Harvesting the inferior epigastric artery through a transverse suprapubic incision.

The inferior epigastric artery has been used as an alternative arterial conduit in coronary artery bypass graft surgery. Its harvesting requires a single or double, long abdominal paramedian incision that is technically difficult and does not yield a good cosmetic result. We describe an alternative new approach to one or both inferior epigastric arteries through a transverse suprapubic cosmetic incision.

Limited Left Thoracotomy for Reoperative Coronary Artery Bypass Grafting without Cardiopulmonary Bypass for Circumflex Grafting in Patients with Patent Internal Thoracic Artery Graft.

Abstract Background: We describe our experience with the limited left thoracotomy strategy for reoperative coronary artery bypass graft (CABG)to the circumflex coronary artery system, emphasizing the indications, our particular operative technique, and early clinical follow-up. Methods: From January 2001 to January 2002, 8 consecutive patients underwent redo revascularization via limited left thoracotomy and without cardiopulmonary bypass. This operation was indicated for patients with recurrent myocardial ischemia confined to the lateral wall of the left ventricle, especially if a patent left internal thoracic artery (LITA)-to-left anterior descending coronary artery (LAD)graft was present. Results: All 8 patients underwent successful redo revascularization via limited left thoracotomy. Eight patients received 14 saphenous vein grafts (mean 1.7 grafts/patient). No instances of postoperative myocardial infarction or death occurred. During a follow-up period ranging from 1 to 12 months (mean, 5. 2 months), all patients were asymptomatic and without evidence of ischemia or infarction. Conclusions: For select patients who have patent LITA grafted into the LAD and who need redo CABG to the coronary artery circumflex system, the limited left thoracotomy approach without cardiopulmonary bypass is a safe operation and a less invasive alternative to repeat sternotomy and conventional CABG.

Mitral valve replacement and remodeling of the left ventricle in dilated cardiomyopathy with mitral regurgitation: initial results.

OBJECTIVE: This study evaluated the effects of a new method of mitral valve replacement on left ventricular (LV) remodeling and heart failure functional class. METHODS: Eight patients (6 men) with severe mitral regurgitation from end-stage dilated cardiomyopathy underwent surgery. Five patients were in functional class (FC) IV, 2 were in FC III and 1 was in FC III/IV. Age ranged from 33 to 63 years. Both the anterior and posterior leaflets of the mitral valve were divided into hemileaflets. The resultant 4 pedicles were displaced under traction toward the left atrium and anchored between the mitral annulus and an implanted valvular prosthesis. The beating heart facilitated ideal chordae tendineae positioning. RESULTS: All patients survived and were discharged from the hospital. After a mean follow-up period of 6.5 months (1-12 m), 5 patients were in FC I; 2 in FC I/II; and 1 in FC II. The preoperative ejection fraction ranged from 19% to 30% (mean: 25.7 +/- 3.4 %), and the postoperative ejection fraction ranged from 21% to 40% (mean: 31.1 +/- 5.8%). Doppler echocardiography showed evidence of LV remodeling in 4 patients, including lateral wall changes and a tendency of the LV cavity to return to its elliptical shape. CONCLUSION: This technique of mitral valve replacement, involving new positioning of the chordae tendineae, allowed LV remodeling and improvement in FC during this brief follow-up period.

On-pump or off-pump? Impact of risk scores in coronary artery bypass surgery.

OBJECTIVE: Remain controversies about the use of cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG). The aim of this study was to evaluate the impact of the 2000 Bernstein Parsonnet (2000BP) and EuroSCORE (EU) for choice CPB in CABG. METHODS: 1.551 consecutive patients underwent CABG. CPB was used in 1.121 (72.3%) patients. The performance of 2000BP and EU was assessed by calibration, discrimination and correlation tests. For both risk scores, increasing the value of the score and presence of CPB were directly related to a higher risk of death (P<0.05). Therefore with these two variables was constructed a logistic regression model for each risk score, in order to determine in which value of score the presence of CPB increases significantly the risk of death. RESULTS: The calibration, like the area under the ROC curve for the group with CPB [2000BP=0.80; EU=0.78] and without CPB [2000BP=0.81; EU=0.85] were appropriate. The Spearman correlation for groups with and without CPB was 0.66 (P<0.001) and 0.62 (P<0.001), respectively. Using the 2000BP, for a value>17.75 the presence of CPB increased the chance of death to 7.4 [CI 95% (4.4-12.3), P<0.0001]. With the EU, for a value >4.5 the presence of CPB increased the chance of death to 5.4 [CI 95% (3.3-9), P<0.0001]. CONCLUSION: In decision making, the 2000BP>17.75 or the EU>4.5 guide to identify patients who underwent CABG with CPB increases significantly the chance of death.

