Cardiotoxic Effects Produced by Omeprazole and Methylene Blue in an Animal Model of Cardiac Ischemia and Reperfusion and Potential Implications for the Pharmacological Strategy for Vasoplegic Syndrome.

Defined as systemic hypotension caused by intense vasodilation due to the loss of systemic vascular resistance, vasoplegic syndrome (VS) is associated with elevated morbidity and mortality in humans. Although vasopressors such as norepinephrine and vasopressin are the first-choice drugs for VS treatment, several other drugs such as methylene blue (MB) can be used as adjuvant therapy including rescue therapy. To develop new pharmacological strategies to reduce the risk of VS, we investigated the effects of treatments with MB (2 mg/kg/IV), omeprazole (OME, 10 mg/kg/IV), and their combination in an animal model of cardiac ischemia-reperfusion (CIR). The ventricular arrhythmia (VA), atrioventricular block (AVB), and lethality (LET) incidence rates caused by CIR (evaluated via ECG) and serum levels of the cardiac lesion biomarkers creatine kinase-MB (CK-MB) and troponin I (TnI) in adult rats pretreated with saline solution 0.9% and submitted to CIR (SS + CIR group) were compared to those pretreated with MB (MB + CIR group), OME (OME + CIR group), or the MB + OME combination (MB + OME + CIR group). The AVB and LET incidence rates in the MB + CIR (100%), OME + CIR (100%), and MB + OME + CIR (100%) groups were significantly higher compared to the SS + CIR group (60%). The serum level of CK-MB in these groups were also significantly higher compared to the SS + CIR group, demonstrating that the treatments before CIR with MB, OME, and MB + OME produced similar effects in relation to cardiac function and the occurrence of lesions. These results demonstrate that the treatment of animals subjected to the CIR protocol with OME produced the same effects promoted by the treatment with MB, which may suggest the possibility of using OME alone or in combination with MB in medical clinics in treatment of VS.

Early Six-Minute Walk Test May Predict Midterm Outcomes Following Coronary Artery Bypass Grafting.

OBJECTIVE: This study aims to investigate the ability of the six-minute walk distance (6MWD) as a prognostic marker for midterm clinical outcomes three months after coronary artery bypass grafting (CABG), to identify possible predictors of fall in 6MWD in the early postoperative period, and to establish the percentage fall in early postoperative 6MWD, considering the preoperative baseline as 100%. METHODS: A prospective cohort of patients undergoing elective CABG were included. The percentage fall in 6MWD was assessed by the difference between preoperative and postoperative day (POD) five. Clinical outcomes were evaluated three months after hospital discharge. RESULTS: There was a significant decrease in 6MWD on POD5 compared with preoperative baseline values (percentage fall of 32.5±16.5%, P<0.0001). Linear regression analysis showed an independent association of the percentage fall of 6MWD with cardiopulmonary bypass (CPB) and preoperative inspiratory muscle strength. Receiver operating characteristic curve analysis revealed that the best cutoff value of percentage fall in 6MWD to predict poorer clinical outcomes at three months was 34.6% (area under the curve = 0.82, sensitivity = 78.95%, specificity = 76.19%, P=0.0001). CONCLUSION: This study indicates that a cutoff value of 34.6% in percentage fall of 6MWD on POD5 was able to predict poorer clinical outcomes at three months of follow-up after CABG. Use of CPB and preoperative inspiratory muscle strength were independent predictors of percentage fall of 6MWD in the postoperative period. These findings further support the clinical application of 6MWD and propose an inpatient preventive strategy to guide clinical management over time.

