Human pilot study of bare-metal stent: INC-01

ABSTRACT Background: The cost of performing a percutaneous coronary intervention is considerably high for the patient as well as for health systems, which have promoted the development of local technology to help meet the need for these devices. Methods: The INC-01 bare-metal stent was developed at the National Institute of Cardiology in Mexico City and was first implanted on porcine models with technical success in 100% of the evaluated parameters. Presentation of Cases: We present the first three cases of patients with ischemic heart disease, to whom the INC-01 bare-metal stent was implanted. Intracoronary ultrasonography was performed post-stent implantation, showing all the characteristics of implant success during evaluation and clinical follow-up. Conclusions: Angiography and intracoronary ultrasound were carried out demonstrating that the INC-01 bare-metal stent has physical, biological, and histological characteristics similar to those found in commercial metallic stents.

Patency of individual and sequential coronary artery bypass in patients with ischemic heart disease: a meta-analysis

Abstract Objective: To evaluate the patency of individual and sequential coronary artery bypass in patients with ischemic heart disease. Methods: We searched PubMed, Cochrane Library, Excerpta Medica Database, and ClinicalTrials.gov databases for controlled trials. Endpoints included graft patency, anastomosis patency, occluded rates in left anterior descending (LAD) system and right coronary artery (RCA) system, in-hospital mortality, and follow-up mortality. Pooled risk ratios (RRs) and standardized mean difference (SMD) were used to assess the relative data. Results: Nine cohorts, including 7100 patients and 1440 grafts under individual or sequential coronary artery bypass. There were no significant differences between individual and sequential coronary artery bypass in the graft patency (RR=0.96; 95% CI=0.91-1.02; P=0.16; I2=87%), anastomosis patency (RR=0.95; 95% CI=0.91-1.00; P=0.05; I2=70%), occluded rate in LAD system (RR=1.03; 95% CI=0.92-1.16; P=0.58; I2=37%), occluded rate in RCA system (RR=1.36; 95% CI=0.72-2.57; P=0.35; I2=95%), in-hospital mortality (RR=1.57; 95% CI=0.92-2.69; P=0.10; I2=0%), and follow-up mortality (RR=0.96; 95% CI=0.36-2.53; P=0.93; I2=0%). Conclusion: No significant differences on clinical data were observed regarding anastomosis patency, occluded rate in LAD system, occluded rate in RCA system, in-hospital mortality, and follow-up mortality, indicating that the patency of individual and the patency of sequential coronary artery bypass are similar to each other.

Coronary artery bypass graft surgery improves survival without increasing the risk of stroke in patients with ischemic heart failure in comparison to percutaneous coronary intervention: a meta-analysis with 54, 173 patients

Abstract Objective: To evaluate whether there is any difference on the results of patients treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in the setting of ischemic heart failure (HF). Methods: Databases (MEDLINE, Embase, Cochrane Controlled Trials Register [CENTRAL/CCTR], ClinicalTrials.gov, Scientific Electronic Library Online [SciELO], Literatura Latino-americana e do Caribe em Ciências da Saúde [LILACS], and Google Scholar) were searched for studies published until February 2019. Main outcomes of interest were mortality, myocardial infarction, repeat revascularization, and stroke. Results: The search yielded 5,775 studies for inclusion. Of these, 20 articles were analyzed, and their data were extracted. The total number of patients included was 54,173, and those underwent CABG (N=29,075) or PCI (N=25098). The hazard ratios (HRs) for mortality (HR 0.763; 95% confidence interval [CI] 0.678-0.859; P<0.001), myocardial infarction (HR 0.481; 95% CI 0.365-0.633; P<0.001), and repeat revascularization (HR 0.321; 95% CI 0.241-0.428; P<0.001) were lower in the CABG group than in the PCI group. The HR for stroke showed no statistically significant difference between the groups (random effect model: HR 0.879; 95% CI 0.625-1.237; P=0.459). Conclusion: This meta-analysis found that CABG surgery remains the best option for patients with ischemic HF, without increase in the risk of stroke.

