Valvuloplasty Without Prosthetic Ring or Band in Patients with Degenerative Mitral Regurgitation: Long-Term Results and Predictive Factors for Outcomes

Abstract Introduction: Mitral valvuloplasty including ring/band support is widely performed despite potential drawbacks of rings. Unsupported valvuloplasty is performed in only a few centers. This study aimed to report long-term outcomes of patients undergoing unsupported valvuloplasty for degenerative mitral regurgitation (MR) and to identify predictive factors for outcomes. Methods: This is a retrospective cohort including patients undergoing mitral valve repair for degenerative MR from 2000 to 2018. The main techniques were Wooler annuloplasty and quadrangular resection. Kaplan-Meier curves and Cox regression models were used for statistical analysis. Results: One hundred fifty-eight patients were included (median age: 64.0 years). In-hospital mortality was 2.5%. Maximum follow-up was 19.6 years, with a median of 4.7 years (992 patient-years). Overall survival at 5, 10, and 15 years was 91.0% (95% confidence interval [CI]: 85.7-96.3), 87.6% (95% CI: 80.7-94.5), and 78.1% (95% CI: 65.9-90.3), respectively. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was an independent predictor of late death (hazard ratio [HR] 1.42; P=0.016). Freedom from mitral reoperation at 5, 10, and 15 years was 88.1% (95% CI: 82.0-94.2), 82.4% (95% CI: 74.6-90.2), and 75.7% (95% CI: 64.1-87.3), respectively. Left atrial diameter > 56 mm was associated with late reintervention in univariate analysis (HR 1.06; P=0.049). Conclusion: Degenerative MR can be successfully treated with repair techniques without annular support, thus avoiding the technical and logistical drawbacks of ring/band implantation while maintaining good long-term results. EuroSCORE II was a risk factor for late death, and larger left atrium was associated with late reoperation.

Valvuloplasty Without Prosthetic Ring or Band in Patients with Degenerative Mitral Regurgitation: Long-Term Results and Predictive Factors for Outcomes.

INTRODUCTION: Mitral valvuloplasty including ring/band support is widely performed despite potential drawbacks of rings. Unsupported valvuloplasty is performed in only a few centers. This study aimed to report long-term outcomes of patients undergoing unsupported valvuloplasty for degenerative mitral regurgitation (MR) and to identify predictive factors for outcomes. METHODS: This is a retrospective cohort including patients undergoing mitral valve repair for degenerative MR from 2000 to 2018. The main techniques were Wooler annuloplasty and quadrangular resection. Kaplan-Meier curves and Cox regression models were used for statistical analysis. RESULTS: One hundred fifty-eight patients were included (median age: 64.0 years). In-hospital mortality was 2.5%. Maximum followup was 19.6 years, with a median of 4.7 years (992 patient-years). Overall survival at 5, 10, and 15 years was 91.0% (95% confidence interval [CI]: 85.7-96.3), 87.6% (95% CI: 80.7-94.5), and 78.1% (95% CI: 65.9-90.3), respectively. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was an independent predictor of late death (hazard ratio [HR] 1.42; P=0.016). Freedom from mitral reoperation at 5, 10, and 15 years was 88.1% (95% CI: 82.0-94.2), 82.4% (95% CI: 74.6-90.2), and 75.7% (95% CI: 64.1-87.3), respectively. Left atrial diameter > 56 mm was associated with late reintervention in univariate analysis (HR 1.06; P=0.049). CONCLUSION: Degenerative MR can be successfully treated with repair techniques without annular support, thus avoiding the technical and logistical drawbacks of ring/band implantation while maintaining good long-term results. EuroSCORE II was a risk factor for late death, and larger left atrium was associated with late reoperation.

Gene therapy for refractory angina and cell therapy for heart failure: experience of a Brazilian research group.

Cell therapy has shown impressive effects in experimental cardiomyopathy models. To a lesser extent, gene therapy has also been studied. In both cases, translation to clinical therapy has been disappointing. This paper is intended to describe the experience and achievements of a multicenter working group located in Porto Alegre, southern Brazil, in experimental and translational research projects for cell-based and gene therapy methods in the treatment of dilated and ischemic cardiomyopathies. The results of preclinical and clinical studies showed that bone marrow mononuclear stem cells indeed have an effect in improving myocardial perfusion and contractile function, but the overall results are poorly translated to the clinical level. Gene therapy studies with direct myocardial injections of naked VEGF 165 plasmid showed improvement in myocardial perfusion and function in animal models. A randomized clinical trial found that this method is safe and improved myocardial perfusion, but the benefits disappeared after 1 year. An animal experiment associating VEGF 165 with angiopoietin was undertaken in mini pigs to extend the durability of that therapy. In conclusion, our efforts to better understand the mechanisms and functions of gene and cell-based therapies in cardiology resulted in significant findings and propose a future look at cell-free therapeutic approaches.

Direct intramyocardial transthoracic transplantation of bone marrow mononuclear cells for non-ischemic dilated cardiomyopathy: INTRACELL, a prospective randomized controlled trial.

OBJECTIVE: We tested the hypothesis that direct intramyocardial injection of bone marrow mononuclear cells in patients with non-ischemic dilated cardiomyopathy can improve left ventricular function and physical capacity. METHODS: Thirty non-ischemic dilated cardiomyopathy patients with left ventricular ejection fraction <35% were randomized at a 1:2 ratio into two groups, control and treated. The bone marrow mononuclear cells group received 1.06±108 bone marrow mononuclear cells through mini-thoracotomy. There was no intervention in the control group. Assessment was carried out through clinical evaluations as well as a 6-min walk test, nuclear magnectic resonance imaging and echocardiogram. RESULTS: The bone marrow mononuclear cells group showed a trend toward left ventricular ejection fraction improvement, with magnectic resonance imaging - at 3 months, showing an increase from 27.80±6.86% to 30.13±9.06% (P=0.08) and returning to baseline at 9 months (28.78%, P=0.77). Magnectic resonance imaging showed no changes in left ventricular ejection fraction during follow-up of the control group (28.00±4.32%, 27.42±7.41%, and 29.57±4.50%). Echocardiogram showed left ventricular ejection fraction improved in the bone marrow mononuclear cells group at 3 months, 25.09±3.98 to 30.94±9.16 (P=0.01), and one year, 30.07±7.25% (P=0.001). The control group showed no change (26.1±4.4 vs 26.5±4.7 and 30.2±7.39%, P=0.25 and 0.10, respectively). Bone marrow mononuclear cells group showed improvement in New York Heart Association functional class, from 3.40±0.50 to 2.41±0.79 (P=0.002); patients in the control group showed no change (3.37±0.51 to 2.71±0.95; P=0.17). Six-minute walk test improved in the bone marrow mononuclear cells group (348.00±93.51m at baseline to 370.41±91.56m at 12 months, P=0.66) and there was a non-significant decline in the control group (361.25±90.78m to 330.00±123.42m after 12 months, P=0.66). Group comparisons were non-significant. CONCLUSION: The trend of intragroup functional and subjective improvement was not confirmed when compared to the control group. Direct intramyocardial application of bone marrow mononuclear cells in non-ischemic dilated cardiomyopathy was not associated with significant changes in left ventricular function. Differences observed within the bone marrow mononuclear cells group could be due to placebo effect or low statistical power.