Early Six-Minute Walk Test May Predict Midterm Outcomes Following Coronary Artery Bypass Grafting

ABSTRACT Objective: This study aims to investigate the ability of the six-minute walk distance (6MWD) as a prognostic marker for midterm clinical outcomes three months after coronary artery bypass grafting (CABG), to identify possible predictors of fall in 6MWD in the early postoperative period, and to establish the percentage fall in early postoperative 6MWD, considering the preoperative baseline as 100%. Methods: A prospective cohort of patients undergoing elective CABG were included. The percentage fall in 6MWD was assessed by the difference between preoperative and postoperative day (POD) five. Clinical outcomes were evaluated three months after hospital discharge. Results: There was a significant decrease in 6MWD on POD5 compared with preoperative baseline values (percentage fall of 32.5±16.5%, P<0.0001). Linear regression analysis showed an independent association of the percentage fall of 6MWD with cardiopulmonary bypass (CPB) and preoperative inspiratory muscle strength. Receiver operating characteristic curve analysis revealed that the best cutoff value of percentage fall in 6MWD to predict poorer clinical outcomes at three months was 34.6% (area under the curve = 0.82, sensitivity = 78.95%, specificity = 76.19%, P=0.0001). Conclusion: This study indicates that a cutoff value of 34.6% in percentage fall of 6MWD on POD5 was able to predict poorer clinical outcomes at three months of follow-up after CABG. Use of CPB and preoperative inspiratory muscle strength were independent predictors of percentage fall of 6MWD in the postoperative period. These findings further support the clinical application of 6MWD and propose an inpatient preventive strategy to guide clinical management over time.

Most deaths in low-risk cardiac surgery could be avoidable.

It is observed that death rates in cardiac surgery has decreased, however, root causes that behave like triggers of potentially avoidable deaths (AD), especially in low-risk patients (less bias) are often unknown and underexplored, Phase of Care Mortality Analysis (POCMA) can be a valuable tool to identify seminal events (SE), providing valuable information where it is possible to make improvements in the quality and safety of future procedures. Our results show that in São Paul State, only one third of AD in low-risk cardiac surgery was related to specific surgical problems. After a revisited analysis, 75% of deaths could have been avoided, which in the pre-operative phase, the SE was related judgment, patient evaluation and preparation. In the intra-operative phase, most occurrences could have been avoided if other surgical technique had been used. Sepsis was responsible for 75% of AD in the intensive care unit. In the ward phase, the recognition/management of clinical decompensations and sepsis were the contributing factors. Logistic regression model identified age, previous coronary stent implantation, coronary artery bypass grafting + heart valve surgery, ≥ 2 combined heart valve surgery and hospital-acquired infection as independent predictors of AD.

Validation and quality measurements for STS, EuroSCORE II and a regional risk model in Brazilian patients.

OBJECTIVES: The objectives of this study were to describe a novel statewide registry for cardiac surgery in Brazil (REPLICCAR), to compare a regional risk model (SPScore) with EuroSCORE II and STS, and to understand where quality improvement and safety initiatives can be implemented. METHODS: A total of 11 sites in the state of São Paulo, Brazil, formed an online registry platform to capture information on risk factors and outcomes after cardiac surgery procedures for all consecutive patients. EuroSCORE II and STS values were calculated for each patient. An SPScore model was designed and compared with EuroSCORE II and STS to predict 30-day outcomes: death, reoperation, readmission, and any morbidity. RESULTS: A total of 5222 patients were enrolled in this study between November 2013 and December 2017. The observed 30-day mortality rate was 7.6%. Most patients were older, overweight, and classified as New York Heart Association (NYHA) functional class III; 14.5% of the patient population had a positive diagnosis of rheumatic heart disease, 10.9% had insulin-dependent diabetes, and 19 individuals had a positive diagnosis of Chagas disease. When evaluating the prediction performance, we found that SPScore outperformed EuroSCORE II and STS in the prediction of mortality (0.90 vs. 0.76 and 0.77), reoperation (0.84 vs. 0.60 and 0.56), readmission (0.84 vs. 0.55 and 0.51), and any morbidity (0.80 vs. 0.65 and 0.64), respectively (p<0.001). CONCLUSIONS: The REPLICCAR registry might stimulate the creation of other cardiac surgery registries in developing countries, ultimately improving the regional quality of care provided to patients.