Early and medium outcomes of on-pump beating-heart versus off-pump cabg in patients with moderate left ventricular dysfunction

Abstract Objective: This study aims to compare the early and medium outcomes of on-pump beating-heart (OPBH) coronary artery bypass grafting (CABG) and off-pump CABG (OPCABG) in patients with left ventricular ejection fraction (LVEF) between 30% and 40%. Methods: This is a retrospective study of ischemic heart disease patients with LVEF between 30% and 40% who underwent surgical revascularization from January 2013 to December 2017. Patients were divided into OPBH group (n=44) and OPCABG group (n=68), according to the surgical method. Clinical material with early and medium outcomes were investigated and compared between these groups. Results: The two groups had similar baseline. Two OPBH patients and 3 OPCABG patients died in the hospital, which had no statistical significance (P>0.05). OPBH patients received a greater number of grafts (3.74±0.84) and presented more improved LVEF (45.92±7.11%) than OPCABG patients (3.36±0.80) and (42.81±9.29%), respectively, which had statistical significance (P<0.05). An increased amount of drainage during the first 12 hours was found in the OPBH group (P<0.05). Reoperation for bleeding, duration of mechanic ventilation, and other early outcomes had no statistical significance between the two groups. During the medium-time follow-up, OPBH patients showed significantly lower major adverse cardiovascular events (MACE)-free survival time (P=0.049) than OPCABG patients. Conclusion: The OPBH technique was a safe and an acceptable alternative for surgical revascularization in patients with moderate left ventricular dysfunction which provided better mid-term MACE-free survival compared with OPCABG.

Up to 15-Year Survival of Men and Women after Percutaneous Coronary Intervention Paid by the Brazilian Public Healthcare System in the State of Rio de Janeiro, 1999-2010 / Sobrevida em até 15 Anos de Homens e Mulheres após Intervenção Coronariana Percutânea Paga pelo Sistema Único de Saúde no Estado do Rio de Janeiro, 1999-2010

Abstract Background: Percutaneous coronary intervention (PCI) is the most frequently used invasive therapy for ischemic heart disease (IHD). Studies able to provide information about PCI's effectiveness should be conducted in a population of real-world patients. Objectives: To assess the survival rate of IHD patients treated with PCI in the state of Rio de Janeiro (RJ). Methods: Administrative (1999-2010) and death (1999-2014) databases of dwellers aged ≥ 20 years old in the state of RJ submitted to one single PCI paid by the Brazilian public healthcare system (SUS) between 1999 and 2010 were linked. Patients were grouped as follows: 20-49 years old, 50-69 years old and ≥ 70 years old, and PCI in primary PCI, with stent and without stent placement (bare metal stent). Survival probabilities in 30 days, one year and 15 years were estimated by using the Kaplan-Meier method. Cox hazards regression models were used to compare risks among sex, age groups and types of PCI. Test results with a p-value < 0.05 were deemed statistically significant. Results: Data of 19,263 patients (61 ± 11 years old, 63.6% men) were analyzed. Survival rates of men vs. women in 30 days, one year and 15 years were: 97.3% (97.0-97.6%) vs. 97.1% (96.6-97.4%), 93.6% (93.2-94.1%) vs. 93.4% (92.8-94.0%), and 55.7% (54.0-57.4%) vs. 58.1% (55.8-60.3%), respectively. The oldest age group was associated with lower survival rates in all periods. PCI with stent placement had higher survival rates than those without stent placement during a two-year follow-up. After that, both procedures had similar survival rates (HR 0.91, 95% CI 0.82-1.00). Conclusions: In a population of real-world patients, women had a higher survival rate than men within 15 years after PCI. Moreover, using a bare-metal stent failed to improve survival rates after a two-year follow-up compared to simple balloon angioplasty.

