Experiência inicial com operações cardíacas minimamente invasivas / Initial experience with minimally invasive cardiac operations

INTRODUÇÃO: Operações cardíacas minimamente invasivas têm sido propostas como uma alternativa para a correção de diversas cardiopatias congênitas e adquiridas, com o intuito de reduzir a morbimortalidade. OBJETIVOS: Descrever a experiência inicial de dois anos com operações cardíacas minimamente invasivas, com ênfase nos aspectos técnicos e na curva de aprendizado. MÉTODOS: Entre julho de 2009 a março de 2012, 95 pacientes foram operados com técnicas minimamente invasivas. A média de idade foi de 55±15 anos e 53% pacientes eram do sexo feminino. As operações foram fechamento de comunicação interatrial (25), substituição valvar aórtica (32), plastia mitral (23), substituição valvar mitral (12), ressecção de mixoma de átrio esquerdo (2) e ressecção de membrana subaórtica (1). A incisão consistiu de minitoracotomia lateral direita em 87 casos e de miniesternotomia em oito. RESULTADOS: A mortalidade imediata foi de 4,2%, e o tamanho médio da incisão foi de 6,3 ± 1,2 cm. A extensão da toracotomia só foi necessária em um caso. Dois pacientes apresentaram acidente vascular cerebral, e a quantidade total de sangramento foi de 470 ± 277 ml. Nenhum paciente teve infecção de ferida operatória, e 67% dos casos não apresentaram morbidade pós-operatória significativa. CONCLUSÕES: Os resultados iniciais com operações minimamente invasivas demonstraram que elas podem ser realizadas de forma segura e com resultados iniciais satisfatórios. O índice de satisfação dos pacientes foi elevado. Uma vez ultrapassada a curva de aprendizado, as operações minimamente invasivas podem ser uma excelente alternativa para muitos pacientes com cardiopatias valvares e congênitas.

BACKGROUND: Minimally invasive cardiovascular operations have been proposed as an alternative method to correct several cardiac congenital and acquired heart diseases, with the aim to reduce morbidity and mortality. OBJECTIVES: Describe the two years initial experience with minimally invasive operations, with emphasis on technical aspects and the learning curve. METHODS: Between July 2009 and March 2012, 95 patients were operated using minimally invasive operations. Mean age was 55 ± 15 years and 53% were females. The operations performed were atrial septal defect closure (25), aortic valve replacement (32), mitral valve repair (23), mitral valve replacement (12), excision of atrial myxoma (2) and resection of subaortic membrane (1). The incision was a mini right thoracotomy in 87 cases and ministernotomy in 8. RESULTS: Early mortality was 4.2%. Mean size of the incision was 6.3 ±1.2 cm. Extension of the original thoracotomy was necessary in only one case. Two patients suffered a stroke, and the mean total blood loss was 470 ± 277 ml. There were no cases of incision infection and 67% the patients had no major morbidity. CONCLUSIONS: Our initial results with minimally invasive operations demonstrated that it was safe and with good clinical results. Patient satisfaction is quite high. After the learning phase has been transversed, minimally invasive operations may be an excellent alternative for many patients with congenital and acquired diseases.

Effect of SDS-based decelullarization in the prevention of calcification in glutaraldehyde-preserved bovine pericardium: study in rats.

