The cardiovascular disease burden attributable to particulate matter pollution in South America: analysis of the 1990-2019 global burden of disease.

OBJECTIVES: Fine particulate matter <2.5 microns (PM2.5) is the most studied air pollutant. Both short- and long-term exposure to PM2.5 have been linked to cardiovascular disease (CVD). Studies evaluating air pollution in South America are scarce. Therefore, the impact of exposure to PM2.5, household air pollution (HAP), and ambient air pollution (AAP) on CVD mortality and CVD disability-adjusted life years (DALYs) in South American countries from 1990 to 2019 was explored. STUDY DESIGN AND METHODS: The Global Burden of Disease initiative exposure-response function was used to analyze the total PM2.5, ambient PM2.5, and household PM2.5-related CVD deaths and DALYs rates, per 100,000 individuals, in 12 South American countries between 1990 and 2019. The relative change in burden was also assessed by comparing the 1990-1994 to 2015-2019 periods. RESULTS: In 2019, 70,668 deaths and 1,736,414 DALYs due to CVD were attributed to total PM2.5 exposure in South America. Substantial regional heterogeneity was observed concerning the absolute change in PM2.5 concentration levels comparing 1990 to 2019. All South American countries observed a relative decline in CVD deaths and DALYs comparing the 1990-1994 to 2015-2019 periods. No country was able to reach the current World Health Organization 5 µg/m3 recommended limit in 2019. Predominantly, AAP was the greatest contributor to the CVD burden. CONCLUSION: Air pollution substantially impacted CVD in South America; however, this impact was heterogenous, and the relative reduction of HAP and AAP burden was also not uniform. Recognizing PM2.5 importance is key for developing target population and individual-level interventions, which could ultimately alleviate its burden.

High stretch induces endothelial dysfunction accompanied by oxidative stress and actin remodeling in human saphenous vein endothelial cells.

The rate of the remodeling of the arterialized saphenous vein conduit limits the outcomes of coronary artery bypass graft surgery (CABG), which may be influenced by endothelial dysfunction. We tested the hypothesis that high stretch (HS) induces human saphenous vein endothelial cell (hSVEC) dysfunction and examined candidate underlying mechanisms. Our results showed that in vitro HS reduces NO bioavailability, increases inflammatory adhesion molecule expression (E-selectin and VCAM1) and THP-1 cell adhesion. HS decreases F-actin in hSVECs, but not in human arterial endothelial cells, and is accompanied by G-actin and cofilin's nuclear shuttling and increased reactive oxidative species (ROS). Pre-treatment with the broad-acting antioxidant N-acetylcysteine (NAC) supported this observation and diminished stretch-induced actin remodeling and inflammatory adhesive molecule expression. Altogether, we provide evidence that increased oxidative stress and actin cytoskeleton remodeling play a role in HS-induced saphenous vein endothelial cell dysfunction, which may contribute to predisposing saphenous vein graft to failure.

Surgical treatment of endomyocardial fibrosis: a new approach.

Endomyocardial fibrosis has been treated surgically for many years. For complete removal of fibrosis from both ventricles by the classic technique, each atrioventricular (AV) valve was removed and replaced with a prosthesis. Relapse of endomyocardial fibrosis has not been observed after surgical correction. Reoperations have been carried out because of complications of valve prostheses. A new surgical technique for removal of ventricular fibrous tissue with preservation of the mitral and tricuspid valves was used in nine consecutive patients with endomyocardial fibrosis. Initial results show a reduction of pulmonary hypertension, mean right and left atrial pressures and end-diastolic pressures in both ventricles. Tricuspid annuloplasty was performed in seven patients and mitral annuloplasty in five. No valve prosthesis was used. There was no death and New York Heart Association functional class improved from class III or IV in the preoperative period to class I or II in the postoperative period. These data suggest that resection of endocardial fibrous tissue can be indicated early in the clinical course and performed with preservation of the AV valves.