Direct intramyocardial transthoracic transplantation of bone marrow mononuclear cells for non-ischemic dilated cardiomyopathy: INTRACELL, a prospective randomized controlled trial / Ensaio clínico prospectivo randomizado sobre terapia com células mononucleares da medula óssea para cardiomiopatia dilatada idiopática: INTRACELL

Objective: We tested the hypothesis that direct intramyocardial injection of bone marrow mononuclear cells in patients with non-ischemic dilated cardiomyopathy can improve left ventricular function and physical capacity. Methods: Thirty non-ischemic dilated cardiomyopathy patients with left ventricular ejection fraction <35% were randomized at a 1:2 ratio into two groups, control and treated. The bone marrow mononuclear cells group received 1.06±108 bone marrow mononuclear cells through mini-thoracotomy. There was no intervention in the control group. Assessment was carried out through clinical evaluations as well as a 6-min walk test, nuclear magnectic resonance imaging and echocardiogram. Results: The bone marrow mononuclear cells group showed a trend toward left ventricular ejection fraction improvement, with magnectic resonance imaging - at 3 months, showing an increase from 27.80±6.86% to 30.13±9.06% (P=0.08) and returning to baseline at 9 months (28.78%, P=0.77). Magnectic resonance imaging showed no changes in left ventricular ejection fraction during follow-up of the control group (28.00±4.32%, 27.42±7.41%, and 29.57±4.50%). Echocardiogram showed left ventricular ejection fraction improved in the bone marrow mononuclear cells group at 3 months, 25.09±3.98 to 30.94±9.16 (P=0.01), and one year, 30.07±7.25% (P=0.001). The control group showed no change (26.1±4.4 vs 26.5±4.7 and 30.2±7.39%, P=0.25 and 0.10, respectively). Bone marrow mononuclear cells group showed improvement in New York Heart Association functional class, from 3.40±0.50 to 2.41±0.79 (P=0.002); patients in the control group showed no change (3.37±0.51 to 2.71±0.95; P=0.17). Six-minute walk test improved in the bone marrow mononuclear cells group (348.00±93.51m at baseline to 370.41±91.56m at 12 months, P=0.66) and there was a non-significant decline in the control group ...

Objetivo: Testamos a hipótese de que a injeção intramiocárdica direta de células mononucleares de medula óssea em pacientes portadores de cardiomiopatia dilatada não-isquêmica pode melhorar a função ventricular e a capacidade física. Métodos: Trinta pacientes com cardiomiopatia dilatada não isquêmica e fração de ejeção 35% foram randomizados na razão 1:2 em grupos controle e tratado. Grupo células mononucleares de medula óssea recebeu 1,06 ± 108 células mononucleares de medula óssea por mini-toracotomia. Grupo controle não recebeu intervenção. Avaliação foi feita clinicamente e por teste de caminhada 6 minutos (T6m), ressonância magnética e ecocardiogramas. Resultados: Grupo células mononucleares de medula óssea mostrou tendência de melhora da Fração de ejeção - ressonância magnética aos 3 meses, 27,80±6,86% para 30,13±9,06% (P=0,08), retornando ao basal aos 9 meses (28,78%, P=0,77). Grupo controle não apresentou variação (28,00±4,32%; 27,42±7,41% e 29,57±4,50%). Ecocardiogramas - fração de ejeção melhorou no grupo células mononucleares de medula óssea aos 3 meses: 25,09±3,98 para 30,94±9,16 (P=0,01) e aos 12 meses (30,07±7,25%, P=0,001), enquanto o controle não variou: 26,1±4,4 vs. 26,5±4,7 e 30,2±7,39%, P=0,25 e 0,10, respectivamente). Células mononucleares de medula óssea melhorou classe funcional New York Heart Association: 3,40±0.50 para 2,41±0,79 (P=0,002); controles não mudaram (3,37±0,51 para 2,71±0,95; P=0,17). T6m melhorou no grupo células mononucleares de medula óssea (348,00±93,51 m inicial para 370,41±91,56 m aos 12 m, P=0,66) e declinou sem significância no ...

Advanced age and incidence of atrial fibrillation in the postoperative period of aortic valve replacement.

OBJECTIVE: This study aims to describe the correlation between age and occurrence of atrial fibrillation after aortic stenosis surgery in the elderly as well as evaluate the influence of atrial fibrillation on the incidence of strokes, hospital length of stay, and hospital mortality. METHODS: Cross-sectional retrospective study of > 70 year-old patients who underwent isolated aortic valve replacement. RESULTS: 348 patients were included in the study (mean age 76.8±4.6 years). Overall, post-operative atrial fibrillation was 32.8% (n=114), but it was higher in patients aged 80 years and older (42.9% versus 28.8% in patients aged 70-79 years, P=0.017). There was borderline significance for linear correlation between age and atrial fibrillation (P=0.055). Intensive Care Unit and hospital lengths of stay were significantly increased in atrial fibrillation (P<0.001), but there was no increase in mortality or stroke associated with atrial fibrillation. CONCLUSION: Post-operative atrial fibrillation incidence in aortic valve replacement is high and correlates with age in patients aged 70 years and older and significantly more pronounced in patients aged 80 years. There was increased length of stay at Intensive Care Unit and hospital, but there was no increase in mortality or stroke. These data are important for planning prophylaxis and early treatment for this subgroup.