Pharmacological modulation of b-adrenoceptors as a new cardioprotective strategy for therapy of myocardial dysfunction induced by ischemia and reperfusion.

PURPOSE: To evaluate the cardioprotective response of the pharmacological modulation of ß-adrenergic receptors (ß-AR) in animal model of cardiac ischemia and reperfusion (CIR), in spontaneously hypertensive (SHR) and normotensive (NWR) rats. METHODS: CIR was induced by the occlusion of left anterior descendent coronary artery (10 min) and reperfusion (75 min). The SHR was treated with ß-AR antagonist atenolol (AT, 10 mg/kg, IV) 5 min before CIR, and NWR were treated with ß-AR agonist isoproterenol (ISO, 0.5 mg/kg, IV) 5 min before CIR. RESULTS: The treatment with AT increased the incidence of VA, AVB and LET in SHR, suggesting that spontaneous cardioprotection in hypertensive animals was abolished by blockade of ß-AR. In contrast, the treatment with ISO significantly reduced the incidence of ventricular arrhythmia, atrioventricular blockade and lethality in NWR (30%, 20% and 20%, respectively), suggesting that the activation of ß-AR stimulate cardioprotection in normotensive animals. Serum CK-MB were higher in SHR/CIR and NWR/CIR compared to respective SHAM group (not altered by treatment with AT or ISO). CONCLUSION: The pharmacological modulation of ß-AR could be a new cardioprotective strategy for the therapy of myocardial dysfunctions induced by CIR related to cardiac surgery and cardiovascular diseases.

Oxygen uptake on-kinetics during six-minute walk test predicts short-term outcomes after off-pump coronary artery bypass surgery.

PURPOSE: We aimed to investigate the ability of oxygen uptake kinetics to predict short-term outcomes after off-pump coronary artery bypass grafting. METHODS: Fifty-two patients aged 60.9 ± 7.8 years waiting for off-pump coronary artery bypass surgery were evaluated. The 6-min walk test distance was performed pre-operatively, while simultaneously using a portable cardiopulmonary testing device. The transition of oxygen uptake kinetics from rest to exercise was recorded to calculate oxygen uptake kinetics fitting a monoexponential regression model. Oxygen uptake at steady state, constant time, and mean response time corrected by work rate were analysed. Short-term clinical outcomes were evaluated during the early post-operative of off-pump coronary artery bypass surgery. RESULTS: Multivariate analysis showed body mass index, surgery time, and mean response time corrected by work rate as independent predictors for short-term outcomes. The optimal mean response time corrected by work rate cut-off to estimate short-term clinical outcomes was 1.51 × 10-3 min2/ml. Patients with slower mean response time corrected by work rate demonstrated higher rates of hypertension, diabetes, EuroSCOREII, left ventricular dysfunction, and impaired 6-min walk test parameters. The per cent-predicted distance threshold of 66% in the pre-operative was associated with delayed oxygen uptake kinetics. CONCLUSIONS: Pre-operative oxygen uptake kinetics during 6-min walk test predicts short-term clinical outcomes after off-pump coronary artery bypass surgery. From a clinically applicable perspective, a threshold of 66% of pre-operative predicted 6-min walk test distance indicated slower kinetics, which leads to longer intensive care unit and post-surgery hospital length of stay. Implications for rehabilitation Coronary artery bypass grafting is a treatment aimed to improve expectancy of life and prevent disability due to the disease progression; The use of pre-operative submaximal functional capacity test enabled the identification of patients with high risk of complications, where patients with delayed oxygen uptake kinetics exhibited worse short-term outcomes; Our findings suggest the importance of the rehabilitation in the pre-operative in order to "pre-habilitate" the patients to the surgical procedure; Faster oxygen uptake on-kinetics could be achieved by improving the oxidative capacity of muscles and cardiovascular conditioning through rehabilitation, adding better results following cardiac surgery.