Right mammary-coronary anastomosis in a patient with situs inversus.

We report a patient with situs inversus and ischemic heart disease who had myocardial revascularization with anastomosis of the right mammary artery to the anterior descending coronary artery.

Blood cardioplegia with warm reperfusion versus intermittent aortic crossclamping in myocardial revascularization. Randomized controlled trial.

To compare the efficiency of two methods of myocardial protection--blood cardioplegia and warm reperfusion with aspartate-glutamate enrichment of the solution versus intermittent aortic crossclamping--we randomized 60 patients for coronary artery bypass grafting. Hemodynamic parameters and hospital mortality were the end points. Pathologic antecedents and preoperative clinical conditions were similar in both group I (blood cardioplegia, 30 patients) and group II (aortic crossclamping, 30 patients). An average of 2.9 grafts per patient were performed in group I and 3.1 in group II. Duration of extracorporeal circulation was 100 +/- 28 minutes in group I and 85 +/- 23 minutes in group II (p < 0.05). The total time of aortic crossclamping was 62.8 +/- 24.5 minutes in group I and 44.3 +/- 14.9 minutes in group II (p < 0.05). There were comparable increases in cardiac index in group I and group II from the preoperative period to the first postoperative day, but none of these changes reached statistical significance. There were two deaths, one in the cardioplegia group (3.3%) and another in the intermittent aortic crossclamping group (3.3%). In conclusion, in myocardial revascularization, intermittent aortic crossclamping and blood cardioplegia with warm reperfusion enriched with aspartate-glutamate solution are methods of similar efficiency.

Angiographic evaluation of graft patency in minimally invasive direct coronary artery bypass grafting.

BACKGROUND: The objective of this report is to describe our experience using minimally invasive direct coronary artery bypass grafting and to evaluate angiographic patency of anastomoses. METHODS: A total of 120 patients (86 men) were operated on, with ages ranging from 30 to 83 years (mean = 61.2 years). Two access routes were used: for single left anterior descending coronary artery lesions an 8 cm anterior minithoracotomy was performed at the fourth left intercostal space. Extracorporeal circulation was not used. In the last 82 patients a restraining device was used for the regional reduction of heart beats. Coronary cineangiography was carried out between postoperative days 1 and 3 in 84 (70%) patients. Anastomoses were graded: grade A, no blocks; grade B, blocks of more than 50%; grade C, occlusion. This evaluation was performed for two different periods: in the first period a restraining device was not used and in the second period a restraining device was used. RESULTS: In the first study period (38 anastomoses) coronary cineangiography showed grade A, 79%, grade B, 5.2%, and grade C, 15.8%. In the second study period (62 anastomoses), angiography showed grade A, 90.4%, grade B, 6.4%, and grade C, 3.2%. Early mortality was 1.6%. CONCLUSIONS: Minimally invasive coronary artery bypass grafting is a good alternative for some groups of patients. Anastomotic results seem to be better when a restraining device is used.

A prospective comparison of Doppler echocardiography and postoperative angiography in the assessment of left internal thoracic artery graft in 72 patients submitted to minimally invasive direct coronary artery bypass.

BACKGROUND: Concerns have been raised regarding the accuracy of the left internal thoracic artery (LITA) anastomosis performed during minimally invasive direct coronary artery bypass (MIDCAB). In a prospective study, we tested the hypothesis that transthoracic Doppler echocardiography is an adequate technique to determine LITA patency when compared to "gold standard" postoperative angiography. METHODS: Seventy-two consecutive patients with single left anterior descending (LAD) coronary artery stenosis were submitted to MIDCAB performed on a beating heart using the LITA. All patients underwent transthoracic Doppler Echocardiography and angiography before discharge. LITA was considered patent when diastolic fraction (DF) of time-velocity integral was equal or greater than 0.5. FitzGibbon grading system was used to evaluate LITA patency by angiography (A=excellent; B=stenosis reducing caliber of anastomosis or trunk to < 50% of grafted coronary artery; O=occlusion). RESULTS: Angiography showed that LITA was patent in 70 (97.2%) patients, 69 of them been graded A. Adequate image and flow signal of the LITA was achieved in 65 (90.3%) patients, been considered patent in 61 (93.8%) of them. Comparison between echocardiography and angiography in these 65 patients showed a specificity of 96.8% and a sensitivity of 50%. In 7 (9.7%) patients in whom no adequate echocardiography signal was obtained, the LITA graft was normal in six and occluded in one. CONCLUSIONS: For patients whose LITA graft can be imaged, transthoracic Doppler echocardiography is highly specific and is a valuable method for noninvasive evaluation of LITA graft patency after MIDCAB.