Evoluçãode crianças com idade inferior a 2 anos submetidas a implante de marcapasso cardíaco permanente / late results with permanent cardiac pacing in children less than two years of age

A estimulação epicárdica predomina no implante de marcapasso em crianças pequenas. Objetivo: revisar a evolução de pacientes menores de dois anos submetidos a estimulação epimiocárdica após a alta hospitalar e até uma década. Método: Estudo de coorte histórica entre 1997 e 2010 que incluiu 34 pacientes, 22 (64,7%) do sexo feminino e 12 (35,3%) do masculino, com idades variando de 1 dia a 22 meses, submetidos a implante de marcapasso utilizando cabo-eletrodo epimiocárdico sem sutura e gerador unicameral (VVI). A arritmia pre dominante foi o bloqueio atrioventricular (n=30; 88,2%); 29 (85,3%) tinham cardiopatia estrutural e 22 (67,4%) haviam sido previamente submetidos a cirurgia cardíaca. Acompanhados durante um tempo médio de 60,5 meses, tiveram registrados os eventos adversos e calculada a probabilidade de sobrevida conforme Kaplan-Meyer. Resultados: Ocorreram três óbitos (8,8%) por infecção, cirurgia cardíaca ou mal súbito. A mortalidade foi superior naqueles sem cirurgia cardíaca prévia (16,7% versus 4,5%). Ao longo do acompanhamento, cinco pacientes (14,7%) necessitaram de nova intervenção, dois por infecção e três para reimplante de cabo-eletrodo. Um dos pacientes submetidos a nova intervenção por infecção evoluiu para óbito. A probabilidade de sobrevida foi de 93,8% no primeiro ano e 90,3% até 10º ano. A sobrevida livre de eventos adversos foi de 90,8% no primeiro ano, 79,8% do 5º ao 9º e 66,5% no 10º ano. Conclusão: Os resultados evidenciam sobrevida satisfatória das crianças após o implante epicárdico, especialmente aquelas com cirurgia cardíaca prévia. O implante de cabo-eletrodo epimiocárdico merece cuidados adicionais em pacientes com estatura reduzida, malformações cardíacas específicas, acesso dificultado à veia cava superior ou com procedimento cirúrgico associado...

Objective: Epicardial stimulation remains the technique of choice for pacing in small children. Our objective is to review the results of epicardial pacemaker implantation in patients with less than 2 years of age and after hospital discharge. Methods: Historical cohort study including 34 patients with age ranging from one day to 22 months with hospital discharge after permanent pacemaker implantation with a sutureless epimyocardial electrode and single chamber generator (VVI mode) between 1997 and 2010. Twenty-two patients were female and 12 male. Predominant arrhythmia was atrioventricular block (30 patients; 88.2%). Twenty-nine patients (85.3%) had structural heart disease and 22 (67.4%) had been submitted to a previous heart surgery. Patients were followed-up for a mean time of 60.5 months. Recorded events were analyzed and probability of survival was estimated according to Kaplan-Meyer analysis. Results: There were 3 (8.8%) deaths, due to infection, heart surgery or sudden death. Increased mortality was observed for patients without previous heart surgery (16.7% versus 4.5%). Five patients (14.7%) required pacemaker reintervention during the follow-up, 2 due to infection and 3 to re-implant the electrode. One of the patients who had a reintervention due to infection died. Probability of survival was 93.8% in the first year and 90.3% subsequently up to the 10 years of follow-up. Event-free survival was 90.8% in the first year, 79.8% from year 5 to 9, 66.5% after 10 years. Conclusion: This study demonstrates the probability of satisfactory survival after epicardial pacemaker implantation, especially in patients with previous heart surgery. Epimyocardial electrode implantation deserves consideration in patients with small physical structure, those with specific cardiac malformations, and difficult access to superior vena cava or those who need to have an associated surgical procedure...

Idade avançada e incidência de fibrilação atrial em pós-operatório de troca valvar aórtica / Advanced age and incidence of atrial fibrillation in the postoperative period of aortic valve replacement

Objetivo: Descrever, em idosos, a correlação entre faixa etária e ocorrência de fibrilação atrial após cirurgia por estenose aórtica, além de avaliar a influência da ocorrência de fibrilação atrial na incidência de acidente vascular cerebral, tempo de internação e mortalidade hospitalar. Métodos: Estudo transversal retrospectivo incluindo pacientes com idade > 70 anos submetidos à cirurgia de troca valvar aórtica isolada. Resultados: Foram estudados 348 pacientes com idade média de 76,8±4,6 anos. A incidência de fibrilação atrial no pós-operatório foi 32,8% (n=114), sendo superior nos pacientes > 80 anos (42,9 vs. 28,8% 70-79 anos, P=0,017) e havendo significância estatística limítrofe (P=0,055) para tendência linear na correlação idade e incidência de fibrilação atrial. Verificou-se significativo maior tempo de internação na Unidade de Terapia Intensiva e hospitalar total, porém, não se observou maior taxa de acidente vascular cerebral ou de mortalidade hospitalar decorrente da fibrilação atrial. Conclusão: A incidência de fibrilação atrial no pós-operatório de cirurgia para estenose valvar aórtica em pacientes idosos com > 70 anos foi elevada e linearmente correlacionada ao avanço da idade, especialmente após 80 anos, causando aumento dos tempos de internação total e em Unidade de Terapia Intensiva, sem aumento significativo da morbimortalidade. O conhecimento desses dados é importante para evidenciar a necessidade de medidas profiláticas e de tratamento precoce dessa arritmia nesse subgrupo. .

Objective: This study aims to describe the correlation between age and occurrence of atrial fibrillation after aortic stenosis surgery in the elderly as well as evaluate the influence of atrial fibrillation on the incidence of strokes, hospital length of stay, and hospital mortality. Methods: Cross-sectional retrospective study of > 70 year-old patients who underwent isolated aortic valve replacement. Results: 348 patients were included in the study (mean age 76.8±4.6 years). Overall, post-operative atrial fibrillation was 32.8% (n=114), but it was higher in patients aged 80 years and older (42.9% versus 28.8% in patients aged 70-79 years, P=0.017). There was borderline significance for linear correlation between age and atrial fibrillation (P=0.055). Intensive Care Unit and hospital lengths of stay were significantly increased in atrial fibrillation (P<0.001), but there was no increase in mortality or stroke associated with atrial fibrillation. Conclusion: Post-operative atrial fibrillation incidence in aortic valve replacement is high and correlates with age in patients aged 70 years and older and significantly more pronounced in patients aged 80 years. There was increased length of stay at Intensive Care Unit and hospital, but there was no increase in mortality or stroke. These data are important for planning prophylaxis and early treatment for this subgroup. .