Pharmacological modulation of b-adrenoceptors as a new cardioprotective strategy for therapy of myocardial dysfunction induced by ischemia and reperfusion

Abstract Purpose: To evaluate the cardioprotective response of the pharmacological modulation of β-adrenergic receptors (β-AR) in animal model of cardiac ischemia and reperfusion (CIR), in spontaneously hypertensive (SHR) and normotensive (NWR) rats. Methods: CIR was induced by the occlusion of left anterior descendent coronary artery (10 min) and reperfusion (75 min). The SHR was treated with β-AR antagonist atenolol (AT, 10 mg/kg, IV) 5 min before CIR, and NWR were treated with β-AR agonist isoproterenol (ISO, 0.5 mg/kg, IV) 5 min before CIR. Results: The treatment with AT increased the incidence of VA, AVB and LET in SHR, suggesting that spontaneous cardioprotection in hypertensive animals was abolished by blockade of β-AR. In contrast, the treatment with ISO significantly reduced the incidence of ventricular arrhythmia, atrioventricular blockade and lethality in NWR (30%, 20% and 20%, respectively), suggesting that the activation of β-AR stimulate cardioprotection in normotensive animals. Serum CK-MB were higher in SHR/CIR and NWR/CIR compared to respective SHAM group (not altered by treatment with AT or ISO). Conclusion: The pharmacological modulation of β-AR could be a new cardioprotective strategy for the therapy of myocardial dysfunctions induced by CIR related to cardiac surgery and cardiovascular diseases.

Early Open-Lung Ventilation Improves Clinical Outcomes in Patients with Left Cardiac Dysfunction Undergoing Off-Pump Coronary Artery Bypass: a Randomized Controlled Trial.

Objective: To compare pulmonary function, functional capacity and clinical outcomes amongst three groups of patients with left ventricular dysfunction following off-pump coronary artery bypass, namely: 1) conventional mechanical ventilation (CMV); 2) late open lung strategy (L-OLS); and 3) early open lung strategy (E-OLS). Methods: Sixty-one patients were randomized into 3 groups: 1) CMV (n=21); 2) L-OLS (n=20) initiated after intensive care unit arrival; and 3) E-OLS (n=20) initiated after intubation. Spirometry was performed at bedside on preoperative and postoperative days (PODs) 1, 3, and 5. Partial pressure of arterial oxygen (PaO2) and pulmonary shunt fraction were evaluated preoperatively and on POD1. The 6-minute walk test was applied on the day before the operation and on POD5. Results: Both the open lung groups demonstrated higher forced vital capacity and forced expiratory volume in 1 second on PODs 1, 3 and 5 when compared to the CMV group (P<0.05). The 6-minute walk test distance was more preserved, shunt fraction was lower, and PaO2 was higher in both open-lung groups (P<0.05). Open-lung groups had shorter intubation time and hospital stay and also fewer respiratory events (P<0.05). Key measures were significantly more favorable in the E-OLS group compared to the L-OLS group. Conclusion: Both OLSs (L-OLS and E-OLS) were able to promote higher preservation of pulmonary function, greater recovery of functional capacity and better clinical outcomes following off-pump coronary artery bypass when compared to conventional mechanical ventilation. However, in this group of patients with reduced left ventricular function, initiation of the OLS intra-operatively was found to be more beneficial and optimal when compared to OLS initiation after intensive care unit arrival.

