Immediate Results after Multiple Arterial Grafts in Coronary Artery Bypass Graft Surgery in the São Paulo State: Cross Cohort Study. / Resultados Imediatos após Múltiplos Enxertos Arteriais em Cirurgia de Revascularização Miocárdica no Estado de São Paulo: Estudo de Coorte.

BACKGROUND: The short-term results after using arterial grafts still raise questions and doubts for medical society. OBJECTIVE: To compare the immediate outcomes of patients undergoing single arterial graft versus multiple arterial grafts coronary artery bypass grafting surgery. METHODS: Cross-sectional cohort study in the São Paulo Registry of Cardiovascular Surgery II (REPLICCAR II). Perioperative data from 3122 patients were grouped by the number of arterial grafts used, and their outcomes were compared: reoperation, deep sternal wound infection (DSWI), stroke, acute kidney injury, prolonged intubation (>24 hours), short hospital stay (<6 days), prolonged hospital stay (>14 days), morbidity and mortality. Propensity Score Matching (PSM) matched 1062 patients, adjusted for the mortality risk. RESULTS: After PSM, the single arterial graft group showed patients with advanced age, more former smokers, hypertension, diabetes, stable angina, and previous myocardial infarction. In the multiple arterial grafts, there was a predominance of males, recent pneumonia, and urgent surgeries. After the procedure, there was a higher incidence of pleural effusion (p=0.042), pneumonia (p=0.01), reintubation (p=0.006), DSWI (p=0.007), and sternal debridement (p=0.015) in the multiple arterial grafts group, however, less need for blood transfusion (p=0.005), extremity infections (p=0.002) and shorter hospital stays (p=0.036). Bilateral use of the internal thoracic artery was not related to increased DSWI rate, but glycosylated hemoglobin >6.40% (p=0.048). CONCLUSION: Patients undergoing the multiarterial technique had a higher incidence of pulmonary complications, and DSWI, where glycosylated hemoglobin ≥6.40%, had a greater influence on the infectious outcome than the choice of grafts.

FUNDAMENTO: Os resultados a curto prazo após o uso de enxertos arteriais ainda suscitam questionamentos e dúvidas na sociedade médica. OBJETIVO: Comparar os resultados imediatos de pacientes submetidos à cirurgia de revascularização do miocárdio com enxerto arterial único versus enxertos arteriais múltiplos. MÉTODOS: Estudo de coorte transversal no Registro Paulista de Cirurgia Cardiovascular II (REPLICCAR II). Os dados perioperatórios de 3122 pacientes foram agrupados pelo número de enxertos arteriais utilizados e seus desfechos foram comparados: reoperação, infecção profunda da ferida torácica (IPFT), acidente vascular cerebral, lesão renal aguda, intubação prolongada (>24 horas), tempo de internação curta (<6 dias), tempo de internação prolongada (>14 dias), morbidade e mortalidade. O Propensity Score Matching (PSM) correspondeu a 1062 pacientes, ajustado para o risco de mortalidade. RESULTADOS: Após PSM, o grupo enxerto arterial único apresentou pacientes com idade avançada, mais ex-fumantes, hipertensos, diabéticos, portadores de angina estável e infarto do miocárdio prévio. Nos enxertos arteriais múltiplos houve predomínio do sexo masculino, pneumonia recente e cirurgias de urgência. Após o procedimento, houve maior incidência de derrame pleural (p=0,042), pneumonia (p=0,01), reintubação (p=0,006), IPFT (p=0,007) e desbridamento esternal (p=0,015) no grupo de enxertos multiarteriais, porém, menor necessidade de hemotransfusão (p=0,005), infecções de extremidades (p=0,002) e menor tempo de internação (p=0,036). O uso bilateral da artéria torácica interna não foi relacionado ao aumento da taxa de IPFT, e sim a hemoglobina glicosilada >6,40% (p=0,048). CONCLUSÃO: Pacientes submetidos a técnica multiarterial apresentaram maior incidência de complicações pulmonares e IPFT, sendo que a hemoglobina glicosilada ≥6,40% teve maior influência no resultado infeccioso do que a escolha dos enxertos.

Resultados Imediatos após Múltiplos Enxertos Arteriais em Cirurgia de Revascularização Miocárdica no Estado de São Paulo: Estudo de Coorte / Immediate Results after Multiple Arterial Grafts in Coronary Artery Bypass Graft Surgery in the São Paulo State: Cross Cohort Study

Resumo Fundamento Os resultados a curto prazo após o uso de enxertos arteriais ainda suscitam questionamentos e dúvidas na sociedade médica. Objetivo Comparar os resultados imediatos de pacientes submetidos à cirurgia de revascularização do miocárdio com enxerto arterial único versus enxertos arteriais múltiplos. Métodos Estudo de coorte transversal no Registro Paulista de Cirurgia Cardiovascular II (REPLICCAR II). Os dados perioperatórios de 3122 pacientes foram agrupados pelo número de enxertos arteriais utilizados e seus desfechos foram comparados: reoperação, infecção profunda da ferida torácica (IPFT), acidente vascular cerebral, lesão renal aguda, intubação prolongada (>24 horas), tempo de internação curta (<6 dias), tempo de internação prolongada (>14 dias), morbidade e mortalidade. O Propensity Score Matching (PSM) correspondeu a 1062 pacientes, ajustado para o risco de mortalidade. Resultados Após PSM, o grupo enxerto arterial único apresentou pacientes com idade avançada, mais ex-fumantes, hipertensos, diabéticos, portadores de angina estável e infarto do miocárdio prévio. Nos enxertos arteriais múltiplos houve predomínio do sexo masculino, pneumonia recente e cirurgias de urgência. Após o procedimento, houve maior incidência de derrame pleural (p=0,042), pneumonia (p=0,01), reintubação (p=0,006), IPFT (p=0,007) e desbridamento esternal (p=0,015) no grupo de enxertos multiarteriais, porém, menor necessidade de hemotransfusão (p=0,005), infecções de extremidades (p=0,002) e menor tempo de internação (p=0,036). O uso bilateral da artéria torácica interna não foi relacionado ao aumento da taxa de IPFT, e sim a hemoglobina glicosilada >6,40% (p=0,048). Conclusão Pacientes submetidos a técnica multiarterial apresentaram maior incidência de complicações pulmonares e IPFT, sendo que a hemoglobina glicosilada ≥6,40% teve maior influência no resultado infeccioso do que a escolha dos enxertos.