OBJECTIVE: The aim of study was to investigate the SDS-based decellularization process as an anticalcification method in glutaraldehyde-preserved bovine pericardium in subcutaneous rat model. METHODS: Pericardium samples with 0.5 cm² area were divide in four groups: group GDA: 0.5% glutaraldehyde-preserved pericardium (GDA); group GDA-GL: GDA + 0.2% glutamic acid (GL); group D-GDA: decellularized (D) pericardium with 0.1% SDS + GDA and group D-GDA-GL: decellularized pericardium + GDA + 0.2% glutamic acid. After this samples were implanted in 18 rats in subcutaneous position till 90 days. Each animal received samples of the four groups. The explants were performed at 45 and 90 days. The explants were subjected to histology in glass slides stained with hematoxilin-eosin and alizarin red, morphometry evaluation and the calcium content was measured by flame atomic absorption spectrometry. RESULTS: The inflammatory infiltrate was the same in all groups, however more intense in GDA and GDA-GL groups in 45 days, increasing at 90 days. The calcium contents for 45 days were: 32.52 ± 3.19 µg/mg in GDA group; 22.12 ± 3.87 µg/ mg in GDA-GL group; 1.06 ± 0.38 µg/mg in D-GDA group and 3.99 ± 5.78 µg/mg in D-GDA-GL (P< 0.001). For 90 days were 65.91 ± 24.67 µg/mg in GDA group; 38.37 ± 13.79 µg/mg in GDA-GL group; 1.24 ± 0.99 µg/mg in D-GDA group and 30.54 ± 8.21 µg/mg in D-GDA-GL (P< 0.001). Only D-GDA did not show increase rates of calcium at 45 to 90 days (P=0.314). CONCLUSION: SDS-based decellularization process reduced the inflammatory intensity and calcification in bovine pericardium in subcutaneous rat model for 90 days.

Aortic valve replacement with the Cardioprotese Premium bovine pericardium bioprosthesis: four-year clinical results.

OBJECTIVES: This study reports the initial clinical and echocardiographic results of the Premium bioprosthetic aortic valve up to 4 years of follow-up. METHODS: Between October 2007 and July 2011, 121 consecutive patients were submitted for aortic valve replacement with the Premium bioprosthetic valve. The mean age was 68 ± 9 years and 64 patients were males. The patients were periodically evaluated by clinical and echocardiographic examinations. The mean follow-up was 21 months (min = 2, max = 48), yielding 217 patients/year for the analysis. RESULTS: The hospital mortality was 8%. Late survival at 3 years was 89% (95% CI: 81.9-93.3%), and 80% of the patients were in NYHA functional class I/II. The rates of valve-related complications were low, with a linearized incidence of 0.9%/100 patients/year for thromboembolic complications, 0% for haemorrhagic events and 0.9%/100 patients/year of bacterial endocarditis. There was no case of primary structural valve dysfunction. The mean effective orifice area was 1.61 ± 0.45 cm(2); mean gradient 13 ± 5 mmHg and peak gradient 22 ± 9 mmHg. Significant patient-prosthesis mismatch was found in only 11% of the cases. CONCLUSIONS: The Premium bioprosthetic aortic valve demonstrated very satisfactory clinical and echocardiographic results up to 4 years, similar to other commercially available, third-generation bioprosthetic valves.

Efeito da descelularização com SDS na prevenção da calcificação em pericárdio bovino fixado em glutaraldeído: estudo em ratos / Effect of SDS-based decelullarization in the prevention of calcification in glutaraldehyde-preserved bovine pericardium: study in rats

OBJETIVO: Avaliar a descelularização com SDS como tratamento anticalcificante em pericárdio bovino fixado em glutaraldeído. MÉTODOS: Peças de 0,5 cm² foram implantadas em modelo subcutâneo de 18 ratos por até 90 dias. Foram formados quatro grupos: grupo GDA: pericárdio fixado em glutaraldeído 0,5% (GDA), grupo GDA-GL: pericárdio fixado em GDA + ácido glutâmico (GL) 0,2%, grupo D-GDA: pericárdio descelularizado (D) com SDS 0,1% e fixado em GDA e grupo D-GDA-GL: pericárdio descelularizado + GDA + ácido glutâmico 0,2%. Cada animal recebeu enxertos dos quatro grupos. Os explantes foram realizados com 45 e 90 dias. As avaliações foram: análise histológica com as colorações hematoxilina-eosina e alizarina-red, análise morfométrica e quantificação de cálcio por espectrometria de absorção atômica. RESULTADOS: O padrão de infiltrado inflamatório foi o mesmo nos quatro grupos, sendo mais intenso nos grupos GDA e GDA-GL aos 45 dias, ficando mais evidente aos 90 dias. O conteúdo de cálcio aos 45 dias foi de 32,52 ± 3,19 µg/ mg no grupo GDA; 22,12 ± 3,87 µg/mg no grupo GDA-GL; 1,06 ± 0,38 µg/mg no grupo D-GDA e 3,99 ± 5,78 µg/mg no grupo D-GDA-GL (P< 0,001). Aos 90 dias, foi de 65,91 ± 24,67 µg/mg no grupo GDA; 38,37 ± 13,79 µg/mg no grupo GDA-GL; 1,24 ± 0,99 µg/mg no grupo D-GDA e 30,54 ± 8,21 µg/mg no grupo D-GDA-GL (P< 0,001). O grupo D-GDA foi o único que não apresentou progressão da calcificação de 45 para 90 dias (P=0,314). CONCLUSÃO: A descelularização com SDS reduziu o processo inflamatório e inibiu a calcificação em pericárdio bovino implantado em modelo subcutâneo de ratos até 90 dias.