Previous percutaneous coronary intervention as risk factor for coronary artery bypass grafting.

BACKGROUND: Percutaneous coronary intervention (PCI) has increased as the initial revascularization strategy in chronic coronary artery disease. Consequently, more patients undergoing coronary artery bypass grafting (CABG) have history of coronary stent. OBJECTIVE: Evaluate the impact of previous PCI on in-hospital mortality after CABG in patients with multivessel coronary artery disease. METHODS: Between May/2007 and June/2009, 1099 consecutive patients underwent CABG on cardiopulmonary bypass. Patients with no PCI (n=938, 85.3%) were compared with patients with previous PCI (n=161, 14.6%). Logistic regression models and propensity score matching analysis were used to assess the risk-adjusted impact of previous PCI on in-hospital mortality. RESULTS: Both groups were similar, except for the fact that patients with previous PCI were more likely to have unstable angina (16.1% x 9.9%, P=0.019). In-hospital mortality after CABG was higher in patients with previous PCI (9.3% x 5.1%, P=0.034) and it was comparable with EuroSCORE and 2000 Bernstein-Parsonnet risk score. Using multivariate logistic regression analysis, previous PCI emerged as an independent predictor of postoperative in-hospital mortality (odds ratio 1.94, 95% CI 1.02-3.68, P=0.044) as strong as diabetes (odds ratio 1.86, 95% CI 1.07-3.24, P=0.028). After computed propensity score matching based on preoperative risk factors, in-hospital mortality remained higher among patients with previous PCI (odds ratio 3.46, 95% CI 1.10-10.93, P=0.034). CONCLUSIONS: Previous PCI in patients with multivessel coronary artery disease is an independent risk factor for in-hospital mortality after CABG.This fact must be considered when PCI is indicated as initial alternative in patients with more severe coronary artery disease.

The 2000 Bernstein-Parsonnet score and EuroSCORE are similar in predicting mortality at the Heart Institute, USP.

OBJECTIVE: To evaluate the performance of 2000 Bernstein-Parsonnet (2000BP) and additive EuroSCORE (ES) for predicting surgical mortality at the Heart Institute, University of São Paulo. METHODS: A prospective observational design. Seven hundred and seventy four patients were operated for coronary artery bypass graft, valve or combined procedure between May and October, 2007, were analyzed. The mortality was estimated with the 2000BP and ES. The correlation between expected mortality and observed mortality was validated through calibration and discrimination test. RESULTS: The patients were stratified into five groups for the 2000BP and three for the ES. The Hosmer-Lemeshow test for 2000BP (P = 0.70) and for ES (P = 0.39) indicate a good calibration. The ROC curve for the 2000BP = 0.84 and for the ES = 0.81 confirms that the models are good predictors (P<0.001). CONCLUSION: Both models are similar and adequate in predicting surgical mortality at the InCor-USP.

Spondylodiscitis and infectious endocarditis: a round-trip to be considered.

The association between spondylodiscitis and endocarditis was first reported in 1965 by de Sèze et al. The most common clinical picture of this association is musculoskeletal symptoms preceding endocarditis diagnosis, but we report here a case of spondylodiscitis complicating endocarditis in its late course. A 70-year-old man, with an established diagnosis of mitral valve endocarditis caused by Streptococcus intermedius, early submitted to surgical treatment because of heart failure, who had an uneventful recovery up to the 12th day of antibiotic therapy when he presented intensive backache, with tenderness in the two lower lumbar vertebras. Spondylodiscitis was confirmed by a magnetic resonance imaging and the treatment was non-esteroidal anti-inflammatory and analgetics drug, with good results, and prolongation of antibiotic treatment up to 3 months. Appropriate diagnosis of this association has important consequences, as the need of a longer antibiotic therapy course, which can range from 6 weeks to 3 months.