Abstract Background The short-term results after using arterial grafts still raise questions and doubts for medical society. Objective To compare the immediate outcomes of patients undergoing single arterial graft versus multiple arterial grafts coronary artery bypass grafting surgery. Methods Cross-sectional cohort study in the São Paulo Registry of Cardiovascular Surgery II (REPLICCAR II). Perioperative data from 3122 patients were grouped by the number of arterial grafts used, and their outcomes were compared: reoperation, deep sternal wound infection (DSWI), stroke, acute kidney injury, prolonged intubation (>24 hours), short hospital stay (<6 days), prolonged hospital stay (>14 days), morbidity and mortality. Propensity Score Matching (PSM) matched 1062 patients, adjusted for the mortality risk. Results After PSM, the single arterial graft group showed patients with advanced age, more former smokers, hypertension, diabetes, stable angina, and previous myocardial infarction. In the multiple arterial grafts, there was a predominance of males, recent pneumonia, and urgent surgeries. After the procedure, there was a higher incidence of pleural effusion (p=0.042), pneumonia (p=0.01), reintubation (p=0.006), DSWI (p=0.007), and sternal debridement (p=0.015) in the multiple arterial grafts group, however, less need for blood transfusion (p=0.005), extremity infections (p=0.002) and shorter hospital stays (p=0.036). Bilateral use of the internal thoracic artery was not related to increased DSWI rate, but glycosylated hemoglobin >6.40% (p=0.048). Conclusion Patients undergoing the multiarterial technique had a higher incidence of pulmonary complications, and DSWI, where glycosylated hemoglobin ≥6.40%, had a greater influence on the infectious outcome than the choice of grafts.

Adherence to the cardiac surgery checklist decreased mortality at a teaching hospital: A retrospective cohort study.

OBJECTIVE: To evaluate the impact of adherence to the cardiac surgical checklist on mortality at the teaching hospital. METHODS: A retrospective cohort study after the implementation of the cardiac surgical safety checklist in a reference hospital in Latin America. All patients undergoing coronary artery bypass surgery and/or heart valve surgery from 2013 to 2019 were analyzed. After the implementation of the project InCor-Checklist "Five steps to safe cardiac surgery" in 2015, the correlation between adherence and completeness of this instrument with surgical mortality was assessed. The EuroSCORE II was used as a reference to assess the risk of expected mortality for patients. Cross-sectional questionnaires were during the implementation of the InCor-Checklist. To perform the correlation, Pearson's coefficient was calculated using R software. RESULTS: Since 2013, data from 8139 patients have been analyzed. The average annual mortality was 5.98%. In 2015, the instrument was used in only 58% of patients; in contrast, it was used in 100% of patients in 2019. There was a decrease in surgical mortality from 8.22% to 3.13% for the same group of procedures. The results indicate that the greater the checklist use, the lower the surgical mortality (r = 88.9%). In addition, the greater the InCor-Checklist completeness, the lower the surgical mortality (r = 94.1%). CONCLUSION: In the formation of the surgical patient safety culture, the implementation and adherence to the InCor-Checklist "Five steps to safe cardiac surgery" was associated with decreased mortality after cardiac surgery.

Adherence to the cardiac surgery checklist decreased mortality at a teaching hospital: A retrospective cohort study

Abstract Objectives To evaluate the impact of adherence to the cardiac surgical checklist on mortality at the teaching hospital. Methods A retrospective cohort study after the implementation of the cardiac surgical safety checklist in a reference hospital in Latin America. All patients undergoing coronary artery bypass surgery and/or heart valve surgery from 2013 to 2019 were analyzed. After the implementation of the project InCor-Checklist "Five steps to safe cardiac surgery" in 2015, the correlation between adherence and completeness of this instrument with surgical mortality was assessed. The EuroSCORE II was used as a reference to assess the risk of expected mortality for patients. Cross-sectional questionnaires were during the implementation of the InCor-Checklist. To perform the correlation, Pearson's coefficient was calculated using R software. Results Since 2013, data from 8139 patients have been analyzed. The average annual mortality was 5.98%. In 2015, the instrument was used in only 58% of patients; in contrast, it was used in 100% of patients in 2019. There was a decrease in surgical mortality from 8.22% to 3.13% for the same group of procedures. The results indicate that the greater the checklist use, the lower the surgical mortality (r = 88.9%). In addition, the greater the InCor-Checklist completeness, the lower the surgical mortality (r = 94.1%). Conclusion In the formation of the surgical patient safety culture, the implementation and adherence to the InCor-Checklist "Five steps to safe cardiac surgery" was associated with decreased mortality after cardiac surgery. HIGHLIGHTS Checklists avoid human errors and are commonly used in high-reliability industries. The "InCor Checklist" was associated with decreased mortality over time. Adherence, completeness, and sustainability within public policies are necessary.