Early open-lung ventilation improves clinical outcomes in patients with left cardiac dysfunction undergoing off-pump coronary artery bypass: a randomized controlled trial

Abstract Objective: To compare pulmonary function, functional capacity and clinical outcomes amongst three groups of patients with left ventricular dysfunction following off-pump coronary artery bypass, namely: 1) conventional mechanical ventilation (CMV); 2) late open lung strategy (L-OLS); and 3) early open lung strategy (E-OLS). Methods: Sixty-one patients were randomized into 3 groups: 1) CMV (n=21); 2) L-OLS (n=20) initiated after intensive care unit arrival; and 3) E-OLS (n=20) initiated after intubation. Spirometry was performed at bedside on preoperative and postoperative days (PODs) 1, 3, and 5. Partial pressure of arterial oxygen (PaO2) and pulmonary shunt fraction were evaluated preoperatively and on POD1. The 6-minute walk test was applied on the day before the operation and on POD5. Results: Both the open lung groups demonstrated higher forced vital capacity and forced expiratory volume in 1 second on PODs 1, 3 and 5 when compared to the CMV group (P<0.05). The 6-minute walk test distance was more preserved, shunt fraction was lower, and PaO2 was higher in both open-lung groups (P<0.05). Open-lung groups had shorter intubation time and hospital stay and also fewer respiratory events (P<0.05). Key measures were significantly more favorable in the E-OLS group compared to the L-OLS group. Conclusion: Both OLSs (L-OLS and E-OLS) were able to promote higher preservation of pulmonary function, greater recovery of functional capacity and better clinical outcomes following off-pump coronary artery bypass when compared to conventional mechanical ventilation. However, in this group of patients with reduced left ventricular function, initiation of the OLS intra-operatively was found to be more beneficial and optimal when compared to OLS initiation after intensive care unit arrival.

Papel do suporte circulatório nas síndromes coronarianas aguda / The role of circulatory support in acute coronary syndromes

O tratamento da síndrome coronariana aguda obteve expressiva redução da mortalidade graças ao desenvolvimento de novos fármacos e da angioplastia coronariana primária. Entretanto, apesar desta terapêutica ser eficiente e oferecer resultados adequados no tratamento do infarto agudo do miocárdio (IAM), o choque cardiogênico ainda ocorre em 5 a 10% dos casos e continua a ser a principal causa de mortalidade intra-hospitalar. Portanto, temos um desfecho clínico insatisfatório neste grupo de pacientes com prognóstico reservado a curto e longo prazo. O balão intra-aórtico, embora empregado de forma rotineira no tratamento do choque cardiogênico refratário, apresenta benefícios limitados e não apresenta impacto no prognóstico destes pacientes, como demonstrado em ensaios randomizados recentes. Os sistemas de suporte de vida extracorpóreo (ECLS) são considerados dispositivos eficazes para o tratamento do choque cardiogênico refratário no IAM, uma vez que oferecem fluxo sanguíneo adequado e são instalados rapidamente pela canulação de vasos periféricos. Deste modo, permitem a tomada de decisões médicas para a realização de intervenções diagnósticas e terapêuticas – ponte para decisão – para tratamento da causa clínica e anatômica, com resultados clínicos consistentes e encorajadores para autilização deste tipo de tecnologia...

The treatment of acute coronary syndrome has achieved a significant reduction in mortality, thanks to the development of new drugs and primary coronary angioplasty. However, although this therapy is efficient and offers adequate results in the treatment of acute myocardial infarction (AMI), cardiogenic shock still occurs in 5% to 10% of cases, and continues to be the main cause of intra hospital mortality. Therefore, we have an unsatisfactory clinical outcome in this group of patients, with a reserved prognosis in the short and long terms.The intra-aortic balloon pump, although used routinely in the treatment of refractory cardiogenic shock, has limited benefits and does not have any impact on patient prognosis, as demonstrated in recent randomized trials. Extracorporeal life support systems (ECLS) are considered effective devices for the treatment of refractory cardiogenic shock in AMI, as they offer adequate blood flow and are rapidly installed through cannulation of the peripheral veins. They therefore enable medical decision-making for diagnostic and therapeutic interventions – decision-making bridge – for treatment of the clinical and anatomical cause, with consistent and encouraging clinical results for the use of this type of technology...

