB hemodilution and blood transfusions.

Reflections on the 24 years durability of an isolate tricuspid bovine pericardium IMC/Braile bioprosthesis.

We were challenged by the experience of one patient reoperation for a bioprosthetic bovine pericardium degenerative stenosis, 24 years after implantation. This bioprosthesis was implanted due to tricuspid valve bacterial staphylococcal endocarditis after septic abortion.

Surgicel packing and an erroneous diagnosis of mediastinitis in a neonate.

Internal accumulation of the topical hemostatic agent Surgicel can mimic fluid collections that might be misdiagnosed as an abscess or a hematoma upon 3 common postoperative imaging methods. Herein, we report the unusual case of a neonate who underwent surgical repair of complex congenital heart conditions and then required early re-exploration, prompted by initial suspicion of mediastinitis on the basis of computed tomographic findings. During reoperation, it was determined that the mass on computed tomography was an accumulation of oxidized Surgicel. We discuss the capabilities and limitations of various imaging methods in the achievement of an accurate differential diagnosis.

Methylene blue for vasoplegic syndrome treatment in heart surgery: fifteen years of questions, answers, doubts and certainties.

OBJECTIVE: There is strong evidence that methylene blue (MB), an inhibitor of guanylate cyclase, is an excellent therapeutic option for vasoplegic syndrome (VS) treatment in heart surgery. The aim of this article is to review the MB's therapeutic function in the vasoplegic syndrome treatment. METHODS: Fifteen years of literature review. RESULTS: 1) Heparin and ACE inhibitors are risk factors; 2) In the recommended doses it is safe (the lethal dose is 40 mg/kg); 3) The use of MB does not cause endothelial dysfunction; 4) The MB effect appears in cases of nitric oxide (NO) up-regulation; 5) MB is not a vasoconstrictor, by blocking of the GMPc system it releases the AMPc system, facilitating the norepinephrine vasoconstrictor effect; 6) The most used dosage is 2 mg/kg as IV bolus followed by the same continuous infusion because plasmatic concentrations strongly decays in the first 40 minutes; 7) There is a possible 'window of opportunity' for the MB's effectiveness. CONCLUSIONS: Although there are no definitive multicentric studies, the MB used to treat heart surgery VS, at the present time, is the best, safest and cheapest option, being a Brazilian contribution for the heart surgery.

Fatores de risco para lesão renal aguda após cirurgia cardíaca / Risk factors for acute renal failure after heart surgery

Objetivo: Identificar fatores de risco associados à lesão renal aguda em pacientes com níveis séricos normais de creatinina sérica que foram submetidos à revascularização cirúrgica do miocárdio e/ou cirurgia valvar. Métodos: Os dados de uma coorte de 769 pacientes foram analisados utilizando análise bivariável e regressão logística binária. Resultados: Trezentos e oitenta e um pacientes foram submetidos à revascularização isolada, 339 a cirurgia valvar e 49 a ambas. Quarenta e seis por cento dos pacientes eram do sexo feminino e a idade média foi 57 ± 14 anos. Setenta e oito (10 por cento) pacientes apresentavam disfunção renal no pósoperatório, 23 por cento destes necessitaram hemodiálise. A mortalidade geral foi 10 por cento. A mortalidade para pacientes com disfunção renal pós-operatória foi de 40 por cento (versus 7 por cento, P <0,001), 29 por cento para aqueles que não precisam diálise e 67 por cento para aqueles que necessitaram de diálise (P = 0,004). Os fatores de risco independentes identificados foram: idade (P <0,000, OR: 1,056), insuficiência cardíaca congestiva (P = 0,091, OR: 2,238), DPOC (P = 0,003, OR: 4,111), endocardite (P = 0,001, OR: 12,140, infarto do miocárdio < 30 dias (P = 0,015, OR: 4,205), cirurgia valvar (P = 0,016, OR: 2,137), tempo de circulação extracorpórea > 120 minutos (P = 0,001, OR: 7,040), doença arterial periférica (P = 0,107, 2,296). Conclusão: A disfunção renal foi a disfunção orgânica pós-operatória mais frequente em pacientes submetidos à revascularização do miocárdio e/ou cirurgia valvar e idade, presença de insuficiência cardíaca, DPOC, endocardite, infarto do miocárdio < 30 dias, doença arterial periférica, cirurgia valvar e tempo de circulação extracorpórea > 120 minutos foram os fatores de risco independentemente associados à lesão renal aguda.