Resumo Fundamento: A intervenção coronariana percutânea (ICP) é o tratamento invasivo mais frequentemente realizado na doença isquêmica do coração (DIC). Estudos capazes de prover informação sobre a sua efetividade são importantes. Objetivo: Avaliar a sobrevida em até 15 anos de pacientes submetidos a ICP no estado do Rio de Janeiro (ERJ). Métodos: Bases de dados administrativas (1999-2010) e de óbitos (1999-2014) dos residentes com idade ≥ 20 anos do ERJ submetidos a uma única ICP paga pelo Sistema Único de Saúde (SUS) entre 1999-2010 foram relacionadas. Os pacientes foram agrupados em 20-49, 50-69 ou ≥ 70 anos, e as ICP em primária (ICP-P), sem stent (ICP-SS) e com stent convencional (ICP-CS). As probabilidades de sobrevida em 30 dias, um ano e 15 anos foram estimadas pelo método de Kaplan-Meier. Modelos de regressão de risco de Cox foram utilizados para comparar riscos entre sexo, faixas etárias e tipos de ICP. Resultados dos testes com um valor de p < 0,05 foram considerados estatisticamente significativos. Resultados: Foram analisados os dados de 19.263 pacientes (61±11 anos, 63,6% homens). A sobrevida de homens vs. mulheres em 30 dias, um ano e 15 anos foram: 97,3% (97,0-97,6%) vs. 97,1% (96,6-97,4%), 93,6% (93,2-94,1%) vs. 93,4% (92,8-94,0%), e 55,7% (54,0-57,4%) vs. 58,1% (55,8-60,3%), respectivamente. Idade ≥ 70 anos foi associada à menor taxa de sobrevida em todos os períodos. A ICP-CS foi associada a uma sobrevida maior do que a ICP-SS até dois anos de acompanhamento, e após este período ambos os procedimentos apresentaram taxas de sobrevida semelhantes (HR 0,91, IC 95% 0,82-1,00). Conclusões: Mulheres apresentaram maiores taxas de sobrevida em 15 anos após ICP, e o uso de stent convencional não esteve associado a um aumento de sobrevida em longo prazo.

Rehabilitación cardiaca luego de la cirugía de revascularización miocárdica / Cardiac rehabilitation after coronary artery bypass surgery

La cardiopatía isquémica representa la principal causa de muerte a nivel mundial con un incremento en la incidencia en las poblaciones más jóvenes. Hoy en día existen estrategias de revascularización para el manejo de la isquemia aguda y/o crónica del miocardio. Estas son del tipo percutáneas así como también quirúrgicas. Aunque logremos mejorar la vascularización miocárdica mediante estos métodos, el principal determinante para mantener la permeabilidad coronaria y de los bypass confeccionados es una adecuada prevención secundaria. En esto se centran las propuestas de rehabilitación cardiaca a nivel mundial. Aunque se ha publicado mucho sobre el rol de la rehabilitación cardiaca luego de la revascularización percutánea, existen pocos trabajos capaces de sintetizar la situación actual del la rehabilitación cardiaca en el paciente que recibe cirugía de revascularización coronaria. El objetivo del presente trabajo es revisar el efecto de la rehabilitación en el retorno laboral, supervivencia, capacidad funcional, depresión y ansiedad, así como comparar la rehabilitación centralizada vs. domiciliaria en esta población de pacientes.

Ischemic heart disease is the leading cause of death worldwide with an increase in the incidence in younger populations. Today revascularization strategies are capable of alleviating acute ischemia and/or chronic ischemia. These can be performed percutaneously or through surgery. Even if we improve myocardial perfusion by these methods, the main determinant in maintaining patency of coronary arteries and bypass is a correctly instituted secondary prevention. This is the main focus of cardiac rehabilitation proposals. Although much has been published about the role of cardiac rehabilitation after percutaneous revascularization, there is little work able to synthesize the current state of cardiac rehabilitation in patients undergoing coronary artery bypass surgery. The aim of this paper is to review the effect of rehabilitation in the return to work, survival, functional capacity, depression and anxiety, as well as compare centralized vs. home rehabilitation in this patient population.

Spectral Analysis Related to Bare-Metal and Drug-Eluting Coronary Stent Implantation / Análise Espectral Relacionada ao Implante de Stent Coronariano Convencional e Farmacológico