Current Impact of Cardiopulmonary Bypass in Coronary Artery Bypass Grafting in São Paulo State. / Impacto Atual da Circulação Extracorpórea na Cirurgia de Revascularização Miocárdica no Estado de São Paulo.

BACKGROUND: Previous results on the use of cardiopulmonary bypass (CPB) have generated difficulties in choosing the best treatment for each patient undergoing myocardial revascularization surgery (CABG) in the current context. OBJECTIVE: Evaluate the current impact of CPB in CABG in São Paulo State. METHODS: A total of 2905 patients who underwent CABG were consecutively analyzed in 11 São Paulo State centers belonging to the São Paulo Registry of Cardiovascular Surgery (REPLICCAR) I. Perioperative and follow-up data were included online by trained specialists in each hospital. Associations of the perioperative variables with the type of procedure and with the outcomes were analyzed. The study outcomes were morbidity and operative mortality. The expected mortality was calculated using EuroSCORE II (ESII). The values of p <5% were considered significant. RESULTS: There were no significant differences concerning the patients' age between the groups (p=0.081). 72.9% of the patients were males. Of the patients, 542 underwent surgery without CPB (18.7%). Of the preoperative characteristics, patients with previous myocardial infarction (p=0.005) and ventricular dysfunction (p=0.031) underwent surgery with CPB. However, emergency or New York Heart Association (NYHA) class IV patients underwent surgery without CPB (p<0.001). The ESII value was similar in both groups (p=0.427). In CABG without CPB, the radial graft was preferred (p<0.001), and in CABG with CPB the right mammary artery was the preferred one (p<0.001). In the postoperative period, CPB use was associated with reoperation for bleeding (p=0.012). CONCLUSION: Currently in the REPLICCAR, reoperation for bleeding was the only outcome associated with the use of CPB in CABG. (Arq Bras Cardiol. 2020; 115(4):595-601).

FUNDAMENTO: Resultados prévios com o uso de circulação extracorpórea (CEC) geram dificuldades na escolha do melhor tratamento para cada paciente na cirurgia de revascularização miocárdica (CRM) no contexto atual. OBJETIVO: Avaliar o impacto da CEC no cenário atual da CRM no estado de São Paulo. MÉTODOS: Foram analisados 2.905 pacientes submetidos à CRM de forma consecutiva em 11 centros do estado de São Paulo pertencentes ao Registro Paulista de Cirurgia Cardiovascular (REPLICCAR) I. Dados perioperatórios e de seguimento foram colocados via on-line por especialistas treinados e capacitados em cada hospital. Foram analisadas as associações das variáveis perioperatórias com o tipo de procedimento (com ou sem CEC) e com os desfechos. A mortalidade esperada foi calculada por meio do EuroSCORE II (ESII). Os valores de p menores de 5% foram considerados significativos. RESULTADOS: Não houve diferença significativa em relação à idade dos pacientes entre os grupos (p=0,081). Dentre os pacientes, 72,9% eram de sexo masculino; 542 pacientes foram operados sem CEC (18,7%). Das características pré-operatórias, pacientes com infarto agudo do miocárdio (IAM) prévio (p=0,005) e disfunção ventricular (p=0,031) foram operados com CEC; no entanto, pacientes de emergência ou em classe funcional New York Heart Association (NYHA) IV foram operados sem CEC (p<0,001). O valor do ESII foi semelhante para ambos os grupos (p=0,427). Na CRM sem CEC, houve preferência pelo uso do enxerto radial (p<0,001) e com CEC pela artéria mamária direita (p<0,001). No pós-operatório, o uso de CEC esteve associado com reoperação por sangramento (p=0,012). CONCLUSÃO: Atualmente, no REPLICCAR, reoperação por sangramento foi o único desfecho associado ao uso da CEC na CRM. (Arq Bras Cardiol. 2020; 115(4):595-601).

Impacto Atual da Circulação Extracorpórea na Cirurgia de Revascularização Miocárdica no Estado de São Paulo / Current Impact of Cardiopulmonary Bypass in Coronary Artery Bypass Grafting in São Paulo State

Resumo Fundamento Resultados prévios com o uso de circulação extracorpórea (CEC) geram dificuldades na escolha do melhor tratamento para cada paciente na cirurgia de revascularização miocárdica (CRM) no contexto atual. Objetivo Avaliar o impacto da CEC no cenário atual da CRM no estado de São Paulo. Métodos Foram analisados 2.905 pacientes submetidos à CRM de forma consecutiva em 11 centros do estado de São Paulo pertencentes ao Registro Paulista de Cirurgia Cardiovascular (REPLICCAR) I. Dados perioperatórios e de seguimento foram colocados via on-line por especialistas treinados e capacitados em cada hospital. Foram analisadas as associações das variáveis perioperatórias com o tipo de procedimento (com ou sem CEC) e com os desfechos. A mortalidade esperada foi calculada por meio do EuroSCORE II (ESII). Os valores de p menores de 5% foram considerados significativos. Resultados Não houve diferença significativa em relação à idade dos pacientes entre os grupos (p=0,081). Dentre os pacientes, 72,9% eram de sexo masculino; 542 pacientes foram operados sem CEC (18,7%). Das características pré-operatórias, pacientes com infarto agudo do miocárdio (IAM) prévio (p=0,005) e disfunção ventricular (p=0,031) foram operados com CEC; no entanto, pacientes de emergência ou em classe funcional New York Heart Association (NYHA) IV foram operados sem CEC (p<0,001). O valor do ESII foi semelhante para ambos os grupos (p=0,427). Na CRM sem CEC, houve preferência pelo uso do enxerto radial (p<0,001) e com CEC pela artéria mamária direita (p<0,001). No pós-operatório, o uso de CEC esteve associado com reoperação por sangramento (p=0,012). Conclusão Atualmente, no REPLICCAR, reoperação por sangramento foi o único desfecho associado ao uso da CEC na CRM. (Arq Bras Cardiol. 2020; 115(4):595-601)