Cardiovascular Surgery Residency Program: Training Coronary Anastomosis Using the Arroyo Simulator and UNIFESP Models

ABSTRACT OBJECTIVE: Engage the UNIFESP Cardiovascular Surgery residents in coronary anastomosis, assess their skills and certify results, using the Arroyo Anastomosis Simulator and UNIFESP surgical models. METHODS: First to 6th year residents attended a weekly program of technical training in coronary anastomosis, using 4 simulation models: 1. Arroyo simulator; 2. Dummy with a plastic heart; 3. Dummy with a bovine heart; and 4. Dummy with a beating pig heart. The assessment test was comprised of 10 items, using a scale from 1 to 5 points in each of them, creating a global score of 50 points maximum. RESULTS: The technical performance of the candidate showed improvement in all items, especially manual skill and technical progress, critical sense of the work performed, confidence in the procedure and reduction of the time needed to perform the anastomosis after 12 weeks practice. In response to the multiplicity of factors that currently influence the cardiovascular surgeon training, there have been combined efforts to reform the practices of surgical medical training. CONCLUSION: 1 - The four models of simulators offer a considerable contribution to the field of cardiovascular surgery, improving the skill and dexterity of the surgeon in training. 2 - Residents have shown interest in training and cooperate in the development of innovative procedures for surgical medical training in the art.

Cardiopulmonary bypass increases the risk of vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure / O uso da circulação extracorpórea aumenta o risco de síndrome vasoplégica em pacientes com insuficiência renal crônica hemodialítica submetidos à revascularização cirúrgica do miocárdio

AbstractObjective:Coronary artery bypass grafting is currently the best treatment for dialysis patients with multivessel coronary artery involvement. Vasoplegic syndrome of inflammatory etiology constitutes an important postoperative complication, with highly negative impact on prognosis. Considering that these patients have an intrinsic inflammatory response exacerbation, our goal was to evaluate the incidence and mortality of vasoplegic syndrome after myocardial revascularization in this group.Methods:A retrospective, single-center study of 50 consecutive and non-selected dialysis patients who underwent myocardial revascularization in a tertiary university hospital, from 2007 to 2012. The patients were divided into 2 groups, according to the use of cardiopulmonary bypass or not (off-pump coronary artery bypass). The incidence and mortality of vasoplegic syndrome were analyzed. The subgroup of vasoplegic patients was studied separately.Results:There were no preoperative demographic differences between the cardiopulmonary bypass (n=20) and off-pump coronary artery bypass (n=30) group. Intraoperative data showed a greater number of distal coronary arteries anastomosis (2.8 vs. 1.8, P<0.0001) and higher transfusion rates (65% vs. 23%, P=0.008) in the cardiopulmonary bypass group. Vasoplegia incidence was statistically higher (P=0.0124) in the cardiopulmonary bypass group (30%) compared to the off-pump coronary artery bypass group (3%). Vasoplegia mortality was 50% in the cardiopulmonary bypass group and 0% in the off-pump coronary artery bypass group. The vasoplegic subgroup analysis showed no statistically significant clinical differences.Conclusion:Cardiopulmonary bypass increased the risk for developing postoperative vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure.