[Coronary-cavitary fistula. Embryogenesis and report of a case surgically treated]. / Fístula coronário-cavitária. Embriogênese e relato de um caso tratado cirurgicamente.

The authors report the case of a 6-year-old female patient with congenital left coronary artery-right cardiac chamber fistula. The anomalous communication began at the left main coronary artery and extended to the top of the heart, throughout the myocardial muscle thickness. Diagnosis done by 2-D echocardiogram and cineangiography. The patient underwent to surgical treatment and both sides of the anomalous fistula was closed with pericardium bovinus patch. There was found no arterial ventricular branch originary of the fistulas course. The patient had a good post-operative outcome and there was no clinical or laboratorial evidences of myocardial ischemia.

[Hemorrhagic infarction due to myocardial reperfusion. Report of 4 cases]. / Infarto hemorrágico conseqüente à reperfusão miocárdica. Relato de quatro casos.

Four different clinical cases in which the myocardial reperfusion occurred after acute myocardial infarction, and was followed by significant hemorrhagic ventricular damage. We discuss some possible etiologic mechanism of the problem and present some methods of myocardial protection which are meant to lessen those negative effects of the reperfusion. We conclude setting the difficulty to determine the critical moment after which the myocardial reperfusion turns inefficient or even harmful.

[Valvular surgical treatment concurrent with myocardial revascularization]. / Tratamento cirúrgico valvar concomitante à revascularização do miocárdio.

PURPOSE: To study the morbidity and mortality due to valvar surgical treatment performed concomitantly to myocardial revascularization. METHODS: From 1650 patients submitted to mitral or aortic valve surgical treatment, 103 (6.24%) had it associated to myocardial revascularization. Coronary insufficiency was associated to aortic valvar lesion in 66 (64.0%) patients, group I, with mean age of 62.3 +/- 8 years; and in 37 (35.9%) patients with mitral valve lesion, group II, with mean age of 57.8 +/- 5.8 years. Diagnosis was based upon the anamnesis, physical examination and confirmed by cine-coronarographic findings. RESULTS: I-Complications at the immediate postoperative; a) mortality 11 (10.6%) patients, 6 (9.09%) from group I: by low cardiac output 3, uncontrolled arrhythmia 1, mediastinitis 1; acute infarction with cardiogenic shock 1, and 5 (134.5%) of group II: uncontrolled hemorrhage 2, sudden death 1, saphenous vein graft occlusion, respiratory insufficiency and sepsis 2; b) controlled intercurrences that increased the time of hospitalization: mental disorder 5 patients; CVA 7, diabetes decompensation 2, worsening of chronic renal insufficiency 1, upper level digestive hemorrhage 1 and respiratory insufficiency 3 patients. II-late postoperative complications of 77 (83.6%) patients which could be followed up during a period of 60 months: 1) mortality: 3 (3.89%) patients; 2 due to cardiomyopathy and 1 by acute myocardial infarction; 2) late evolution-functional capacity III (NYHA) by cardiomyopathy 6; I/II 68 patients; mild angina 6 patients, 2 underwent revascularization at the end of final 36-42 months. CONCLUSION: The clinical improvement and mortality indexes statistically similar to the isolate surgical acts stimulate us to keep up with such associate procedures.