High doses of vascular endothelial growth factor 165 safely, but transiently, improve myocardial perfusion in no-option ischemic disease.

UNLABELLED: Gene therapy can induce angiogenesis in ischemic tissues. The aim of this study was to assess safety, feasibility, and results, both clinical and on myocardial perfusion, of gene therapy in refractory angina. This was a phase I/II, prospective, temporal-controlled series, clinical trial. Thirteen patients were maintained for minimum 6 months under optimized clinical management, and then received intramyocardial injections of 2000 µg plasmid vascular endothelial growth factor 165 and were followed by single-photon emission computed tomography (SPECT), treadmill tests, Minnesota quality of life questionnaire (QOL), and New York Heart Association (NYHA) functional plus Canadian Cardiovascular Society (CCS) angina classifications. There were no deaths, early or late. During the optimized clinical treatment, we observed worsening of rest ischemia scores on SPECT (p<0.05). After treatment, there was a transitory increase in myocardial perfusion at the third-month SPECT under stress (pre-operative [pre-op] 18.38 ± 7.51 vs. 3 months 15.31 ± 7.30; p<0.01) and at the sixth month under rest (pre-op 13.23 ± 7.98 vs. 6 months: 16.92 ± 7.27; p<0.01). One year after, there were improvements in treadmill test steps (pre-op 2.46 ± 2.07 vs.12 months 4.15 ± 2.23; p<0.01) and oxygen consumption (pre-op 7.66 ± 4.47 vs.12 months 10.89 ± 4.65; p<0.05), QOL (pre-op 48.23 ± 18.35 vs.12 months 28.31 ± 18.14; p<0.01) scores, and CCS (pre-op 3 [3-3.5] vs.12 months 2 [1-2.5]; p<0.01) and NYHA (pre-op 3 [3-3] vs. 2 [2-2] vs. 12 months 2 [1-2]; p<0.01) classes. Gene therapy demonstrated to be feasible and safe in this advanced ischemic cardiomyopathy patient sample. There were improvements in clinical evaluation parameters, and a transitory increase in myocardial perfusion detectable by SPECT scintigraphy. CLINICAL TRIAL REGISTRATION: NCT00744315 http://clinicaltrials.gov/

Terapia gênica com fator de crescimento endotelial vascular 165 para pacientes com angina refratária: mobilização de células progenitoras endoteliais / VEGF 165 gene therapy for patients with refractory angina: mobilization of endothelial progenitor cells

FUNDAMENTO: O fator de crescimento endotelial vascular (VEGF - vascular endothelial growth factor) induz a mobilização de células progenitoras endoteliais (CPEs) com capacidade de proliferação e diferenciação em células endoteliais, contribuindo, dessa forma, para o processo angiogênico. OBJETIVO: Buscamos avaliar o comportamento de CPEs em pacientes com doença cardíaca isquêmica e angina refratária que receberam injeções intramiocardicas de 2000 µg de VEGF165 como terapia única. MÉTODOS: O estudo foi uma subanálise de um ensaio clínico. Pacientes com doença cardíaca isquêmica avançada e angina refratária foram avaliados para inclusão no estudo. Os critérios de inclusão foram: sinais e sintomas de angina e/ou insuficiência cardíaca apesar de tratamento medicamentoso máximo e área de isquemia miocárdica de, no mínimo, 5% conforme avaliado por uma tomografia computadorizada por emissão de fóton único (TCEFU). Os critérios de exclusão foram: idade > 65 anos, fração de ejeção do ventrículo esquerdo < 25% e cancer diagnosticado. Os pacientes cujos níveis de CPE foram avaliados foram incluídos. A intervenção consistiu na administração de 2000 µg de VEGF 165 de plasmídeo injetado no miocárdio isquêmico. A frequência de células CD34+/KDR+ foi analisada por citometria de fluxo antes e 3, 9, e 27 dias após a intervenção. RESULTADOS: Um total de 9 pacientes foram incluídos, 8 homens, média de idade de 59,4 anos, fração de ejeção ventricular esquerda de 59,3%, e classe de angina predominante III. Observou-se um aumento significativo dos níveis de CPEs no terceiro dia após a intervenção. Todavia, 9 e 27 dias após a intervenção, os níveis de CPEs foram similares aos basais. CONCLUSÃO: Identificamos uma mobilização transitória de CPE, com pico no terceiro dia após a intervenção com VEGF 165 em pacientes com angina refratária. Todavia, os níveis de CPEs apresentaram-se semelhantes aos basais 9 e 27 dias após a intervenção.

BACKGROUND: Vascular endothelial growth factor (VEGF) induces mobilization of endothelial progenitor cells (EPCs) with the capacity for proliferation and differentiation into mature endothelial cells, thus contributing to the angiogenic process. OBJECTIVE: We sought to assess the behavior of EPCs in patients with ischemic heart disease and refractory angina who received an intramyocardial injections of 2000 µg of VEGF 165 as the sole therapy. METHODS: The study was a subanalysis of a clinical trial. Patients with advanced ischemic heart disease and refractory angina were assessed for eligibility. Inclusion criteria were as follows: signs and symptoms of angina and/or heart failure despite maximum medical treatment and a myocardial ischemic area of at least 5% as assessed by single-photon emission computed tomography (SPECT). Exclusion criteria were as follows: age > 65 years, left ventricular ejection fraction < 25%, and a diagnosis of cancer. Patients whose EPC levels were assessed were included. The intervention was 2000 µg of VEGF 165 plasmid injected into the ischemic myocardium. The frequency of CD34+/KDR+ cells was analyzed by flow cytometry before and 3, 9, and 27 days after the intervention. RESULTS: A total of 9 patients were included, 8 males, mean age 59.4 years, mean left ventricular ejection fraction of 59.3% and predominant class III angina. The number of EPCs on day 3 was significantly higher than that at baseline (p = 0.03); however, that on days 9 and 27 was comparable to that at baseline. CONCLUSION: We identified a transient mobilization of EPCs, which peaked on the 3th day after VEGF 165 gene therapy in patients with refractory angina and returned to near baseline levels on days 9 and 27.

VEGF 165 gene therapy for patients with refractory angina: mobilization of endothelial progenitor cells.