Objective: The aim of the present study was to identify risk factors for acute renal failure in patients with normal levels of serum creatinine who had undergone coronary artery bypass graft (CABG) surgery and/or valve surgery. Methods: Data from a cohort of 769 patients were assessed using bivariate analyses and binary logistic regression modeling. Results: Three hundred eighty one patients underwent CABG, 339 valve surgery and 49 had undergone both simultaneously. Forty six percent of the patients were female and the mean age was 57 ± 14 years (13 to 89 years). Seventy eight (10 percent) patients presented renal dysfunction postoperatively, of these 23 percent needed hemodialysis (2.4 percent of all patients). The mortality for the whole cohort was 10 percent. The overall mortality for patients experiencing postoperative renal dysfunction was 40 percent (versus 7 percent, P < 0.001), 29 percent for those who did not need dialysis and 67 percent for those who needed dialysis (P = 0.004). The independent risk factors found were: age (P < 0.000, OR: 1.056), congestive heart failure (P = 0.091, OR: 2.238), COPD (P = 0.003, OR: 4.111), endocarditis (P = 0.001, OR: 12.140), myocardial infarction < 30 days (P = 0.015, OR: 4.205), valve surgery (P = 0.016, OR: 2.137), cardiopulmonary bypass time > 120 min (P = 0.001, OR: 7.040), peripheral arterial vascular disease (P = 0.107, 2.296). Conclusion: Renal dysfunction was the most frequent postoperative organ dysfunction in patients undergone CABG and/or valve surgery and age, congestive heart failure, COPD, endocarditis, myocardial infarction < 30 days, valve surgery, cardiopulmonary bypass time >120 min, and peripheral arterial vascular disease were the risk factors independently associated with acute renal failure (ARF).

Cirurgia da insuficiência mitral no tratamento da insuficiência cardíaca avançada: [revisão] / Mitral insufficiency surgery to treat advanced heart failure: [review]

A cardiomiopatia dilatada caracteriza-se por disfunção miocárdica grave, progressiva e, quase sempre, irreversível. Essa síndrome cursa com remodelamento cardíaco e, em especial, por aumento do volume e da esfericidade do ventrículo esquerdo com dilatação do anel mitral. Como consequência ocorre deslocamento lateral dos músculos papilares, estiramento das cordas tendíneas e consequente restrição da excursão sistólica dos folhetos mitrais. Esse conjunto de alterações biomecânicas causa insuficiência mitral funcional, um indicador de mau prognóstico. A plastia ou a troca da valva mitral foram introduzidas como alternativas cirúrgicas coadjuvantes ao tratamento clínico convencional e têm se mostrado eficazes em combater os sintomas de insuficiência cardíaca. Resta, todavia, demonstrar, seu benefício sobre o aumento da sobrevida em longo prazo.

Dilated cardiomyopathy is characterized by severe, progressive myocardial dysfunction that is, irreversible. That syndrome leads to cardiac remodeling with augmentation of left ventricle volume and sphericity, dilation of the mitral annulus and dislocation of papillary muscles that pulls up the mitral cords thereby restraining leaflet excursion. These biomechanical modifications generate functional mitral valve regurgitation, a dismal prognostic sign. Mitral valve plasty or replacement was introduced as surgical coadjuvants to conventional medical treatment, with good symptomatic improvement. The long term survival benefit is yet to be demonstrated.