[Bilateral diaphragmatic paralysis in the immediate postoperative period after cardiac surgery]. / Paralisia bilaterial do diafragma no pós-operatório imediato de cirurgia cardíaca.

A 56 years old man was submitted to an aortic replacement with mechanical prosthesis and to saphenous vein graft to the right coronary artery. He developed respiratory insufficiency after surgery which was finally related to bilateral diaphragmatic paralysis whose diagnosis was confirmed through thorax ultrasonography. The patient remained under ventilatory assistance with positive pressure for 75 days. The introduction of thorax ventilatory negative pressure (VNP), jacket type, allowed the tracheostomy closure. The patient gradually recovered his spontaneous breathing and was discharged after 90 days with instructions to use VNP at night. He returned to his normal professional activities, without auxiliary respiratory support, 40 days after his discharge.

[Inadvertent anastomosis to a coronary vein]. / Anastomose inadvertida para veia coronária.

The inadvertent revascularization of the anterior interventricular vein in patients with obstructive lesions of the anterior interventricular artery was the cause of recurrent angina in two patients. In one of the patients the bypass was performed with autogenous saphenous vein graft, in the other one the bypass was performed with the left internal thoracic artery. The reoperation was performed in one patient after one year and in the other one after five years from the first operation. In both cases the arteriovenous fistulas were interrupted and bypasses were performed using the left internal thoracic artery to the anterior interventricular arteries. The postoperative course was uneventful in both patients. In both patients the anterior interventricular arteries had intramyocardial course, what probably had lead into error during the first operation.

Myocardial revascularization with coronary endarterectomy. Stratification of risk factors for early mortality.

OBJECTIVE: To determine the risk factors for mortality related to myocardial revascularization when performed in association with coronary endarterectomy. METHODS: We assessed retrospectively 353 patients who underwent 373 coronary endarterectomies between January '89 and November '98, representing 3.73% of the myocardial revascularizations in this period of time. The arteries involved were as follows: right coronary artery in 218 patients (58.45%); left anterior descending in 102 patients (27.35%); circumflex artery in 39 patients (10.46%); and diagonal artery in 14 patients (3.74%). We used 320 (85.79%) venous grafts and 53 (14.21%) arterial grafts. RESULTS: In-hospital mortality among our patients was 9.3% as compared with 5.7% in patients with myocardial revascularizations without endarterectomy (p=0.003). Cause of death was related to acute myocardial infarction in 18 (54.55%) patients. The most significant risk factors for mortality identified were as follows: diabetes mellitus (p=0.001; odds ratio =7.168), left main disease (<0.001; 9.283), female sex (0.01; 3.111), acute myocardial infarction (0.02; 3.546), ejection fraction <35% (<0.001; 5.89), and previous myocardial revascularization (<0.001; 4.295). CONCLUSION: Coronary endarterectomy is related to higher mortality, and the risk factors involved are important elements of a poor outcome.

[Coronary artery perforation with rotational coronary atherectomy]. / Perfuração de artéria coronária com rotablator.

The authors describe a rare case of circumflex coronary artery perforation during rotational coronary atherectomy complicated with cardiac tamponade and good outcome. The possible causes of perforation are discussed and the burr oversize (burr/artery ratio was 0.58) was refused. Shortening and artery plicature (accordeon effect) might have been the cause of this event. Quantitative measurement was made in order to strengthen this hypothesis. It is emphasized the importance of selecting lesions that should be submitted to rotational coronary atherectomy.

Coronary bilateral ostial enlargement using the saphenous vein in a patient with syphilitic aortitis.

A patient with tertiary syphilis presenting with bilateral coronary ostial lesions and aortic regurgitation underwent surgical reconstruction of the coronary ostia by the anterior approach with autogenous saphenous vein grafting and substitution of the aortic valve with a bovine bioprosthesis. The procedure was easily performed and had good outcomes both early and late. The rarity of the association of a lesion in both coronary ostia with aortic regurgitation in syphilis and the surgical technique employed are discussed.