BACKGROUND: Vascular endothelial growth factor (VEGF) induces mobilization of endothelial progenitor cells (EPCs) with the capacity for proliferation and differentiation into mature endothelial cells, thus contributing to the angiogenic process. OBJECTIVE: We sought to assess the behavior of EPCs in patients with ischemic heart disease and refractory angina who received an intramyocardial injections of 2000 µg of VEGF 165 as the sole therapy. METHODS: The study was a subanalysis of a clinical trial. Patients with advanced ischemic heart disease and refractory angina were assessed for eligibility. Inclusion criteria were as follows: signs and symptoms of angina and/or heart failure despite maximum medical treatment and a myocardial ischemic area of at least 5% as assessed by single-photon emission computed tomography (SPECT). Exclusion criteria were as follows: age > 65 years, left ventricular ejection fraction < 25%, and a diagnosis of cancer. Patients whose EPC levels were assessed were included. The intervention was 2000 µg of VEGF 165 plasmid injected into the ischemic myocardium. The frequency of CD34+/KDR+ cells was analyzed by flow cytometry before and 3, 9, and 27 days after the intervention. RESULTS: A total of 9 patients were included, 8 males, mean age 59.4 years, mean left ventricular ejection fraction of 59.3% and predominant class III angina. The number of EPCs on day 3 was significantly higher than that at baseline (p = 0.03); however, that on days 9 and 27 was comparable to that at baseline. CONCLUSION: We identified a transient mobilization of EPCs, which peaked on the 3th day after VEGF 165 gene therapy in patients with refractory angina and returned to near baseline levels on days 9 and 27.

Results of simplified single-patch repair for complete atrioventricular septal defect.

BACKGROUND: Since Wilcox's description of the simplified single-patch technique for atrioventricular septal defect (AVSD) repair in 1997, several studies have compared that technique with the two-patch technique. OBJECTIVE: To report the mid- and long-term results of the simplified single-patch technique for complete AVSD repair. METHODS: Retrospective study of 16 consecutive cases between January 2001 and December 2011. The patients' mean age was 18.31 ± 34.19 months (2 months - 11 years), and their mean weight, 7.80 ± 6.12 kg (3.77 - 25.0 kg). Six patients were males and 14 had Down syndrome. Mean follow-up duration was 54.97 ± 47.79 months. RESULTS: Mean cardiopulmonary bypass time was 74.63 ± 18.48 min (49 - 112 min), and mean aortic cross-clamp time, 46.44 ± 11.89 min (34 - 67 min). Two patients died during hospitalization (12.5%), both of cardiovascular causes. Three patients underwent reoperation due to left atrioventricular (AV) valve regurgitation, and two had third-degree VA block, requiring permanent pacemaker implantation. No patient had left ventricular outflow tract obstruction. The 14 surviving patients remain asymptomatic, ten of whom with mild left VA valve regurgitation (71.42%). CONCLUSION: The simplified single-patch technique for complete AVSD repair proved to be feasible, providing adequate correction of the defects and favorable clinical and echocardiographic outcome in the mean 57.97-month follow-up.

Resultados da correção simplificada com enxerto único no defeito septal atrioventricular completo / Results of simplified single-patch repair for complete atrioventricular septal defect

FUNDAMENTO: Desde que Wilcox, em 1997, descreveu uma forma simplificada de correção do Defeito Septal Atrioventricular (DSAV) com enxerto único, diversos estudos têm sido realizados comparando-a à técnica com duplo enxerto. OBJETIVO: Relatar os resultados em médio e longo prazos da correção de DSAV completo pela técnica simplificada de enxerto único. MÉTODOS: Estudo retrospectivo de 16 casos consecutivos arrolados entre janeiro de 2001 e dezembro de 2011. A idade média foi 18,31 ± 34,19 meses (2 meses - 11 anos) e o peso 7,80 ± 6,12 Kg (3,77 - 25,0 Kg); 6 pacientes eram do sexo masculino e 14 eram portadores de Síndrome de Down. O tempo de seguimento médio foi de 54,97 ± 47,79 meses. RESULTADOS: O tempo médio de circulação extracorpórea foi 74,63 ± 18,48 min (49 - 112 min) e o de pinçamento aórtico, de 46,44 ± 11,89 min (34 - 67 min). Foram observados dois óbitos hospitalares (12,5%), ambos por causa cardiovascular. Três pacientes foram reoperados por regurgitação da valva atrioventricular (VA) esquerda e dois apresentaram bloqueio atrioventricular (BAV) completo com necessidade de implante de marca-passo definitivo. Não houve nenhum caso de obstrução da via de saída do ventrículo esquerdo. Os 14 pacientes sobreviventes permanecem assintomáticos, 10 deles com insuficiência da valva VA esquerda leve (71,42%). CONCLUSÃO: A técnica simplificada com enxerto único para correção de DSAV completo mostrou-se factível, associada à correção adequada dos defeitos e à favorável evolução clínica e ecocardiográfica nos 57,97 meses de seguimento médio avaliados.

BACKGROUND: Since Wilcox's description of the simplified single-patch technique for atrioventricular septal defect (AVSD) repair in 1997, several studies have compared that technique with the two-patch technique. OBJECTIVE: To report the mid- and long-term results of the simplified single-patch technique for complete AVSD repair. METHODS: Retrospective study of 16 consecutive cases between January 2001 and December 2011. The patients' mean age was 18.31 ± 34.19 months (2 months - 11 years), and their mean weight, 7.80 ± 6.12 kg (3.77 - 25.0 kg). Six patients were males and 14 had Down syndrome. Mean follow-up duration was 54.97 ± 47.79 months. RESULTS: Mean cardiopulmonary bypass time was 74.63 ± 18.48 min (49 - 112 min), and mean aortic cross-clamp time, 46.44 ± 11.89 min (34 - 67 min). Two patients died during hospitalization (12.5%), both of cardiovascular causes. Three patients underwent reoperation due to left atrioventricular (AV) valve regurgitation, and two had third-degree VA block, requiring permanent pacemaker implantation. No patient had left ventricular outflow tract obstruction. The 14 surviving patients remain asymptomatic, ten of whom with mild left VA valve regurgitation (71.42%). CONCLUSION: The simplified single-patch technique for complete AVSD repair proved to be feasible, providing adequate correction of the defects and favorable clinical and echocardiographic outcome in the mean 57.97-month follow-up.