Methylene blue for vasoplegic syndrome treatment in heart surgery: fifteen years of questions, answers, doubts and certainties / Azul de metileno no tratamento da síndrome vasoplégica em cirurgia cardíaca: quinze anos de perguntas, respostas, dúvidas e certezas

OBJECTIVE: There is strong evidence that methylene blue (MB), an inhibitor of guanylate cyclase, is an excellent therapeutic option for vasoplegic syndrome (VS) treatment in heart surgery. The aim of this article is to review the MB's therapeutic function in the vasoplegic syndrome treatment. METHODS: Fifteen years of literature review. RESULTS: 1) Heparin and ACE inhibitors are risk factors; 2) In the recommended doses it is safe (the lethal dose is 40 mg/kg); 3) The use of MB does not cause endothelial dysfunction; 4) The MB effect appears in cases of nitric oxide (NO) up-regulation; 5) MB is not a vasoconstrictor, by blocking of the GMPc system it releases the AMPc system, facilitating the norepinephrine vasoconstrictor effect; 6) The most used dosage is 2 mg/kg as IV bolus followed by the same continuous infusion because plasmatic concentrations strongly decays in the first 40 minutes; 7) There is a possible "window of opportunity" for the MB's effectiveness. CONCLUSIONS: Although there are no definitive multicentric studies, the MB used to treat heart surgery VS, at the present time, is the best, safest and cheapest option, being a Brazilian contribution for the heart surgery

OBJETIVO: Existem fortes evidências de que o azul de metileno (AM), um inibidor da guanilato ciclase, é uma excelente opção terapêutica para o tratamento da síndrome vasoplégica (SV) em cirurgia cardíaca. O objetivo deste artigo é rever o papel terapêutico do AM no tratamento da SV. MÉTODOS: Revisão da literatura em período de 15 anos. RESULTADOS: 1) A heparina e inibidores da ECA são fatores de risco; 2) Nas doses preconizadas é droga segura (a dose letal é de 40 mg/kg); 3) O AM não causa disfunção endotelial; 4) O efeito do AM só aparece em caso de supra-regulação de óxido nítrico (NO); 5) O AM não é um vasoconstritor, pelo bloqueio do sistema GMPc ele "libera" o sistema AMPc, facilitando o efeito vasoconstritor da noradrenalina; 6) A dosagem mais utilizada é 2 mg/kg em bolus endovenosa, seguida de infusão contínua, pois a concentração plasmática decai acentuadamente nos primeiros 40 minutos; 7) Existe possível "janela de oportunidade" para efetividade do AM. CONCLUSÃO: Embora não existam estudos multicêntricos definitivos, a utilização do AM no tratamento da SV em cirurgia cardíaca é, na atualidade, a melhor, mais segura e barata opção, sendo contribuição brasileira

Substituição valvar isolada com próteses metálicas St. Jude Medical em posição aórtica ou mitral: seguimento de médio prazo / Sustitución valvular aislada con prótesis metálicas St. Jude Medical en posición aórtica o mitral: seguimiento de medio plazo / Isolated mitral and aortic valve replacement with the St. Jude Medical valve: a midterm follow-up

FUNDAMENTO: Em nosso meio as próteses valvares biológicas predominam, considerando-se as dificuldades relacionadas à anticoagulação, mesmo em pacientes jovens, a despeito da necessidade de repetidas operações devido à degeneração das próteses biológicas. OBJETIVO: Apresentar a evolução em médio prazo de pacientes submetidos à substituição da valva mitral ou aórtica por prótese valvar mecânica St. Jude. MÉTODOS: Foi analisada retrospectivamente a evolução dos pacientes operados entre janeiro de 1995 e dezembro de 2003 e seguidos até dezembro de 2006. RESULTADOS: Cento e sessenta e oito pacientes receberam prótese valvar mitral e 117, aórtica. A idade média de ambos os grupos foi de 45 anos. Entre os mitrais, 75 por cento tinham até 55 anos e 65 por cento eram mulheres. Entre os aórticos, 66 por cento tinham até 55 anos e 69 por cento eram homens. Considerando-se apenas mortes relacionadas às próteses valvares, a sobrevida foi de 85,6 por cento para os mitrais e de 88,7 por cento para os aórticos (p=0,698). Entre os mitrais, 97 por cento estavam livres de reoperação, e entre os aórticos 99 por cento (p=0,335). Quanto aos eventos tromboembólicos, a porcentagem de pacientes livres foi de 82 por cento entre os mitrais e de 98 por cento entre os aórticos (p=0,049), e para os eventos hemorrágicos foi de 71 por cento e 86 por cento respectivamente (0,579). Quanto à ocorrência de endocardite, 98 por cento entre os mitrais e 99 por cento entre os aórticos estavam livres ao final de 10 anos (p=0,534). CONCLUSÃO: Nossa experiência com próteses metálicas St. Jude em uma população predominantemente jovem confirma o bom desempenho desta prótese, em acordo com outras experiências publicadas.