Background: The autonomic nervous system plays a central role in cardiovascular regulation; sympathetic activation occurs during myocardial ischemia. Objective: To assess the spectral analysis of heart rate variability during stent implantation, comparing the types of stent. Methods: This study assessed 61 patients (mean age, 64.0 years; 35 men) with ischemic heart disease and indication for stenting. Stent implantation was performed under Holter monitoring to record the spectral analysis of heart rate variability (Fourier transform), measuring the low-frequency (LF) and high-frequency (HF) components, and the LF/HF ratio before and during the procedure. Results: Bare-metal stent was implanted in 34 patients, while the others received drug-eluting stents. The right coronary artery was approached in 21 patients, the left anterior descending, in 28, and the circumflex, in 9. As compared with the pre-stenting period, all patients showed an increase in LF and HF during stent implantation (658 versus 185 ms2, p = 0.00; 322 versus 121, p = 0.00, respectively), with no change in LF/HF. During stent implantation, LF was 864 ms2 in patients with bare-metal stents, and 398 ms2 in those with drug-eluting stents (p = 0.00). The spectral analysis of heart rate variability showed no association with diabetes mellitus, family history, clinical presentation, beta-blockers, age, and vessel or its segment. Conclusions: Stent implantation resulted in concomitant sympathetic and vagal activations. Diabetes mellitus, use of beta-blockers, and the vessel approached showed no influence on the spectral analysis of heart rate variability. Sympathetic activation was lower during the implantation of drug-eluting stents. .

Fundamento: O sistema nervoso autônomo tem papel central na regulação cardiovascular, ocorrendo uma ativação simpática durante a isquemia miocárdica. Objetivo: Avaliar a análise espectral da frequência cardíaca (AE) durante o implante de stent, comparando os tipos de stent. Métodos: Foram estudados 61 pacientes (idade média de 64 anos), 35 homens, com cardiopatia isquêmica e indicação de implante de stent. O implante foi feito sob monitoramento pelo Holter para o registro da AE (transformação de Fourier), com medidas dos componentes LF (baixa frequência), HF (alta frequência) e relação LF/HF, antes e durante o procedimento. Resultados: Implante de stent convencional feito em 34 pacientes; nos demais, farmacológico. A coronária abordada foi a direita em 21 pacientes, a descendente anterior em 28, a circunflexa em nove. Houve aumento do LF e do HF durante o implante em todos os pacientes, comparando-se com o período antes do implante (658 versus 185 ms2, p = 0,00, para LF; 322 versus 121 ms2, p = 0,00, para HF, respectivamente), sem alteração da LF/HF. LF durante o implante foi de 864 ms2 nos pacientes com stent convencional e de 398 com farmacológico (p = 0,00). Não houve associação entre a AE e a presença de diabetes, história familiar, apresentação clínica, uso de betabloqueador (BB), idade, vaso ou seu segmento. Conclusões: O implante de stent resultou em ativação simpática e concomitante ativação vagal. Não houve influência do quadro de diabetes, uso de BB e vaso sobre a AE. Houve menor ativação simpática durante o implante de stent farmacológico. .

Efficacy of aneurysmectomy in patients with severe left ventricular dysfunction: favorable short-and long-term results in ischemic cardiomyopathy

INTRODUCTION: The purpose of this study was to (1) identify the functional results after aneurysm surgery in patients with ischemic cardiomyopathy and (2) identify predictors of favorable outcomes. METHODS AND MATERIAL: Patients (n = 169) with angiographic left ventricular ejection fraction of 22±5 percent underwent aneurysm surgery and were prospectively followed for three years. Prior to surgery, 40 percent and 60 percent of the patients were in congestive heart failure NYHA class I/II and III/IV, respectively. Concomitant revascularization was performed on 95 percent of the patients. RESULTS: Cumulative in-hospital and 36-month mortalities were 7 percent and 15 percent, respectively. These respective rates varied according to preoperative parameters: CHF class I-II, 4 percent and 13 percent; CHF class III-IV, 8 percent and 16 percent; LVEF,20 percent, 12 percent and 26 percent; LVEF 21-30 percent, 2 percent and 6 percent; gated LVEF exercise/rest .5 percent, ,1 percent and 4 percent; and gated LVEF exercise/rest #5 percent, 17 percent and 38 percent. Higher LVEF ex/rest ratio (p = 0.01), male sex (p = 0.05), and a higher number of grafts (p = 0.01) were predictive of improvement in CHF class at follow-up based on the results of a multivariate analysis. After three years of follow-up, 84 percent of the patients were in class I/II, LVEF was 45±7 percent, and gated LVEF ex/rest ratio was 13 percent higher (p,0.01) compared to the beginning of the study. CONCLUSIONS: These data suggest that aneurysmectomy among patients with severe LV dysfunction result in shortand long-term favorable functional outcome and survival. Selection of appropriate surgical candidates may substantially improve survival rates among these patients.