Abstract Background Previous results on the use of cardiopulmonary bypass (CPB) have generated difficulties in choosing the best treatment for each patient undergoing myocardial revascularization surgery (CABG) in the current context. Objective Evaluate the current impact of CPB in CABG in São Paulo State. Methods A total of 2905 patients who underwent CABG were consecutively analyzed in 11 São Paulo State centers belonging to the São Paulo Registry of Cardiovascular Surgery (REPLICCAR) I. Perioperative and follow-up data were included online by trained specialists in each hospital. Associations of the perioperative variables with the type of procedure and with the outcomes were analyzed. The study outcomes were morbidity and operative mortality. The expected mortality was calculated using EuroSCORE II (ESII). The values of p <5% were considered significant. Results There were no significant differences concerning the patients' age between the groups (p=0.081). 72.9% of the patients were males. Of the patients, 542 underwent surgery without CPB (18.7%). Of the preoperative characteristics, patients with previous myocardial infarction (p=0.005) and ventricular dysfunction (p=0.031) underwent surgery with CPB. However, emergency or New York Heart Association (NYHA) class IV patients underwent surgery without CPB (p<0.001). The ESII value was similar in both groups (p=0.427). In CABG without CPB, the radial graft was preferred (p<0.001), and in CABG with CPB the right mammary artery was the preferred one (p<0.001). In the postoperative period, CPB use was associated with reoperation for bleeding (p=0.012). Conclusion Currently in the REPLICCAR, reoperation for bleeding was the only outcome associated with the use of CPB in CABG. (Arq Bras Cardiol. 2020; 115(4):595-601)

REPLICCAR II Study: Data quality audit in the Paulista Cardiovascular Surgery Registry.

The quality of data in electronic healthcare databases is a critical component when used for research and health practice. The aim of the present study was to assess the data quality in the Paulista Cardiovascular Surgery Registry II (REPLICCAR II) using two different audit methods, direct and indirect. The REPLICCAR II database contains data from 9 hospitals in São Paulo State with over 700 variables for 2229 surgical patients. The data collection was performed in REDCap platform using trained data managers to abstract information. We directly audited a random sample (n = 107) of the data collected after 6 months and indirectly audited the entire sample after 1 year of data collection. The indirect audit was performed using the data management tools in REDCap platform. We computed a modified Aggregate Data Quality Score (ADQ) previously reported by Salati et al. (2015). The agreement between data elements was good for categorical data (Cohen κ = 0.7, 95%CI = 0.59-0.83). For continuous data, the intraclass coefficient (ICC) for only 2 out of 15 continuous variables had an ICC < 0.9. In the indirect audit, 77% of the selected variables (n = 23) had a good ADQ score for completeness and accuracy. Data entry in the REPLICCAR II database proved to be satisfactory and showed competence and reliable data for research in cardiovascular surgery in Brazil.

REPLICCAR II Study: data quality audit in the paulista cardiovascular surgery registry

The quality of data in electronic healthcare databases is a critical component when used for research and health practice. The aim of the present study was to assess the data quality in the Paulista Cardiovascular Surgery Registry II (REPLICCAR II) using two different audit methods, direct and indirect. The REPLICCAR II database contains data from 9 hospitals in São Paulo State with over 700 variables for 2229 surgical patients. The data collection was performed in REDCap platform using trained data managers to abstract information. We directly audited a random sample (n = 107) of the data collected after 6 months and indirectly audited the entire sample after 1 year of data collection. The indirect audit was performed using the data management tools in REDCap platform. We computed a modified Aggregate Data Quality Score (ADQ) previously reported by Salati et al. (2015). The agreement between data elements was good for categorical data (Cohen κ = 0.7, 95%CI = 0.59-0.83). For continuous data, the intraclass coefficient (ICC) for only 2 out of 15 continuous variables had an ICC < 0.9. In the indirect audit, 77% of the selected variables (n = 23) had a good ADQ score for completeness and accuracy. Data entry in the REPLICCAR II database proved to be satisfactory and showed competence and reliable data for research in cardiovascular surgery in Brazil.

Synergistic anti-inflammatory effect: simvastatin and pioglitazone reduce inflammatory markers of plasma and epicardial adipose tissue of coronary patients with metabolic syndrome.