BACKGROUND: In our country, the biological valvular prostheses predominate, considering the difficulties related to anticoagulation, even in young patients, in spite of the need for repeated operations due to the degeneration of the bioprostheses. OBJECTIVES: To report our consecutive series of recipients of isolated St Jude Medical mechanical valve prosthesis in the mitral (MVR) or aortic (AVR) position. METHODS: Data from patients operated between January 1995 and December 2003 were revised in order to determine patient survival and prosthesis-related events up to December 2006. RESULTS: One hundred sixty eight patients had MVR and 117 had AVR. In the MVR cohort, the mean age was 45 years, 75 percent were 55 years old or younger, and 65 percent were females. In the ARV cohort, the mean age was 45 years, 66 percent were 55 years old or younger and 69 percent were males. Operative mortality for AVR and MVR was 7 percent and 7.5 percent, respectively. Freedom from late mortality was 81.8 percent at 10 years for MVR and 83 percent for AVR (p=0.752). Freedom from valve-related death at 10 years for the MVR cohort and AVR was 85.6 percent and 88.7 percent, respectively (p=0.698). In the MVR cohort, the freedom from reoperation was 97 percent and 99 percent in the AVR cohort (p=0.335). Freedom from thromboembolic events was 82 percent in the MVR cohort and 98 percent in the AVR cohort (p=0.049). Freedom from bleeding was 71 percent in the MVR cohort and 86 percent n the AVR cohort (0.579). Freedom from endocarditis was 98 percent in the MVR cohort and 99 percent in the AVR cohort (p=0.534). CONCLUSIONS: This series of predominantly young adult patients undergoing isolated MVR and AVR with the St Jude Medical mechanical prosthesis confirms the good performance of this valve prosthesis in agreement with previous reports.

FUNDAMENTO: En nuestro medio, las prótesis valvulares biológicas predominan, teniendo en cuenta las dificultades relacionadas a la anticoagulación, incluso en pacientes jóvenes, pese a la necesidad de repetidas operaciones debido a la degeneración de las prótesis biológicas. OBJETIVO: Presentar la evolución en medio plazo de pacientes sometidos a la sustitución de la válvula mitral o aórtica por prótesis valvular mecánica St. Jude. MÉTODOS: Se analizó retrospectivamente la evolución de los pacientes operados entre enero de 1995 y diciembre de 2003 y seguidos hasta diciembre de 2006. RESULTADOS: Un total de 168 pacientes recibió prótesis valvular mitral y otros 117, aórtica. La edad promedio de ambos grupos fue de 45 años. Entre los mitrales, el 75 por ciento tenía hasta 55 años y el 65 por ciento era mujeres. Entre los aórticos, el 66 por ciento tenía hasta 55 años y el 69 por ciento era de varones. Teniendo en cuenta solamente las muertes relacionadas a las prótesis valvulares, la sobrevida fue del 85,6 por ciento para los mitrales y del 88,7 por ciento para los aórticos (p=0.698). Entre los mitrales, el 97 por ciento estaba libre de reoperación, y entre los aórticos el 99 por ciento (p=0,335) lo estaba. En cuanto a los eventos tromboembólicos, el porcentaje de pacientes libres fue del 82 por ciento entre los mitrales y del 98 por ciento entre los aórticos (p=0,049), y para los eventos hemorrágicos fue del 71 por ciento y el 86 por ciento respectivamente (0,579). En cuanto a la ocurrencia de endocarditis, el 98 por ciento entre los mitrales y el 99 por ciento entre los aórticos estaba libre al final de 10 años (p=0.534). CONCLUSIÓN: Nuestra experiencia con prótesis metálicas St. Jude en una población predominantemente joven confirma el buen desempeño de esta prótesis, según otras experiencias publicadas.