Fatores de risco hospitalar para pacientes submetidos à substituição valvar com a bioprótese porcina em instituição universitária / Risk factors for hospital mortality in valve replacement with porcine bioprosthesis at an universitary institution

OBJETIVO: Identificar fatores de risco hospitalar em pacientes submetidos ao implante de bioprótese porcina no Instituto de Cardiologia do Rio Grande do Sul. MÉTODOS: Estudo retrospectivo, com informações de prontuário, de 808 pacientes submetidos ao implante de pelo menos uma bioprótese porcina St. Jude Medical Biocor, no período entre 1994 e 2009. Foi analisada a relação entre mortalidade hospitalar e características clínicas e demográficas definidas em estudos reconhecidos, visando identificar fatores de risco. Foram utilizados testes qui-quadrado, t de Student e regressão logística uni e multivariável (P<0,05). RESULTADOS: Ocorreram 80 (9,9%) óbitos hospitalares. Fatores de risco identificados na regressão logística univariável foram: plastia tricúspide (odds ratio 6,11); lesão mitral (OR 3,98); fração de ejeção de ventrículo esquerdo < 30% (OR 3,82); diabete melito (OR 2,55); fibrilação atrial (OR 2,32); hipertensão pulmonar (OR 2,30); creatinina > 1,4 mg/dL (OR 2,28); cirurgia cardíaca prévia (OR 2,17); hipertensão arterial sistêmica (OR 1,93); classe funcional III e IV (OR 1,92); revascularização miocárdica (OR 1,81); idade > 70 anos (OR 1,80); insuficiência cardíaca congestiva (OR 1,73); e sexo feminino (OR 1,68). Pela regressão logística multivariável, para fatores independentes, identificados: lesão mitral (OR 5,29); plastia tricúspide (OR 3,07); diabete melito (OR 2,72); idade > 70 anos (OR 2,62); revascularização miocárdica (OR 2,43); cirurgia cardíaca prévia (OR 1,82); e hipertensão arterial sistêmica (OR 1,79). CONCLUSÕES: A mortalidade observada nesta casuística é compatível com literatura. Fatores de risco preponderantes são reconhecidos e devem motivar programas específicos de neutralização.

OBJECTIVE: Study designed to identify characteristics of patients related to increased hospital mortality after valve replacement, assumed as risk factors. METHODS: Retrospective study including 808 patients submitted to the implant of St. Jude Biocor porcine bioprosthesis between 1994 and 2009 at Instituto de Cardiologia do Rio Grande do Sul. Primary outcome was hospital death and hospital mortality was related to demographic and surgical characteristics. Statistics include t-test, qui-square test and logistical regression analysis. RESULTS: There were 80 (9.9%) hospital deaths. Risk factors identified with univariable logistical analysis (and respective odds-ratio) were: tricuspid surgery (OR 6.11); mitral valve replacement (OR 3.98); left ventricular ejection fraction < 30% (OR 3.82); diabetes mellitus (OR 2.55); atrial fibrillation (OR 2.32); pulmonary arterial hypertension (OR 2.30); serum creatinine > 1,4 mg/dL (OR 2.28); previous cardiac surgery (OR 2.17); systemic arterial hypertension (OR 1.93); functional class III e IV (OR 1.92); coronary bypass (OR 1.81); age > 70 years-old (OR 1.80); congestive heart failure (OR 1.73); e female gender (OR 1.68). Multivariable logistic regression for independent factors identified preponderant risk factors mitral valve replacement (OR 5,29); tricuspid surgery (OR 3.07); diabetes mellitus (OR 2.72); age > 70 years-old (OR 2.62); coronary bypass (OR 2.43); previous cardiac surgery (OR 1.82); e systemic arterial hypertension (OR 1.79). CONCLUSIONS: Mortality rate is within values found in literature. Identification of risk factors could contribute to changes in surgical indication and medical management in order to reduce hospital mortality.

Does diabetes mellitus increase immediate surgical risk in octogenarian patients submitted to coronary artery bypass graft surgery? / Diabetes mellitus aumenta risco cirúrgico imediato em pacientes octogenários submetidos à cirurgia de revascularização miocárdica?

INTRODUCTION: Diabetes is a well known risk factor for early and late adverse outcomes in patients undergoing coronary artery bypass graft surgery (CABG); however, few studies have investigated the impact of this risk factor in the group of older patients, especially octogenarians. OBJECTIVES: To compare in-hospital mortality and morbidity of diabetic and nondiabetic patients aged > 80 years submitted to CABG. METHODS: A total of 140 consecutive cases were studied, of whom 37 (26.4%) were diabetics, in a retrospective cross-sectional study, that included all patients aged > 80 years submitted to isolated/associated CABG. The patients' mean age was 82.5 ± 2.2 years and 55.7% were males. RESULTS: The hospital mortality rate did not significantly differ in multivariate analysis: 16.2% diabetic x 13.6% nondiabetic (P = 0.554), as well as morbidity: 43.2% x 37.9%, respectively (P = 0.533). Regarding to operative morbidity, the occurrence of stroke was significantly higher in diabetic patients in the univariate analysis (10.8% x 1.9%, P = 0.042). In multivariate analysis, however, the incidence of stroke was not associated with the presence of diabetes (P = 0.085), but it was associated with atrial fibrillation (P = 0.044). There was no significant difference related to other complications. CONCLUSION: In this small consecutive retrospectively analyzed series, there was no significant increase in hospital mortality and morbidity related to diabetes for CABG in octogenarian patients. The impact of the results of this study is limited by the sample size and might be confirmed by future randomized clinical trials.

INTRODUÇÃO: O diabetes é um fator de risco conhecido para eventos adversos precoces e tardios em pacientes submetidos à cirurgia de revascularização miocárdica (CRM); entretanto, poucos estudos investigaram sua influência no grupo de pacientes mais idosos, especialmente nos octogenários. OBJETIVOS: Comparar a mortalidade e a morbidade hospitalar de pacientes com idade > 80 anos diabéticos e não-diabéticos submetidos à CRM. MÉTODOS: Foram estudados 140 casos consecutivos, sendo 37 (26,4%) diabéticos, em um estudo transversal retrospectivo incluindo todos os pacientes com idade > 80 anos submetidos à CRM isolada/associada. A idade média dos pacientes foi de 82,5 ± 2,2 anos e 55,7% eram do sexo masculino. RESULTADOS: A taxa de mortalidade hospitalar não diferiu de maneira significativa na análise multivariada entre os grupos, 16,2% diabéticos x 13,6% não-diabéticos (P=0,554), assim como a morbidade pós-operatória, 43,2 x 37,9%, respectivamente (P=0,533). Em relação à morbidade, a ocorrência de acidente vascular cerebral foi significativamente maior em pacientes diabéticos na análise univariada (10,8% x 1,9%; P = 0,042). Na análise multivariada, no entanto, a incidência dessa complicação não foi associada com a presença de diabetes (P=0,085), mas com a presença de fibrilação atrial (P=0,044). Não se observou nenhuma diferença significativa em relação às outras complicações. CONCLUSÃO: Nessa pequena série de casos retrospectiva, não houve um aumento significativo da morbimortalidade hospitalar no grupo de pacientes octogenários diabéticos. O impacto dos resultados desta série é limitado pelo tamanho amostral e poderá ser confirmado por futuros ensaios clínicos randomizados.