BACKGROUND: The inappropriate secretion of adipocytokines plays a critical role in chronic inflammatory states associated with obesity-linked type 2 diabetes and atherosclerosis. The pleiotropic actions of simvastatin and pioglitazone on epicardial adipose tissue (EAT) are unknown. This study assessed the anti-inflammatory actions of simvastatin and pioglitazone on EAT in patients with coronary artery disease (CAD) and metabolic syndrome (MS). METHODS: A total of 73 patients with multivessel CAD who underwent elective bypass grafting were non-randomly allocated to one of four subgroups: Control (n = 17), simvastatin (20 mg/day, n = 20), pioglitazone (15 mg or 30 mg/day, n = 18), or simvastatin + pioglitazone (20 mg/day + 30 mg/day, respectively, n = 18); 20 valvar patients were also included. EAT samples were obtained during surgery. The infiltration of macrophages and lymphocytes and cytokines secretion were investigated using immunohistochemical staining and compared to plasma inflammatory biomarkers. RESULTS: Simvastatin significantly reduced plasma interleukin-6, leptin, resistin and monocyte chemoattractant protein-1 (p < 0.001 for all); pioglitazone reduced interleukin-6, tumoral necrose factor-alpha, resistin and matrix metalloproteinase-9 (p < 0.001 for all). Simvastatin + pioglitazone treatment further reduced plasmatic variables, including interleukin-6, tumoral necrose factor-alpha, resistin, asymmetric dimethylarginine and metalloproteinase-9 vs. the control group (p < 0.001). Higher plasma adiponectin and lower high sensitivity C-reactive protein concentrations were found simultaneously in the combined treatment group. A positive correlation between the mean percentage systemic and tissue cytokines was observed after treatments. T- and B-lymphocytes and macrophages clusters were observed in the fat fragments of patients treated with simvastatin for the first time. CONCLUSIONS: Pioglitazone, simvastatin or combination treatment substantially reduced EAT and plasma inflammatory markers in CAD and MS patients. These tissue effects may contribute to the control of coronary atherosclerosis progression.

The descending branch of the lateral femoral circumflex artery is a good option in CABG with arterial grafts.

INTRODUCTION: The descending branch of the lateral femoral circumflex artery is an option for coronary artery bypass grafting. OBJECTIVE: To evaluate the early patency and adaptation of lumen diameter using multidetector computed angiotomography. METHODS: Thirty-two patients were selected to undergo coronary artery bypass grafting using the descending branch of the lateral circumflex artery, the internal thoracic artery, and other grafts. Evaluations were carried out through high resolution computed tomography performed on the 7th and 90th postoperative day. Diameters of the descending branch of the lateral circumflex artery and the left internal thoracic artery were measured 3 cm before the distal anastomosis, in the middle portion, and 3 cm after the proximal anastomosis. Diameters were compared using paired t-test (P<0.05). RESULTS: Descending branch of the lateral femoral circumflex artery wDescending branch of the lateral femoral circumflex artery was used in 26 patients, as its use was not viable in six patients (18%). It was used as composite graft in all cases. The anterior descending branch was revascularized by the left internal thoracic artery in all cases. Patency rates of the descending branch of the lateral femoral circumflex artery were 96% and 92%, respectively. No occlusions were observed in the left internal thoracic artery (LITA) and no ischemic events were observed in the descending branch of the lateral circumflex. Descending branch of the lateral femoral circumflex artery increased the lumen diameter in the middle (P=0.001) and distal portions (P=0.006); the left internal thoracic artery (LITA) increased in the middle portion (P=0.001). CONCLUSION: Similar to the left internal thoracic artery, the descending branch of the lateral femoral circumflex artery showed high patency rate and positive luminal adaptation. This early evaluation confirms the descending branch of the lateral femoral circumflex artery as a potential alternative for grafting. Due to anatomical variations, preoperative femoral angiographic evaluation appears to be mandatory.

The descending branch of the lateral femoral circumflex artery is a good option in CABG with arterial grafts / Ramo descendente da artéria circunflexa lateral femoral é boa opção para revascularização do miocárdio com enxertos arteriais

INTRODUCTION: The descending branch of the lateral femoral circumflex artery is an option for coronary artery bypass grafting. OBJECTIVE: To evaluate the early patency and adaptation of lumen diameter using multidetector computed angiotomography. METHODS: Thirty-two patients were selected to undergo coronary artery bypass grafting using the descending branch of the lateral circumflex artery, the internal thoracic artery, and other grafts. Evaluations were carried out through high resolution computed tomography performed on the 7th and 90th postoperative day. Diameters of the descending branch of the lateral circumflex artery and the left internal thoracic artery were measured 3 cm before the distal anastomosis, in the middle portion, and 3 cm after the proximal anastomosis. Diameters were compared using paired t-test (P<0.05). RESULTS: Descending branch of the lateral femoral circumflex artery wDescending branch of the lateral femoral circumflex artery was used in 26 patients, as its use was not viable in six patients (18%). It was used as composite graft in all cases. The anterior descending branch was revascularized by the left internal thoracic artery in all cases. Patency rates of the descending branch of the lateral femoral circumflex artery were 96% and 92%, respectively. No occlusions were observed in the left internal thoracic artery (LITA) and no ischemic events were observed in the descending branch of the lateral circumflex. Descending branch of the lateral femoral circumflex artery increased the lumen diameter in the middle (P=0.001) and distal portions (P=0.006); the left internal thoracic artery (LITA) increased in the middle portion (P=0.001). CONCLUSION: Similar to the left internal thoracic artery, the descending branch of the lateral femoral circumflex artery showed high patency rate and positive luminal adaptation. This early evaluation confirms the descending branch of the lateral femoral circumflex artery as a potential alternative for grafting. Due to anatomical variations, preoperative femoral angiographic evaluation appears to be mandatory.