[Nuclear magnetic resonance imaging in the diagnosis of left ventricular pseudoaneurysm. An old problem, a new option]. / Ressonância nuclear magnética no diagnóstico de pseudoaneurisma de ventrículo esquerdo. Antigo problema, nova opção.

We describe the case of a 61 year-old female patient admitted to the hospital with acute lateral myocardial infarction, in pulmonary edema, who evolved to cardiogenic shock in the first hours. Transesophageal echodoppler-cardiogram and nuclear magnetic resonance imaging showed the diagnosis of a left ventricular pseudoaneurysm. Surgical repair was successfully undertaken.

Transmyocardial laser revascularization. Early clinical experience.

OBJECTIVE: To analyze the initial clinical experience of transmyocardial laser revascularization (TMLR) in patients with severe diffuse coronary artery disease. METHODS: Between February, 1998 and February, 1999, 20 patients were submitted to TMLR at the Heart Institute (InCor), University of São Paulo Medical School, Brazil, isolated or in association with conventional coronary artery bypass graft (CABG). All patients had severe diffuse coronary artery disease, with angina functional class III/IV (Canadian Cardiovascular Society score) unresponsive to medical therapy. Fourteen patients were submitted to TMLR as the sole therapy, whereas 6 underwent concomitant CABG. Fifty per cent of the patients had either been previously submitted to a CABG or to a percutaneous transluminal coronary angioplasty (PTCA). Mean age was 60 years, ranging from 45 to 74 years. RESULTS: All patients had three-vessel disease, with normal or mildly impaired left ventricular global function. Follow-up ranged from 1 to 13 months (mean 6.6 months), with no postoperative short or long term mortality. There was significant symptom improvement after the procedure, with 85% of the patients free of angina, and the remaining 15% of the patients showing improvement in functional class, as well as in exercise tolerance. CONCLUSION: This novel technique can be considered a low risk alternative for a highly selected group of patients not suitable for conventional revascularization procedures.

[Ischemic mitral valve insufficiency. Incidence, diagnosis and surgical treatment]. / Insuficiência valvar mitral isquêmica. Incidência, diagnóstico e tratamento cirúrgico.

PURPOSE: To study the incidence of ischemic mitral regurgitation (MR) and the mortality. METHODS: One-hundred-five cases of acute myocardial infarction (AMI) with MR were reviewed. Patients were divided in two groups: group A-59 (56.2%) necropsied patients without previous surgical procedures to correlate clinical pictures with the aim to determine the cause of death; group B-46 (43.8%) patients were submitted to surgical treatment. This group was subdivided in mild, moderate and severe forms of MR, and studied comparatively the type of surgical treatment and its evolution. RESULTS: Group A-23 (39%) patients with mild forms and predominant ischemic heart disease, responsible for death; 18 (30.5%) patients without previous diagnosis, masked by myocardial failure and 18 (30.5%) with severe MR and coronary heart disease; group B-14 (30.4%) patients died at the immediate post-operatory period. Higher mortality associated to ejection fraction (EF) below 35% (47.6%; p = 0.022), severe MR (41.7%; p = 0.044) and cardiogenic shock (52.9%; p = 0.14). In 41 (89.1%), the mitral valve repair was combined to coronary artery bypass grafting operation (CABG), in 4 (8.7%) this last procedure was made without mitral repair and in the remaining patients the surgery was limited to the valve. Mitral valvuloplasty was performed in 23 (50%) patients with 3 (13%) deaths, and in 19 (42.3%) the mitral valve was replaced with 9 (47.4%) deaths. CONCLUSION: The prognosis is related to the grade of EF and to the severity of MR. In mild to moderate forms, the surgical indication is due to the associated coronary heart disease and the valvuloplasty is preferred, in this instance. In severe forms, surgical intervention must be performed as soon as possible, before cardiogenic shock appears.