Técnica para retirada da artéria radial sem utilização de clipes hemostáticos e experiência clínica / Radial artery harvesting technique without hemostatic clips and clinical experience

OBJETIVO: As diferentes técnicas de dissecção de artéria radial (AR) obtêm resultados semelhantes. Estas técnicas utilizam eletrocautério, bisturi ultra-sônico ou tesouras em diferentes combinações, mas geralmente associadas ao uso de clipes hemostáticos. Este trabalho descreve uma técnica de dissecção de AR com a combinação de tesouras e eletrocautério sem o uso de clipes hemostáticos. MÉTODOS: O estudo apresenta um levantamento retrospectivo de 107 pacientes, entre 28 e 78 anos (média ± desvio padrão 53,3 ± 8 anos), feito entre janeiro de 2000 e junho de 2005, no qual é relatada a incidência de sangramento, reoperação, infarto do miocárdio e mortalidade. RESULTADOS: Não ocorreram sangramentos relacionados à AR e não ocorreram reoperações. Ocorreram três (2,8 por cento) infartos possivelmente relacionados ao território de anastomose de AR. A mortalidade foi de 0,9 por cento não relacionada a causas cardiovasculares. CONCLUSÃO: A dissecção de AR com eletrocautério sem clipes hemostáticos não apresentou sangramento, foi de baixo custo e dispensa investimentos em equipamentos adicionais.

OBJECTIVE: The various techniques of radial artery (RA) harvesting produce similar results. These techniques use electrocautery, ultrasonic scalpel, or sharp scissors in different combinations, but usually associated with the use of hemostatic clips. We describe a RA harvesting technique with the combination of sharp scissors and electrocautery without the use of hemostatic clips. METHODS: We describe a retrospective study of 107 patients ranging from 28 and 78 years of age (mean ± SD; 53.3 ± 8 yrs). Bleeding, re-operation, infarct, and death were analyzed. RESULTS: No bleeding was imputable to the RA and no re-operations were required. There were three (2.8 percent) infarcts possibly related to the RA anastomosis territory. Mortality was 0.9 percent, but unrelated to cardiac complications. CONCLUSION: RA electrocautery harvesting without hemostatic clips presented no bleeding and was an inexpensive procedure, requiring no investments in additional equipment.

Intramyocardial injection of autologous bone marrow cells as an adjunctive therapy to incomplete myocardial revascularization: safety issues

OBJECTIVES: To determine the safety of intramyocardial injection of autologous bone marrow cells in patients undergoing surgical myocardial revascularization (CABG) for severe coronary artery disease. INTRODUCTION: There is little data available regarding the safety profile of autologous bone marrow cells injected during surgical myocardial revascularization. Potential risks include arrythmias, fibrosis in the injected sites and growth of non-cardiac tissues. METHODS: Ten patients (eight men) were enrolled; they were 59±5 years old with limiting angina and were non-optimal candidates for complete CABG. Bone marrow cells (1.3±0.3x10(8)) were obtained prior to surgery, and the lymphomonocytic fraction (CD34+=1.8±0.3 percent) was separated by density gradient centrifugation. During surgery, bone marrow cells were injected in non-grafted areas of ischemic myocardium. During the first year after surgery, the patients underwent laboratory tests, cardiac imaging, and 24-hour ECG monitoring. RESULTS: Injected segments: inferior (n=7), anterior (n=2), septal (n=1), apical (n=1), and lateral (n=1) walls. Except for a transient elevation of C-reactive protein at one month post-surgery (P=0.01), laboratory tests results were within normal ranges; neither complex arrhythmias nor structural abnormalities were detected during follow-up. There was a reduction in functional class of angina from 3.6±0.8 (baseline) to 1.2±0.4 (one year) (P<0.0001). Also, patients had a significant decrease in the ischemic score assessed by magnetic resonance, not only globally from 0.65±0.14 (baseline) to 0.17±0.05 (one year) (P=0.002), but also in the injected areas from 1.11±0.20 (baseline) to 0.34±0.13 (one year) (P=0.0009). CONCLUSIONS: Intramyocardial injection of bone marrow cells combined with CABG appears to be safe. Theoretical concerns with arrhythmias and/or structural abnormalities after cell therapy...