INTRODUÇÃO: O ramo descendente da artéria circunflexa lateral é um enxerto pouco avaliado e pode ser uma opção para a revascularização do miocárdio. OBJETIVO: Avaliar a perviabilidade e o remodelamento arterial do ramo descendente da artéria circunflexa lateral, em três meses de seguimento, por meio de angiotomografia de artérias coronárias. MÉTODOS: Foram analisados 32 pacientes submetidos à revascularização do miocárdio com ramo descendente da artéria circunflexa lateral, artéria torácica interna esquerda e outros enxertos. A avaliação foi realizada por meio da tomografia computadorizada de alta resolução, realizada no 7º e 90º dias de pós-operatório. O diâmetro do ramo descendente da artéria circunflexa lateral foi medido 3 cm antes da anastomose distal, na porção média e 3 cm após a anastomose proximal. As mesmas medidas foram realizadas para a artéria torácica interna esquerda. Os diâmetros foram comparados pelo método t de Student pareado (significância P<0,05). RESULTADOS: O ramo descendente da artéria circunflexa lateral foi adequado para a utilização em 26 pacientes. Em seis (18%) pacientes, o ramo descendente da artéria circunflexa lateral era inviável. Em todos os casos, o ramo descendente da artéria circunflexa lateral foi empregado sob a forma de enxerto composto. Todos os pacientes receberam artéria torácica interna esquerda para o ramo descendente anterior. A perviabilidade do ramo descendente da artéria circunflexa lateral foi de 96% e 92%, em 7 e 90 dias de pós-operatório, respectivamente. Não foram detectadas oclusões da artéria torácica interna esquerda. Não foram detectados sinais de espasmo do ramo descendente da artéria circunflexa lateral. O ramo descendente da artéria circunflexa lateral apresentou aumento de diâmetro nas porções média (P=0,001) e distal (P=0,006) e a artéria torácica interna esquerda, aumento na porção média (P=0,001). CONCLUSÃO: O remodelamento positivo sugere que o ramo descendente da artéria circunflexa lateral tem comportamento semelhante à artéria torácica interna esquerda e pode ser uma excelente opção para a revascularização do miocárdio com enxertos arteriais. Em virtude das variações anatômicas, estudos de pré-operatório podem auxiliar na seleção de casos.

Outcomes after coronary artery bypass in aged patients.

OBJECTIVES: Analyze the octogenarians patients submitted to the surgical myocardium revascularization (CABG) with and without extracorporeal comparing the clinical outcomes and its survival curves. METHODS: Observational study of the cohort type involving 396 octogenarians submitted to the CABG between 01/01/ 2000 and 01/01/2007. Elaboration of an itinerary for collection of data of the handbooks containing 36 variables. Comparison between groups using t test for independent samples, chisquare and survival curves using Kaplan Meier. RESULTS: We analyzed 290 patients that possessed appropriate information. The first group G1, of the patients operated without extracorporeal, was constituted of 111 patients and the second group G2, of the operated ones with extracorporeal was constituted of 179 patients. The univariate analyzes had presented statistics significance for the variables: cardiac insufficiency functional class preoperative (P=0.000), tobacco smoking (P=0.050), number of performed grafts (P=0.050), graft type (P=0,000), associates procedures (P=0.000), preoperative use of intra-aortic balloon (P=0.000), hospital mortality (P=0.000) and type of death (P=0.020). In the postoperative outcomes stroke (P=0,036), re-internment for angina (P=0,038). The analyze of the survival curves presented statistic difference (P=0,009). CONCLUSIONS: Hospital mortality and stroke were bigger in the G2 In the long time the patients of the G1 had respectively presented greater number of re-internments for angina and the late mortality was larger in G2 for the largest prevalence of cardiac deaths.

Desfechos clínicos pós-revascularização do miocárdio no paciente idoso / Outcomes after coronary artery bypass in aged patients

OBJETIVO: Comparar os desfechos clínicos nos pacientes octogenários submetidos à revascularização cirúrgica do miocárdio com e sem a utilização de circulação extracorpórea. MÉTODOS: Estudo de coorte histórico com pacientes octogenários operados no InCor no período entre 1/1/2000 e 1/1/2007, divididos em dois grupos: G1 constituído por 111 pacientes operados sem circulação extracorpórea (CEC) e G2 com 179 operados com CEC. Foram analisadas 36 variáveis utilizando-se o teste t de Student, qui quadrado e as curvas de sobrevida pelo método de Kaplan-Meier; Nível de significância de 5 por cento. RESULTADOS: Na análise univariada apresentaram significância: insuficiência cardíaca congestiva préoperatória (P=0,000), tabagismo (P=0,050), número de enxertos realizados (P=0,050), tipo de enxerto (P=0,000), procedimentos associados (P=0,000), uso de balão intraaórtico no pós-operatório (P=0,000), óbito hospitalar (P=0,000) e tipo de morte (P=0,020). No pós-operatório imediato, foi significativa apenas a incidência de acidente vascular cerebral (AVC) no G2 (P = 0,036). A longo prazo tivemos maior incidência de reinternação por angina (P=0,038) no G1. A análise das curvas de sobrevida apresentou diferença estatística (P=0,009; Log-Rank Test). CONCLUSÃO: A revascularização do miocárdio sem CEC, nesta série, mostrou ser vantajosa para o paciente octogenário a curto prazo, pois os pacientes apresentaram menor índice de AVC no pós-operatório mediato, enquanto a longo prazo houve maior número de reinternação por angina no G1 e uma mortalidade maior no G2.