ResumoObjetivo:O melhor tratamento atual para os pacientes dialíticos com acometimento coronariano multiarterial é a revascularização cirúrgica do miocárdio. Dentre as complicações pós-operatórias, a síndrome vasoplégica de etiopatogenia inflamatória torna-se importante pelo impacto altamente negativo no prognóstico. Considerando que esses pacientes possuem uma exacerbação intrínseca da resposta inflamatória, nosso objetivo foi avaliar a incidência e a mortalidade da síndrome vasoplégica no pós-operatório de revascularização miocárdica nesse grupo.Métodos:Estudo retrospectivo, unicêntrico, de 50 pacientes dialíticos consecutivos e não selecionados, submetidos à revascularização miocárdica, em um hospital terciário universitário, no período de 2007 a 2012. Esses pacientes foram divididos em 2 grupos, de acordo com o emprego ou não da circulação extracorpórea. A incidência e a mortalidade da vasoplegia foram analisadas nos grupos. Após a identificação dos pacientes quanto à presença de vasoplegia, este subgrupo foi estudado separadamente.Resultados:Não houve diferenças demográficas pré-operatórias entre os grupos com circulação extracorpórea (n=20) e sem circulação extracorpórea (n=30). Dados intraoperatórios demonstraram maior número de artérias coronárias revascularizadas (2,8 vs. 1,8; P<0,0001) e maior necessidade de transfusão (65% vs. 23%; P=0,008) no grupo circulação extracorpórea. A incidência de vasoplegia foi estatisticamente maior (P=0,0124) no grupo circulação extracorpórea (30%) em comparação ao grupo sem circulação extracorpórea (3%). A mortalidade dos pacientes com vasoplegia foi 50% no grupo circulação extracorpórea e 0% no grupo sem circulação extracorpórea. A análise do subgrupo vasoplégico não demonstrou diferenças clínicas estatisticamente significantes.Conclusão:O emprego da circulação extracorpórea na revascularização cirúrgica do miocárdio em pacientes com insuficiência renal crônica dialítica aumentou o risco para desenvolvimento de síndrome vasoplégica pós-operatória.

Cardiopulmonary bypass increases the risk of vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure.

OBJECTIVE: Coronary artery bypass grafting is currently the best treatment for dialysis patients with multivessel coronary artery involvement. Vasoplegic syndrome of inflammatory etiology constitutes an important postoperative complication, with highly negative impact on prognosis. Considering that these patients have an intrinsic inflammatory response exacerbation, our goal was to evaluate the incidence and mortality of vasoplegic syndrome after myocardial revascularization in this group. METHODS: A retrospective, single-center study of 50 consecutive and non-selected dialysis patients who underwent myocardial revascularization in a tertiary university hospital, from 2007 to 2012. The patients were divided into 2 groups, according to the use of cardiopulmonary bypass or not (off-pump coronary artery bypass). The incidence and mortality of vasoplegic syndrome were analyzed. The subgroup of vasoplegic patients was studied separately. RESULTS: There were no preoperative demographic differences between the cardiopulmonary bypass (n=20) and off-pump coronary artery bypass (n=30) group. Intraoperative data showed a greater number of distal coronary arteries anastomosis (2.8 vs. 1.8, P<0.0001) and higher transfusion rates (65% vs. 23%, P=0.008) in the cardiopulmonary bypass group. Vasoplegia incidence was statistically higher (P=0.0124) in the cardiopulmonary bypass group (30%) compared to the off-pump coronary artery bypass group (3%). Vasoplegia mortality was 50% in the cardiopulmonary bypass group and 0% in the off-pump coronary artery bypass group. The vasoplegic subgroup analysis showed no statistically significant clinical differences. CONCLUSION: Cardiopulmonary bypass increased the risk for developing postoperative vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure.

Cardiovascular Surgery Residency Program: Training Coronary Anastomosis Using the Arroyo Simulator and UNIFESP Models.

OBJECTIVE: Engage the UNIFESP Cardiovascular Surgery residents in coronary anastomosis, assess their skills and certify results, using the Arroyo Anastomosis Simulator and UNIFESP surgical models. METHODS: First to 6th year residents attended a weekly program of technical training in coronary anastomosis, using 4 simulation models: 1. Arroyo simulator; 2. Dummy with a plastic heart; 3. Dummy with a bovine heart; and 4. Dummy with a beating pig heart. The assessment test was comprised of 10 items, using a scale from 1 to 5 points in each of them, creating a global score of 50 points maximum. RESULTS: The technical performance of the candidate showed improvement in all items, especially manual skill and technical progress, critical sense of the work performed, confidence in the procedure and reduction of the time needed to perform the anastomosis after 12 weeks practice. In response to the multiplicity of factors that currently influence the cardiovascular surgeon training, there have been combined efforts to reform the practices of surgical medical training. CONCLUSION: 1 - The four models of simulators offer a considerable contribution to the field of cardiovascular surgery, improving the skill and dexterity of the surgeon in training. 2 - Residents have shown interest in training and cooperate in the development of innovative procedures for surgical medical training in the art.