Letalidade hospitalar nas angioplastias coronárias no Estado do Rio de Janeiro, Brasil, 1999-2003 / Hospital case fatality associated with coronary angioplasty in Rio de Janeiro State, Brazil, 1999-2003

O estudo analisa a letalidade hospitalar nas angioplastias coronárias, pagas pelo Sistema Unico de Saúde (SUS), realizadas nos hospitais do Estado do Rio de Janeiro, Brasil, de 1999 até 2003. As informações sobre as angioplastias coronárias provieram do banco de Autorizações de Internações Hospitalares da Secretaria de Estado de Saúde do Estado do Rio de Janeiro. As taxas de letalidade foram estimadas segundo faixas etárias, sexo, diagnósticos e hospitais. A letalidade geral foi de 1,9 por cento em 8.735 angioplastias coronárias. A taxa mais baixa ocorreu nas anginas (0,8 por cento), as mais elevadas nos infartos agudos do miocárdio (6 por cento) e em outros diagnósticos (7 por cento). A letalidade foi menor nas mulheres na faixa etária entre 50 e 69 anos, e a partir dos setenta anos foi quase três vezes maior que a dos mais jovens (de 1,4 a 4 por cento), em ambos os sexos. Ocorreu grande variabilidade entre as taxas de letalidade nas angioplastias coronárias nos diferentes hospitais (entre 0 e 6,5 por cento). Portanto, é necessário acompanhar de modo contínuo a adequação da utilização da angioplastia coronária. Em conclusão, a performance deste procedimento no âmbito da modalidade de atenção pelo SUS nos hospitais, dentro do período estudado, não foi satisfatória.

This study analyzes hospital case fatality associated with percutaneous transluminal coronary angioplasties (PTCA) covered by the Brazilian Unified National Health System (SUS) and performed in hospitals in the State of Rio de Janeiro from 1999 to 2003. PTCA data were obtained from the State Health Department's database on Authorizations for Hospital Admissions. Case fatality rates were estimated according to age, gender, diagnosis, and hospital. Overall case fatality was 1.9 percent in 8,735 PTCAs. The lowest rate was associated with angina (0.8 percent) and the highest rates with acute myocardial infarction (6 percent) and other diagnoses (7 percent). In the 50-69-year bracket, case fatality was higher in women. In the over-70 group, it was almost three times that of the youngest group (4 percent versus 1.4 percent). There was great variability among PTCA case fatality rates in different hospitals (from 0 to 6.5 percent). Ongoing monitoring of PTCAs is thus necessary in clinical practice. In conclusion, PTCA performance was still unsatisfactory under the Unified National Health System.

Revascularização do miocárdio sem circulação extracorpórea em pacientes multiarteriais: experiência de 250 casos / Myocardial revascularization without extracorporeal circulation patients with multivessel disease

MÉTODO: No período de agosto de 1997 a maio de 2001, 250 pacientes multiarteriais, consecutivos, foram submetidos à cirurgia de revascularização do miocárdio sem circulação extracorpórea. A faixa etária dos pacientes variou de 38 a 83 anos (média de 59,9 anos), dos quais 62 por cento eram do sexo masculino. A principal indicação cirúrgica foi a insuficiência coronariana crônica (82 por cento). Todos os pacientes foram operados por esternotomia mediana. RESULTADOS: Três (1,2 por cento) pacientes necessitaram de instalação de circulação extracorpórea. Nos demais 247 pacientes, realizou-se 592 anastomoses, com uma média de 2,4 pontes/paciente. A artéria torácica interna esquerda foi utilizada em 198 (80,1 por cento) pacientes, a artéria torácica interna direita em 5 (2 por cento) pacientes e a veia safena em 247 (100 por cento) pacientes. As artérias coronárias mais revascularizadas foram o ramo interventricular anterior (89 por cento) e o ramo marginal esquerdo (53 por cento). A mortalidade hospitalar global foi de 4 por cento, sendo a principal causa o infarto pós-operatório (1,2 por cento). Morbidade pós-operatória foi constatada em 23 (9,3 por cento) pacientes. O tempo médio de permanência hospitalar foi de 7,7 dias. CONCLUSÃO: Conclui-se da presente investigação, que a revascularização do miocárdio sem circulação extracorpórea em pacientes multiarteriais é factível, reprodutível e com baixo índice de complicações pós-operatórias