OBJECTIVES: Analyze the octogenarians patients submitted to the surgical myocardium revascularization (CABG) with and without extracorporeal comparing the clinical outcomes and its survival curves. METHODS: Observational study of the cohort type involving 396 octogenarians submitted to the CABG between 01/01/ 2000 and 01/01/2007. Elaboration of an itinerary for collection of data of the handbooks containing 36 variables. Comparison between groups using t test for independent samples, chisquare and survival curves using Kaplan Meier. RESULTS: We analyzed 290 patients that possessed appropriate information. The first group G1, of the patients operated without extracorporeal, was constituted of 111 patients and the second group G2, of the operated ones with extracorporeal was constituted of 179 patients. The univariate analyzes had presented statistics significance for the variables: cardiac insufficiency functional class preoperative (P=0.000), tobacco smoking (P=0.050), number of performed grafts (P=0.050), graft type (P=0,000), associates procedures (P=0.000), preoperative use of intra-aortic balloon (P=0.000), hospital mortality (P=0.000) and type of death (P=0.020). In the postoperative outcomes stroke (P=0,036), re-internment for angina (P=0,038). The analyze of the survival curves presented statistic difference (P=0,009). CONCLUSIONS: Hospital mortality and stroke were bigger in the G2 In the long time the patients of the G1 had respectively presented greater number of re-internments for angina and the late mortality was larger in G2 for the largest prevalence of cardiac deaths.

A doença coronária aumenta a mortalidade hospitalar de portadores de estenose aórtica submetidos à substituição valvar? / Does the coronary disease increase the hospital mortality in patients with aortic stenosis undergoing valve replacement?

Objetivos: Com o aumento da expectativa de vida nas últimas décadas, tem-se um aumento concomitante da prevalência da estenose aórtica degenerativa e da doença aterosclerótica arterial coronária. O presente estudo visa avaliar a influência da doença aterosclerótica arterial coronária crítica em pacientes portadores de estenose aórtica submetidos ao implante isolado de prótese valvar ou combinado à revascularização do miocárdio. Métodos: No período de janeiro de 2001 a março de 2006, foram analisados 448 pacientes submetidos ao implante isolado de prótese valvar aórtica (Grupo I) e 167 pacientes submetidos à substituição valvar aórtica combinada à revascularização do miocárdio (Grupo II). As variáveis pré e intra-operatórias eleitas para análise foram: sexo, idade, índice de massa corpórea, acidente vascular cerebral, diabete melito, doença pulmonar obstrutiva crônica, febre reumática, hipertensão arterial sistêmica, endocardite, infarto agudo do miocárdio e tabagismo, fração de ejeção do ventrículo esquerdo, doença aterosclerótica arterial coronária crítica, fibrilação atrial crônica, operação valvar aórtica prévia (conservadora), classe funcional de insuficiência cardíaca congestiva, valor sérico de creatinina, colesterol total, tamanho da prótese utilizada, extensão e número de anastomoses distais da revascularização do miocárdio realizada, tempos de circulação extracorpórea de pinçamento aórtico. No estudo estatístico empregou-se análise univariada multivariada. Resultados: A mortalidade hospitalar foi 14,3 por cento (64 óbitos) no Grupo I, sendo 14,5 por cento (58 óbitos) nos pacientes sem doença aterosclerótica arterial coronária crítica associada (Grupo IB) e 12,8 por cento (6 óbitos) nos que apresentavam essa associação (Grupo IA). A mortalidade hospitalar no Grupo II foi 17,6 por cento (29 óbitos), sendo 16,1 por cento (20 óbitos) nos pacientes submetidos à substituição valvar aórtica combinada à revascularização completa do miocárdio...

Objectives: With the increase in life expectancy occurred in recent decades, it has been noted the concomitant increase in the prevalence of aortic stenosis and degenerative disease of atherosclerotic coronary artery. This study aims to evaluate the influence of atherosclerotic coronary artery disease in patients with critical aortic stenosis undergoing isolated or combined implant valve prosthesis and coronary artery by pass grafting. Methods: In the period of January 2001 to March 2006, there were analyzed 448 patients undergoing isolated implant aortic valve prosthesis (Group I) and 167 patients undergoing aortic valve prosthesis implant combined with coronary artery bypass grafting (Group II). Pre- and intra-operative variables elected for analysis were: age, gender, body mass index, stroke, diabetes mellitus, chronic obstructive pulmonary disease, rheumatic fever, hypertension, endocarditis, acute myocardial infarction, smoking, Fraction of the left ventricular ejection, critical atherosclerotic coronary artery disease, chronic atrial fibrillation, aortic valve operation prior (conservative), functional class of congestive heart failure, value serum creatinine, total cholesterol, size of the prosthesis used, length and number of distal anastomoses held in myocardial revascularization, duration of cardiopulmonary bypass and aortic clamping time. The statistical study employed invariant and multivariate analysis. Results: Hospital mortality was 14.3 percent (64 deaths) in Group I, and 14.5 percent (58 deaths) in patients with atherosclerotic coronary artery disease associated criticism (Group IB) and 12.8 percent (six deaths) in which had this association (Group IA). Hospital mortality in Group II was 17.6 percent (29 deaths), and 16.1 percent (20 deaths) in patients undergoing implantation of prosthetic aortic valve combined to complete myocardial revascularization (Group II) and 20.9 percent (nine deaths) in the myocardial revascularization...

Induction of CRP3/MLP expression during vein arterialization is dependent on stretch rather than shear stress.