Bloqueio atrioventricular e endocardite infecciosa em prótese valvar / Atrioventricular block and infectious endocarditis in valve prosthesis

A endocarditre infecciosa é uma infecção grave, rara e pouco diagnosticada. O presente relato de caso visa chamar a atenção para o diagnóstico de endocardite infecciosa complicada, na presença de distúrbios de condução atrioventricular. Trata-se de um paciente do sexo masculino, 68 anos, portador de prótese valvar aórtica biológica, há 5 anos, atendido na sala de emergência de hospital terciário, com quadro de tosse com expectoração clara, dispnéia em repouso (há 3 meses) e febre (há 01 dia). Eletrocardiograma com bloqueio atrioventricular total e ecocardiograma transesofágico, com vegetações nos folhetos da prótese biológica aórtica, abscesso e insuficiência perivalvares.

Risk factors for acute renal failure after heart surgery.

OBJECTIVE: The aim of the present study was to identify risk factors for acute renal failure in patients with normal levels of serum creatinine who had undergone coronary artery bypass graft (CABG) surgery and/or valve surgery. METHODS: Data from a cohort of 769 patients were assessed using bivariate analyses and binary logistic regression modeling. RESULTS: Three hundred eighty one patients underwent CABG, 339 valve surgery and 49 had undergone both simultaneously. Forty six percent of the patients were female and the mean age was 57 +/- 14 years (13 to 89 years). Seventy eight (10%) patients presented renal dysfunction postoperatively, of these 23% needed hemodialysis (2.4% of all patients). The mortality for the whole cohort was 10%. The overall mortality for patients experiencing postoperative renal dysfunction was 40% (versus 7%, P < 0.001), 29% for those who did not need dialysis and 67% for those who needed dialysis (P = 0.004). The independent risk factors found were: age (P < 0.000, OR: 1.056), congestive heart failure (P = 0.091, OR: 2.238), COPD (P = 0.003, OR: 4.111), endocarditis (P = 0.001, OR: 12.140), myocardial infarction < 30 days (P = 0.015, OR: 4.205), valve surgery (P = 0.016, OR: 2.137), cardiopulmonary bypass time > 120 min (P = 0.001, OR: 7.040), peripheral arterial vascular disease (P = 0.107, 2.296). CONCLUSION: Renal dysfunction was the most frequent postoperative organ dysfunction in patients undergone CABG and/or valve surgery and age, congestive heart failure, COPD, endocarditis, myocardial infarction < 30 days, valve surgery, cardiopulmonary bypass time >120 min, and peripheral arterial vascular disease were the risk factors independently associated with acute renal failure (ARF).

Mitral insufficiency surgery to treat advanced heart failure.

Dilated cardiomyopathy is characterized by severe, progressive myocardial dysfunction that is, irreversible. That syndrome leads to cardiac remodeling with augmentation of left ventricle volume and sphericity, dilation of the mitral annulus and dislocation of papillary muscles that pulls up the mitral cords thereby restraining leaflet excursion. These biomechanical modifications generate functional mitral valve regurgitation, a dismal prognostic sign. Mitral valve plasty or replacement was introduced as surgical coadjuvants to conventional medical treatment, with good symptomatic improvement. The long term survival benefit is yet to be demonstrated.

Fatores de risco em septuagenários ou mais idosos submetidos à revascularização do miocárdio e ou operações valvares / Risk factors in septuagenarians or elderly patients undergone coronary artery bypass grafting and or valves operations

OBJETIVO: Pacientes septuagenários ou mais idosos necessitando de cirurgia cardíaca vêm crescendo em todo mundo. O objetivo do estudo é conhecer melhor esse grupo de pacientes e determinar fatores de risco para morbidade operatória. MÉTODOS: Revisamos 783 pacientes submetidos a operações cardíacas valvares e de revascularização do miocárdio isoladas ou associadas no período de 2002 a 2007. Tais pacientes foram divididos em "grupo <70 anos de idade" e "grupo >70 anos de idade". RESULTADOS: Cento e noventa e sete pacientes tinham 70 anos ou mais de idade (idade média 74,1 ± 3,9) e 61 por cento eram do sexo masculino. No grupo > 70 anos, foi significativamente maior o número de pacientes portadores de doença vascular periférica (9 por cento versus 5 por cento, P= 0,019), doença carotídea (5 por cento versus 2 por cento, P= 0,026) e angina instável (17 por cento versus 9 por cento, P= 0,018). Em ambos os grupos, a revascularização do miocárdio foi mais freqüente. No grupo > 70 anos, 41 por cento dos pacientes tiveram ao menos um efeito adverso, versus 22 por cento do grupo <70 anos (P<0,001). Aincidência de sangramento pós-operatório, complicações pulmonares, mediastinite, necessidade de vasopressores, disfunção renal e acidente vascular cerebral foi significativamente maior no grupo > 70 anos. A mortalidade foi maior no grupo > 70 anos (19 por cento versus 8,5 por cento, P<0,001). A regressão logística revelou que DPOC (OR: 8,6), FE (OR: 7,1), operação não eletiva (OR: 17,2) e tempo de circulação extracorpórea > 120 min (OR: 3,4) são preditores de mortalidade hospitalar no grupo estudado. CONCLUSÕES: A mortalidade hospitalar em septuagenários ou mais idosos nas operações de revascularização miocárdica e valvares isoladas ou associadas é maior que nos pacientes mais jovens.