Results of aortic valve surgery in patients over 75 years old, at 4.5 years of follow-up.

BACKGROUND: The increased longevity elevated the frequency of elderly requiring surgery, among them the correction of aortic stenosis. OBJECTIVES: To evaluate medium-term mortality, need for reoperation for valve replacement and valve complications [systemic thromboembolism (STE) and prosthetic endocarditis (PE)] in patients over 75 years old who had undergone surgery for aortic stenosis. METHODS: Retrospective study of 230 patients from 2002 to 2007. Mean age was 83.4 years and 53% were male. The prevalence of hypertension was 73.2%, atrial fibrillation 17.9% and previous cardiac surgery 14.4%. Another cardiac procedure was associated in 39.1%. RESULTS: In a mean follow-up of 4.51 years the overall survival of the population studied was 57.4%. Death in the immediate postoperative period occurred in 13.9% (9.4% in the isolated aortic stenosis surgery group vs. 20.9% when another procedure was associated). Deaths in the medium term occurred in 28.7% of the patients (25.0% vs. 34.4%), with 34 of these because of cardiovascular causes. There were 6 cases of PE, 8 cases of STE and 6 reoperations. The predictors of mortality were ischemia time >90 min (OR 1.99 95% CI 1.06-3.74), ejection fraction <60% (OR 1.76 95% CI 1.10-2.81) and prior stroke (OR 2.43 95% CI 1.18-5.30). CONCLUSION: Although the immediate surgical risk of the elderly is high, survival rates for surgical treatment of patients over 75 years old are acceptable and allow this intervention. The prognosis is worse especially because of the association with coronary artery disease.

Use of intra-aortic balloon pump in cardiac surgery: analysis of 80 consecutive cases.

BACKGROUND: About 10% to 15% of patients undergoing cardiac surgery may develop low cardiac output syndrome in the perioperative period; of this total, 2% require mechanical support for adequate hemodynamic control. OBJECTIVE: To describe the mortality rates of patients who required the use of IABP in the perioperative or postoperative period of cardiac surgery, identifying preoperative variables associated with a worse outcome, as well as to describe the postoperative complications and medium-term survival. METHODS: Retrospective cohort study including 80 consecutive cases between January/2009 and September/ 2011. The patients had on average 62.9 ± 11.3 years and 58.8% were male; 81.3% were hypertensive, 50.0% had prior myocardial infarction and 38.8% has NYHA III/IV heart failure. The mainsurgery performed was isolated coronary artery bypass grafting (37.5%). RESULTS: Hospital mortality was 53.8% (IC 95%: 42.7-64.9), and cross-clamp time > 90 minutes was an independent predictor of mortality in multivariate analysis (OR 1.52 CI 95%: 1.04-2.22). 71.3% of patients (CI 95%: 61.2-81.4) had at least one additional complication in the perioperative period, with lower limb ischemia observed in 5.0% patients. One-year survival was 43.6%, with a plateau in survival rates after a sharp initial drop, related to hospital mortality. CONCLUSION: Patients who require IABP comprise a group of very high risk for morbidity and mortality. IABP use, however, enables the recovery of many patients from an evolution that would invariably be fatal, and patients discharged from hospital have a good medium-term survival.

Uso do balão intra-aórtico no trans e pós-operatório de cirurgia cardíaca: análise de 80 casos consecutivos / Use of intra-aortic balloon pump in cardiac surgery: analysis of 80 consecutive cases

FUNDAMENTO: A síndrome de baixo débito cardíaco no perioperatório de cirurgia cardíaca pode incidir em cerca de 10 a 15% dos pacientes; desse total, 2% necessitam de suporte mecânico para adequado controle hemodinâmico. OBJETIVOS: Descrever a mortalidade de pacientes que necessitaram utilizar balão intra-aórtico (BIAo) no trans ou pós-operatório de cirurgia cardíaca, identificando variáveis pré-operatórias associadas a pior desfecho, assim como descrever as complicações pós-operatórias e a sobrevida em médio prazo. MÉTODOS: Estudo de coorte retrospectivo incluindo 80 casos consecutivos entre janeiro/2009 e setembro/2011. Os pacientes possuíam, em média, 62,9 ± 11,3 anos e 58,8% eram do sexo masculino. Na amostra, 81,3% dos pacientes eram hipertensos, 50% tinham infarto do miocárdio prévio e 38,8%, insuficiência cardíaca NYHA III/IV. A principal cirurgia realizada foi a revascularização miocárdica isolada (37,5%). RESULTADOS:A mortalidade hospitalar nesta série foi de 53,8% (IC95%: 42,7-64,9), sendo o tempo de isquemia > 90 minutos preditor independente de mortalidade em análise multivariada (RR 1,52 IC95%: 1,04-2,22). Em relação às complicações, 71,3% (IC95%: 61,2-81,4) dos pacientes apresentaram ao menos uma complicação adicional no período perioperatório, sendo a isquemia do membro inferior observada em 5% dos pacientes. A sobrevida em 1 ano foi de 43,6%, observando-se um platô na curva de sobrevida após uma queda acentuada inicial, relacionada à mortalidade hospitalar. CONCLUSÕES: Os pacientes que necessitam do BIAo compõem um grupo de muito alto risco para morbidade e mortalidade; seu emprego, entretanto, permite recuperar muitos pacientes de uma evolução que seria invariavelmente fatal, tendo os pacientes com alta hospitalar uma boa sobrevida em médio prazo.