AIMS: Cysteine- and glycine-rich protein 3/muscle LIM-domain protein (CRP3/MLP) mediates protein-protein interaction with actin filaments in the heart and is involved in muscle differentiation and vascular remodelling. Here, we assessed the induction of CRP3/MLP expression during arterialization in human and rat veins. METHODS AND RESULTS: Vascular CRP3/MLP expression was mainly observed in arterial samples from both human and rat. Using quantitative real time RT-PCR, we demonstrated that the CRP3/MLP expression was 10 times higher in smooth muscle cells (SMCs) from human mammary artery (h-MA) vs. saphenous vein (h-SV). In endothelial cells (ECs), CRP3/MLP was scarcely detected in either h-MA or h-SV. Using an ex vivo flow through system that mimics arterial condition, we observed induction of CRP3/MLP expression in arterialized h-SV. Interestingly, the upregulation of CRP3/MLP was primarily dependent on stretch stimulus in SMCs, rather than shear stress in ECs. Finally, using a rat vein in vivo arterialization model, early (1-14 days) CRP3/MLP immunostaining was observed predominantly in the inner layer and later (28-90 days) it appeared more scattered in the vessel layers. CONCLUSION: Here we provide evidence that CRP3/MLP is primarily expressed in arterial SMCs and that stretch is the main stimulus for CRP3/MLP induction in veins exposed to arterial haemodynamic conditions.

Does the coronary disease increase the hospital mortality in patients with aortic stenosis undergoing valve replacement?

OBJECTIVES: With the increase in life expectancy occurred in recent decades, it has been noted the concomitant increase in the prevalence of aortic stenosis and degenerative disease of atherosclerotic coronary artery. This study aims to evaluate the influence of atherosclerotic coronary artery disease in patients with critical aortic stenosis undergoing isolated or combined implant valve prosthesis and coronary artery by pass grafting. METHODS: In the period of January 2001 to March 2006, there were analyzed 448 patients undergoing isolated implant aortic valve prosthesis (Group I) and 167 patients undergoing aortic valve prosthesis implant combined with coronary artery bypass grafting (Group II). Pre- and intra-operative variables elected for analysis were: age, gender, body mass index, stroke, diabetes mellitus, chronic obstructive pulmonary disease, rheumatic fever, hypertension, endocarditis, acute myocardial infarction, smoking, Fraction of the left ventricular ejection, critical atherosclerotic coronary artery disease, chronic atrial fibrillation, aortic valve operation prior (conservative), functional class of congestive heart failure, value serum creatinine, total cholesterol, size of the prosthesis used, length and number of distal anastomoses held in myocardial revascularization, duration of cardiopulmonary bypass and aortic clamping time. The statistical study employed invariant and multivariate analysis. RESULTS: Hospital mortality was 14.3% (64 deaths) in Group I, and 14.5% (58 deaths) in patients with atherosclerotic coronary artery disease associated criticism (Group IB) and 12.8% (six deaths) in which had this association (Group IA). Hospital mortality in Group II was 17.6% (29 deaths), and 16.1% (20 deaths) in patients undergoing implantation of prosthetic aortic valve combined to complete myocardial revascularization (Group II) and 20.9% (nine deaths) in the myocardial revascularization with incomplete (Group IIB). CONCLUSIONS: In patients undergoing implant isolated from aortic valve prosthesis, the presence of atherosclerotic coronary artery disease associated critical in at least two arteries, influenced the hospital mortality. In patients undergoing surgical treatment combined the number of coronary arteries with critical atherosclerotic disease and extent of coronary artery bypass grafting (complete or incomplete), did not affect the hospital mortality, but the realization of more than three anastomoses in the distal myocardial revascularization interfered.

Complicações mecânicas do infarto agudo do miocárdio com supradesnivelamento do segmento ST / Mechanical complications of acute ST-segment elevation myocardial infarction

Neste artigo são discutidas as principais complicações mecânicas que podem surgir na evolução pós-infarto agudo do miocárdio, incluindo insuficiência mitral isquêmica, comunicação interventricular, rotura da parede livre do ventrículo e aneurisma de ventrículo esquerdo.

Myocardial revascularization in the elderly patient: with or without cardiopulmonary bypass?

OBJETIVO: Verificar se há vantagem em revascularizar o paciente idoso sem Circulação Extracorpórea (CEC) em relação à utilização da mesma, considerando-se a viabilidade de Revascularização do Miocárdio (RM) completa e a morbi-mortalidade hospitalar. MÉTODO: Estudados prospectivamente 100 pacientes consecutivos, não randomizados, com idade >= 70 anos, submetidos à revascularização primária e isolada do miocárdio entre janeiro e dezembro de 2000. Os pacientes foram divididos em dois grupos, G1 - 50 pacientes operados com CEC e G2 - 50 pacientes operados sem CEC. Utilizou-se teste de análise univariada ö2, por meio do programa SPSS 10.0, com nível de significância de p < 0,05. RESULTADOS: Não houve ocorrência de insuficiência renal ou Infarto Agudo do Miocárdio (IAM) em ambos os grupos; a incidência de insuficiência respiratória foi idêntica nos dois grupos (4 por cento); dois pacientes do G1 tiveram AVC, e 12 apresentaram baixo débito cardíaco, ocorrências não registradas no G2. A necessidade de suporte ventilatório > 24 h não foi significativa entre os grupos. O tempo médio de internação foi 21,8 e 11,7 dias, respectivamente (NS) e a sobrevida após 30 dias foi semelhante nos dois grupos. Oitenta por cento dos pacientes do G1 tiveram mais de duas artérias abordadas, contra apenas 48 por cento do G2 (p < 0,0001). CONCLUSAO: Levando-se em conta apenas o maior número de enxertos nos pacientes do G1, podemos afirmar que a utilização da CEC pode proporcionar uma maior probabilidade de RM completa.