OBJECTIVES: Septuagenarians or older patients needing heart surgery has increased in whole world. The objective of study is to know the characteristics of this group of patients and determine the risk factors for operative morbidity. METHODS: We revised the medical records of 783 patients undergone heart valve surgery, myocardial revascularization or both between 2002 and 2007. The patients were divided in "control group" (<70 years) "septuagenarian group" (70 years old or more). RESULTS: One hundred ninety seven patients were at least 70 years old (mean age 74.1±3.9) and 61 percent were male. In the control group the mean age was 52.1±11.7 and 54 percent were male. In the septuagenarians group it was significantly higher the proportion of patients suffering from peripheral vascular disease (9 percent versus 5 percent, P=0.019), carotid artery obstruction (5 percent versus 2 percent, P=0.026), unstable angina (17 percent versus 9 percent, P=0.018). In both groups coronary artery bypass surgery prevailed. In the septuagenarian group 41 percent of the patients had a least one morbid event, versus 22 percent of the patients in the control group (P<0.001). Postoperative bleeding, pulmonary complications, mediastinitis, need of vasopressors, renal dysfunction and strokes were significantly higher in the septuagenarian group. The mortality was higher in the septuagenarian (19 percent versus 8.5 percent, P<0.001). The logistic regression revealed that COPD (OR: 8.6), EF < 35 percent (OR: 7,1), non-elective operation (OR: 17,2) and cardiopulmonary bypass time >120 min (OR: 3,4) were predictive of hospital mortality in septuagenarian or older patients. CONCLUSIONS: The hospital mortality of septuagenarians or elderly is significantly higher than younger patients.

Risk factors in septuagenarians or elderly patients undergone coronary artery bypass grafting and or valves operations.

OBJECTIVES: Septuagenarians or older patients needing heart surgery has increased in whole world. The objective of study is to know the characteristics of this group of patients and determine the risk factors for operative morbidity. METHODS: We revised the medical records of 783 patients undergone heart valve surgery, myocardial revascularization or both between 2002 and 2007. The patients were divided in 'control group' (<70 years) 'septuagenarian group' (70 years old or more). RESULTS: One hundred ninety seven patients were at least 70 years old (mean age 74.1+/-3.9) and 61% were male. In the control group the mean age was 52.1+/-11.7 and 54% were male. In the septuagenarians group it was significantly higher the proportion of patients suffering from peripheral vascular disease (9% versus 5%, P=0.019), carotid artery obstruction (5% versus 2%, P=0.026), unstable angina (17% versus 9%, P=0.018). In both groups coronary artery bypass surgery prevailed. In the septuagenarian group 41% of the patients had a least one morbid event, versus 22% of the patients in the control group (P<0.001). Postoperative bleeding, pulmonary complications, mediastinitis, need of vasopressors, renal dysfunction and strokes were significantly higher in the septuagenarian group. The mortality was higher in the septuagenarian (19% versus 8.5%, P<0.001). The logistic regression revealed that COPD (OR: 8.6), EF < 35% (OR: 7,1), non-elective operation (OR: 17,2) and cardiopulmonary bypass time >120 min (OR: 3,4) were predictive of hospital mortality in septuagenarian or older patients. CONCLUSIONS: The hospital mortality of septuagenarians or elderly is significantly higher than younger patients.