Hybrid CABG: an alternative for perfusion time decrease.

OBJECTIVE: To evaluate the decrease of CPB time and its related complications in CABG using a hybrid alternative method. METHODS: Ninety patients were retrospectively analyzed between March 2000 and August 2006. All were treated with three or more grafts and divided into two groups: Group 1 was the hybrid group--45 patients who had been operated by the hybrid technique; Group 2 was the total group--45 patients operated in on-pump. RESULTS: In the hybrid group, the CPB time varied from 20 min. to 81 min. In the total group, the CPB time varied from 60 min. to 210 min. (p<0.001). The aorta cross-clamping time varied in the first group from 7 min. to 70 min. In Group 2, from 34 to 100 min. (p<0.001). A statistically significant difference was found between these two groups in relation to the occurrence of postoperative atrium fibrillation and renal dysfunction. CONCLUSION: Using the hybrid technique it is possible to reduce the CPB time, as well as the occurrence of some postoperative complications. Probably, this decreasing in atrial fibrillation and renal dysfunction incidences could be explained due to a less significant inflammatory activation, which is a consequence of a shorter CPB time.

Long-term follow-up of patients undergone coronary artery bypass grafting with exclusive use of arterial grafts.

OBJECTIVE: To evaluate the long-term results of the coronary artery bypass grafting with exclusive use of arterial grafts for patients with triple vessel disease. METHODS: We evaluated 136 patients who underwent isolated coronary artery bypass grafting between January 1995 and December 1997. 353 grafts were used for revascularization of 449 arteries (mean: 3.30 per patient). Grafts used were left internal thoracic artery (99.2%), right internal thoracic artery (56.6%), radial artery (87.5%), right gastroepiploic artery (20.5%) and one inferior epigastric artery. 76 (55.8%) patients received composite grafts ('Y' shape) and 66 (48.5%) patients received sequential anastomoses. RESULTS: Hospital mortality was 4.4%. In the long-term follow-up (9.5 to 12.8 years), 82.1% of the patients were free of cardiac events. 20 (17.9%) patients had hospital readmission due to cardiac events: 15 presented angina and five presented acute myocardial infarction, and three of them presented associated heart failure. Eighth (7.1%) patients needed coronary reintervention: one of them underwent coronary bypass reoperation and the others underwent coronary angioplasty with stent. Estimated probability of cardiac event-free was 98.2%, 95.4% e 84.2% at 1, 5 and 10 years follow-up respectively. There were 16 (14.2%) late deaths and four of them (3.6%) were cardiac-related. Actuarial 12.8-year-survival of all deaths was 85% in this group. CONCLUSION: Coronary artery bypass grafting with exclusive use of arterial grafts is a safe procedure for patients with triple vessel coronary disease with good long-term results.

Intervenção Coronariana Percutânea prévia como fator de risco para Revascularização Miocárdica / Previous percutaneous coronary intervention as risk factor for coronary artery bypass grafting

FUNDAMENTO: A Intervenção Coronariana Percutânea (ICP) vem aumentando na doença arterial coronariana crônica. Consequentemente, cada vez mais pacientes submetidos a Cirurgia de Revascularização Miocárdica (CRM) apresentam stent coronariano. OBJETIVO: Avaliar a influência do antecedente de stent coronariano na mortalidade hospitalar após CRM. MÉTODOS: Análise prospectiva com 1.099 pacientes consecutivos submetidos a CRM com circulação extracorpórea, entre maio/2007 e junho/2009. Pacientes sem ICP prévia (n = 938; 85,3%) foram comparados com pacientes com ICP prévia (n = 161; 14,6%), utilizando modelos de regressão logística e análise de pareamento de amostras. RESULTADOS: Ambos os grupos apresentavam semelhança em relação aos fatores de risco, exceto pela maior presença de pacientes com angina instável no grupo com ICP prévia (16,1% vs. 9,9%; p = 0,019). A mortalidade hospitalar após CRM foi maior entre os pacientes com ICP prévia (9,3% vs. 5,1%, p = 0,034), e foi semelhante à esperada em relação ao EuroSCORE e ao 2000 Bernstein-Parsonnet score. Na análise com regressão logística multivariada a ICP prévia emergiu como fator de risco independente para mortalidade hospitalar pós-operatória (odds ratio 1,94; IC 95% 1,02-3,68; p = 0,044) tão forte quanto diabetes (odds ratio 1,86; IC 95% 1,07-3,24; p = 0,028). Após o pareamento dos grupos, a mortalidade hospitalar continuou sendo maior entre os pacientes com ICP prévia, com odds ratio 3,46 ; IC 95% 1,10-10,93; p = 0,034. CONCLUSÃO: A ICP prévia em pacientes com doença coronariana multiarterial é fator de risco independente para mortalidade hospitalar após CRM. Tal fato deve ser considerado quando a ICP for indicada como alternativa inicial em pacientes com doença arterial coronariana mais avançada. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).