OBJECTIVE: The aim of study was to investigate the SDS-based decellularization process as an anticalcification method in glutaraldehyde-preserved bovine pericardium in subcutaneous rat model. METHODS: Pericardium samples with 0.5 cm² area were divide in four groups: group GDA: 0.5% glutaraldehydepreserved pericardium (GDA); group GDA-GL: GDA + 0.2% glutamic acid (GL); group D-GDA: decellularized (D) pericardium with 0.1% SDS + GDA and group D-GDA-GL: decellularized pericardium + GDA + 0.2% glutamic acid. After this samples were implanted in 18 rats in subcutaneous position till 90 days. Each animal received samples of the four groups. The explants were performed at 45 and 90 days. The explants were subjected to histology in glass slides stained with hematoxilin-eosin and alizarin red, morphometry evaluation and the calcium content was measured by flame atomic absorption spectrometry. RESULTS: The inflammatory infiltrate was the same in all groups, however more intense in GDA and GDA-GL groups in 45 days, increasing at 90 days. The calcium contents for 45 days were: 32.52 ± 3.19 µg/mg in GDA group; 22.12 ± 3.87 µg/ mg in GDA-GL group; 1.06 ± 0.38 µg/mg in D-GDA group and 3.99 ± 5.78 µg/mg in D-GDA-GL (P< 0.001). For 90 days were 65.91 ± 24.67 µg/mg in GDA group; 38.37 ± 13.79 µg/mg in GDA-GL group; 1.24 ± 0.99 µg/mg in D-GDA group and 30.54 ± 8.21 µg/mg in D-GDA-GL (P< 0.001). Only D-GDA did not show increase rates of calcium at 45 to 90 days (P=0.314). CONCLUSION: SDS-based decellularization process reduced the inflammatory intensity and calcification in bovine pericardium in subcutaneous rat model for 90 days.

Initial experience with minimally invasive cardiac operations.

BACKGROUND: Minimally invasive cardiovascular operations have been proposed as an alternative method to correct several cardiac congenital and acquired heart diseases, with the aim to reduce morbidity and mortality. OBJECTIVES: Describe the two years initial experience with minimally invasive operations, with emphasis on technical aspects and the learning curve. METHODS: Between July 2009 and March 2012, 95 patients were operated using minimally invasive operations. Mean age was 55 ± 15 years and 53% were females. The operations performed were atrial septal defect closure (25), aortic valve replacement (32), mitral valve repair (23), mitral valve replacement (12), excision of atrial myxoma (2) and resection of subaortic membrane (1). The incision was a mini right thoracotomy in 87 cases and ministernotomy in 8. RESULTS: Early mortality was 4.2%. Mean size of the incision was 6.3 ±1.2 cm. Extension of the original thoracotomy was necessary in only one case. Two patients suffered a stroke, and the mean total blood loss was 470 ± 277 ml. There were no cases of incision infection and 67% the patients had no major morbidity. CONCLUSIONS: Our initial results with minimally invasive operations demonstrated that it was safe and with good clinical results. Patient satisfaction is quite high. After the learning phase has been transversed, minimally invasive operations may be an excellent alternative for many patients with congenital and acquired diseases.