BACKGROUND: About 10% to 15% of patients undergoing cardiac surgery may develop low cardiac output syndrome in the perioperative period; of this total, 2% require mechanical support for adequate hemodynamic control. OBJECTIVE: To describe the mortality rates of patients who required the use of IABP in the perioperative or postoperative period of cardiac surgery, identifying preoperative variables associated with a worse outcome, as well as to describe the postoperative complications and medium-term survival. METHODS: Retrospective cohort study including 80 consecutive cases between January/2009 and September/ 2011. The patients had on average 62.9 ± 11.3 years and 58.8% were male; 81.3% were hypertensive, 50.0% had prior myocardial infarction and 38.8% has NYHA III/IV heart failure. The mainsurgery performed was isolated coronary artery bypass grafting (37.5%). RESULTS: Hospital mortality was 53.8% (IC 95%: 42.7-64.9), and cross-clamp time > 90 minutes was an independent predictor of mortality in multivariate analysis (OR 1.52 CI 95%: 1.04-2.22). 71.3% of patients (CI 95%: 61.2-81.4) had at least one additional complication in the perioperative period, with lower limb ischemia observed in 5.0% patients. One-year survival was 43.6%, with a plateau in survival rates after a sharp initial drop, related to hospital mortality. CONCLUSION: Patients who require IABP comprise a group of very high risk for morbidity and mortality. IABP use, however, enables the recovery of many patients from an evolution that would invariably be fatal, and patients discharged from hospital have a good medium-term survival.

Resultados da cirurgia por estenose aórtica em pacientes acima de 75 anos, em 4,5 anos de seguimento / Results of aortic valve surgery in patients over 75 years old, at 4.5 years of follow-up

INTRODUÇÃO: O aumento da expectativa de vida da população tem levado à maior necessidade de intervenções cirúrgicas sobre a valva aórtica. OBJETIVOS: Avaliar a mortalidade precoce e a médio prazo, a necessidade de reoperação para troca valvar e complicações valvares [tromboembolismo sistêmico (TES) e endocardite infecciosa em prótese (EI)] em pacientes acima de 75 anos submetidos a cirurgia de estenose aórtica. MÉTODOS: Estudo retrospectivo de 230 casos, operados no período de 2002 a 2007. A idade média foi de 83,4 anos, sendo 53% do sexo masculino, 73,2% hipertensos, 17,9% portadores de fibrilação atrial e 14,4% com cirurgia cardíaca prévia. Outro procedimento cardíaco esteve associado em 39,1% dos casos. RESULTADOS: Em 4,51 anos de seguimento médio, a sobrevida geral foi de 57,4%. Ocorreram 13,9% óbitos intra-hospitalares (9,4% no grupo cirurgia de estenose aórtica isolada vs. 20,9% quando outro procedimento cirúrgico foi associado) e 28,7% óbitos após a alta hospitalar (25,0% vs. 34,4%), com 34 destes por causas cardiovasculares. Ocorreram seis casos de EI, oito casos de TES e seis reoperações para troca valvar. Os preditores de mortalidade geral foram: tempo de isquemia >90 min (RC 1,99 IC 95% 1,06-3,74), fração de ejeção <60% (RC 1,76 IC 95% 1,10-2,81) e acidente vascular encefálico prévio (RC 2,43 IC 95% 1,18-5,30). CONCLUSÃO: Ainda que o risco cirúrgico imediato de idosos seja elevado, as taxas de sobrevida referentes ao tratamento cirúrgico em pacientes acima de 75 anos são aceitáveis e permitem essa intervenção. O prognóstico é agravado, sobretudo, pela associação com doença arterial coronariana.

BACKGROUND: The increased longevity elevated the frequency of elderly requiring surgery, among them the correction of aortic stenosis. OBJECTIVES: To evaluate medium-term mortality, need for reoperation for valve replacement and valve complications [systemic thromboembolism (STE) and prosthetic endocarditis (PE)] in patients over 75 years old who had undergone surgery for aortic stenosis. METHODS: Retrospective study of 230 patients from 2002 to 2007. Mean age was 83.4 years and 53% were male. The prevalence of hypertension was 73.2%, atrial fibrillation 17.9% and previous cardiac surgery 14.4%. Another cardiac procedure was associated in 39.1%. RESULTS: In a mean follow-up of 4.51 years the overall survival of the population studied was 57.4%. Death in the immediate postoperative period occurred in 13.9% (9.4% in the isolated aortic stenosis surgery group vs. 20.9% when another procedure was associated). Deaths in the medium term occurred in 28.7% of the patients (25.0% vs. 34.4%), with 34 of these because of cardiovascular causes. There were 6 cases of PE, 8 cases of STE and 6 reoperations. The predictors of mortality were ischemia time >90 min (OR 1.99 95% CI 1.06-3.74), ejection fraction <60% (OR 1.76 95% CI 1.10-2.81) and prior stroke (OR 2.43 95% CI 1.18-5.30). CONCLUSION: Although the immediate surgical risk of the elderly is high, survival rates for surgical treatment of patients over 75 years old are acceptable and allow this intervention. The prognosis is worse especially because of the association with coronary artery disease.

Risk factors for hospital mortality in valve replacement with porcine bioprosthesis at an universitary institution.

OBJECTIVE: Study designed to identify characteristics of patients related to increased hospital mortality after valve replacement, assumed as risk factors. METHODS: Retrospective study including 808 patients submitted to the implant of St. Jude Biocor porcine bioprosthesis between 1994 and 2009 at Instituto de Cardiologia do Rio Grande do Sul. Primary outcome was hospital death and hospital mortality was related to demographic and surgical characteristics. Statistics include t-test, qui-square test and logistical regression analysis. RESULTS: There were 80 (9.9%) hospital deaths. Risk factors identified with univariable logistical analysis (and respective odds-ratio) were: tricuspid surgery (OR 6.11); mitral valve replacement (OR 3.98); left ventricular ejection fraction < 30% (OR 3.82); diabetes mellitus (OR 2.55); atrial fibrillation (OR 2.32); pulmonary arterial hypertension (OR 2.30); serum creatinine > 1,4 mg/dL (OR 2.28); previous cardiac surgery (OR 2.17); systemic arterial hypertension (OR 1.93); functional class III e IV (OR 1.92); coronary bypass (OR 1.81); age > 70 years-old (OR 1.80); congestive heart failure (OR 1.73); e female gender (OR 1.68). Multivariable logistic regression for independent factors identified preponderant risk factors mitral valve replacement (OR 5,29); tricuspid surgery (OR 3.07); diabetes mellitus (OR 2.72); age > 70 years-old (OR 2.62); coronary bypass (OR 2.43); previous cardiac surgery (OR 1.82); e systemic arterial hypertension (OR 1.79). CONCLUSIONS: Mortality rate is within values found in literature. Identification of risk factors could contribute to changes in surgical indication and medical management in order to reduce hospital mortality.