Horizontal right axillary minithoracotomy: aesthetic and effective option for atrial and ventricular septal defect repair in infants and toddlers.

INTRODUCTION: Congenital heart defects treatment shows progressive reduction in morbidity and mortality, however, the scar, resulting from ventricular (VSD) and atrial septal defect (ASD) repair, may cause discomfort. Right axillary minithoracotomy approach, by avoiding the breast growth region, is an option for correction of these defects that may provide better aesthetic results at low cost. Since October 2011, we have been using this technique for repairing VSD and ASD defects as well as associated defects. OBJECTIVES: To evaluate the efficacy of this method in children undergoing correction of VSD and ASD, to compare perioperative clinical outcomes with those repaired by median sternotomy, and to evaluate the aesthetic result. METHODS: Perioperative clinical data of 25 patients submitted to axillary thoracotomy were compared with data from a paired group of 25 patients with similar heart defects repaired by median sternotomy, from October 2011 to August 2012. RESULTS: Axillary approach was possible even in infants. There was no mortality and the main perioperative variables were similar in both groups, except for lower use of blood products in the axillary group (6/25) vs. control (13/25), with statistical difference (P =0.04). The VSD size varied from 7 to 15 mm in axillary group. Cannulation of the aorta and vena cavae was performed through the main incision, whose size ranged from 3 to 5 cm in the axillary group, with excellent aesthetic results. CONCLUSION: The axillary thoracotomy was effective, allowing for a heart defect repair similar to the median sternotomy, with more satisfactory aesthetic results and reduced blood transfusion, and it can be safely used in infants.

Clinical use of the volume-time curve for endotracheal tube cuff management.

BACKGROUND: Previous investigation showed that the volume-time curve technique could be an alternative for endotracheal tube (ETT) cuff management. However, the clinical impact of the volume-time curve application has not been documented. The purpose of this study was to compare the occurrence and intensity of a sore throat, cough, thoracic pain, and pulmonary function between these 2 techniques for ETT cuff management: volume-time curve technique versus minimal occlusive volume (MOV) technique after coronary artery bypass grafting. METHODS: A total of 450 subjects were randomized into 2 groups for cuff management after intubation: MOV group (n = 222) and volume-time curve group (n = 228). We measured cuff pressure before extubation. We performed spirometry 24 h before and after surgery. We graded sore throat and cough according to a 4-point scale at 1, 24, 72, and 120 h after extubation and assessed thoracic pain at 24 h after extubation and quantified the level of pain by a 10-point scale. RESULTS: The volume-time curve group presented significantly lower cuff pressure (30.9 ± 2.8 vs 37.7 ± 3.4 cm H2O), less incidence and intensity of sore throat (1 h, 23.7 vs 51.4%; and 24 h, 18.9 vs 40.5%, P < .001), cough (1 h, 19.3 vs 48.6%; and 24 h, 18.4 vs 42.3%, P < .001), thoracic pain (5.2 ± 1.8 vs 7.1 ± 1.7), better preservation of FVC (49.5 ± 9.9 vs 41.8 ± 12.9%, P = .005), and FEV1 (46.6 ± 1.8 vs 38.6 ± 1.4%, P = .005) compared with the MOV group. CONCLUSIONS: The subjects who received the volume-time curve technique for ETT cuff management presented a significantly lower incidence and severity of sore throat and cough, less thoracic pain, and minimally impaired pulmonary function than those subjects who received the MOV technique during the first 24 h after coronary artery bypass grafting.