Dez anos de experiência com a substituição da valva aórtica com homoenxertos valvares aórticos implantados pela técnica da substituição total da raiz / Ten years experience of aortic valve replacement with aortic homograft root replacement

OBJETIVO: Avaliar os resultados imediatos e tardios de 10 anos da substituição da valva aórtica por homoenxertos valvares aórticos implantados pela técnica de substituição total da raiz, e identificar eventuais fatores de risco correlacionados com a degeneração tecidual primária dos enxertos. MÉTODO: Entre maio/1995 e janeiro/2006, 282 pacientes com média de idade de 52,8±16,6 anos foram submetidos à substituição da valva aórtica com homoenxertos valvares. As etiologias prevalentes foram a valva aórtica bicúspide calcificada e a degeneração senil em 49 por cento dos casos. Quarenta e sete pacientes eram reoperações e 26 tinham endocardite bacteriana aguda. Procedimentos associados foram realizados em 113 pacientes. O homoenxerto valvar foi implantado pela técnica de substituição total da raiz em todos os casos. O tempo de seguimento pós-operatório variou de 1 a 129 meses (média = 41±25 meses). RESULTADOS: A mortalidade imediata foi de 7 por cento, sendo de apenas 2,6 por cento nos casos de operação eletiva para a substituição isolada da valva aórtica. Dos 262 que receberam alta hospitalar, foi possível obter avaliação clínica e/ou ecocardiograma em 209 deles, sendo 51 (20 por cento) perdidos durante o seguimento. Houve 17 óbitos tardios, entre o 2° e 81° meses de pós-operatório, o que resultou em curva atuarial de sobrevida global de 90 por cento e 80,1 por cento aos 5 e 10 anos de evolução, respectivamente. Foram observados apenas oito episódios tromboembólicos (quatro imediatos e quatro tardios), durante a evolução para uma incidência linearizada de 0,3 por cento/100 pacientes/ano. Endocardite bacteriana ocorreu em três ocasiões (0,4 por cento/100 pacientes/ano). Nove pacientes foram reoperados, dos quais apenas três por problemas no homoenxerto (uma degeneração tecidual e dois casos de endocardite), o que resultou numa probabilidade de 94 por cento livres dessa complicação aos 10 anos de seguimento. A análise do ecocardiograma...

OBJECTIVE: To evaluate the imediate and late results of 10 years of aortic valve root replacement with aortic homografts and to identify possible risk factors related with homograft primary tissue failure. METHODS: Between May 1995 and January 2006, 282 patients with a mean age of 52.8±16.6 years were submitted to aortic valve root replacement with an aortic homografts. The most prevalent etiologies were calcified bicuspid aortic valves and senile degeneration, corresponding to 49 percent of the cases. Forty-seven patients were reoperations and acute bacterial endocarditis were present in 26. Associated procedures were necessary in 113 patients. The homograft was implanted as a root replacement in all. Follow-up time varied between 1 and 129 months (mean= 41±25 months). RESULTS: Early overall mortality was 7 percent, with only 2.6 percent for cases of aortic valve replacement in isolation. Of the 262 patients discharged from hospital, it was possible to obtain clinical and echocardiographic evaluations in 209. Fifty-one patients (20 percent) were lost in the follow-up. There were 17 late deaths between the 2nd and 81st postoperative months, which resulted in an actuarial survival rate of 90 percent and 80.1 percent at 5 and 10 years respectively. There were eight thromboembolic events (four early and four late), for a linearized incidence of 0.3 percent events/100 patients/year. Bacterial endocarditis occurred in three occasions (0.4 percent/100 patients/year). Nine patients were re-operated, of which only three were related to the homograft (one case of primary tissue failure and two of bacterial endocarditis), corresponding to a probability of 94 percent of the patients free from this complication at 10 years of follow-up. Late echocardiographic analysis demonstrated maximum gradients varying between 3 and 47 mmHg (mean= 14.5 mmHg), with only two patients having a maximum gradient greater than 40 mmHg. Moderate valvar...