Complicaciones operatorias y mortalidad en pacientes octogenarios sometidos a cirugía de revascularización / Surgical complications and mortality in eldery patients treated with bypass surgery

El objetivo fue identificar los factores preoperatorios, operatorios y transoperatorios asociados con complicaciones y mortalidad en pacientes octogenarios con enfermedad arterial coronaria sometidos a cirugía de revascularización. De enero de 1990 a junio de 1994 se incluyeron 37 pacientes: 32 hombres (86.5 por ciento) y cinco mujeres (13.5 por ciento). Las variables son: diabetes mellitus, hipertensión arterial sistémica, enfermedad pulmonar, hipercolesterolemia, función renal, fracción de expulsión, enfermedad arterial coronaria, tiempo de derivación cardiopulmonar, pinzamiento aórtico, número y tipo de puentes, uso de balón intraaórtico de contrapulsación, aminas vasoactivas, soporte ventilatorio, hemorragia, infección insuficiencia hepática o renal, trastornos neurológicos, anormalidades del ritmo o la conducción e isquemia miocardica postoperatoria. Factores de riesgo: diabetes mellitus (p= 0.028), FE < 30 por ciento (p= 0.023), movilidad segmentaria ventricular anormal (p < 0.05), pinzamiento aórtico > 60 minutos (p= 0.026), derivación cardiopulmonar > 120 minutos (p= 0.022), uso de injerto de vena safena, soporte ventilatorio prolongado, aminas vasoactivas y uso de balón intraaórtico de contrapulsación (p= 0.014). Conclusiones: la cirugía deberá ser reservada en enfermedad trivascular, del tronco, lesión próximal de la arteria descendente anterior con isquemia severa y deterioro en la función miocárdica y angina que no responda al tratamiento médico. La sola variable "edad" no es contraindicación. Deberá tenerse en cuenta la morbi-mortalidad de este grupo comparado con la de los grupos sometidos a tratamiento médico u otra alternativa terapéutica

Revascularizaçäo do miocárdio sem circulaçäo extracorpórea: análise dos resultados em 15 anos de experiência / Myocardial revascularization without cardiopulmonary bypass: results of 15 years' experience

A revascularizaçao miocárdica sem circulaçao extracorpórea agora se constitui numa alternativa de tratamento cirúrgico de cardiopatia isquêmica de interesse crescente. O objetivo deste trabalho é apresentar os resultados obtidos ao longo de 15 anos de experiência ininterrupta. De setembro de l981 a março de 1996, 1549 pacientes foram operados sem o auxílio do coraçao-pulmao artificial, o que constitui cerca de 18 por cento do total de pacientes operados no período. As idades variaram de 28 a 86 anos, oscilando em torno de 57 anos, sendo l126 do sexo masculino e 423 do feminino. O número de pontes variou de l a 5, com média de 1,7 pontes/paciente. A técnica nao constituiu problema especial para o emprego de enxertos arteriais, sendo as artérias torácicas internas utilizadas em 1140 artérias coronárias. Em 1515 pacientes a via de acesso foi a esternotomia mediana e, em 34, a toracotomia anterior esquerda mínima. A mortalidade operatória global foi de 2,4 por cento (38/1549), sendo a principal causa o mau débito cardíaco em pacientes operados em isquemia aguda, sendo 8 sob auxílio de balao intra-aórtico. Os resultados desta experiência permitem concluir que a revascularizaçao do miocárdio sem circulaçao extracorpórea é uma excelente alternativa de revascularizaçao para determinado subgrupo de pacientes, oferecendo baixa mortalidade e morbidade pós-operatória, sendo especialmente indicada em pacientes com complicaçoes clínicas pré-existentes e de maior risco operatório.