BACKGROUND: Percutaneous coronary intervention (PCI) has increased as the initial revascularization strategy in chronic coronary artery disease. Consequently, more patients undergoing coronary artery bypass grafting (CABG) have history of coronary stent. OBJECTIVE: Evaluate the impact of previous PCI on in-hospital mortality after CABG in patients with multivessel coronary artery disease. METHODS: Between May/2007 and June/2009, 1099 consecutive patients underwent CABG on cardiopulmonary bypass. Patients with no PCI (n=938, 85.3%) were compared with patients with previous PCI (n=161, 14.6%). Logistic regression models and propensity score matching analysis were used to assess the risk-adjusted impact of previous PCI on in-hospital mortality. RESULTS: Both groups were similar, except for the fact that patients with previous PCI were more likely to have unstable angina (16.1% x 9.9%, P=0.019). In-hospital mortality after CABG was higher in patients with previous PCI (9.3% x 5.1%, P=0.034) and it was comparable with EuroSCORE and 2000 Bernstein-Parsonnet risk score. Using multivariate logistic regression analysis, previous PCI emerged as an independent predictor of postoperative in-hospital mortality (odds ratio 1.94, 95% CI 1.02-3.68, P=0.044) as strong as diabetes (odds ratio 1.86, 95% CI 1.07-3.24, P=0.028). After computed propensity score matching based on preoperative risk factors, in-hospital mortality remained higher among patients with previous PCI (odds ratio 3.46, 95% CI 1.10-10.93, P=0.034). CONCLUSIONS: Previous PCI in patients with multivessel coronary artery disease is an independent risk factor for in-hospital mortality after CABG.This fact must be considered when PCI is indicated as initial alternative in patients with more severe coronary artery disease. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).

Com ou sem CEC?: impacto dos escores de risco na cirurgia de revascularização miocárdica / On-pump or off-pump?: impact of risk scores in coronary artery bypass surgery

OBJETIVO: Permanecem as controvérsias sobre a utilização de circulação extracorpórea (CEC) na cirurgia de revascularização miocárdica (CRM). O objetivo deste estudo foi avaliar o impacto do 2000 Bernstein Parsonnet (2000BP) e EuroSCORE (EU) para escolha de CEC na CRM. MÉTODOS: Foram submetidos à CRM 1.551 pacientes consecutivos. CEC foi utilizada em 1.121 (72,3%) pacientes. O desempenho do 2000BP e EU para a amostra foi avaliado mediante testes de calibração, discriminação e correlação. Para ambos os escores de risco, o aumento do valor do escore e a presença de CEC tiveram relação direta com maior chance de óbito (P<0,05). Portanto, com essas duas variáveis foi construído um modelo de regressão logística para cada escore de risco, com a finalidade de determinar em que valor do escore a presença de CEC aumenta significativamente a chance de óbito. RESULTADOS: A calibração, ao igual que a área abaixo da curva ROC para o grupo com CEC [2000BP=0,80; EU=0,78] e sem CEC [2000BP=0,81; EU=0,85] foram adequadas. A correlação de Spearman para os grupos com e sem CEC foi de 0,66 (P<0,001) e 0,62 (P<0,001), respectivamente. No 2000BP, para um valor>17,75, a presença de CEC aumentou a chance de óbito para 7,4 [IC95% (4,4-12,3), P<0,0001]. No EU, para um valor>4,5, a presença de CEC aumentou a chance de óbito para 5,4 [IC95% (3,3-9), P<0,0001]. CONCLUSÃO: Na tomada de decisões, o 2000BP>17,75 ou o EU>4,5 orientam a identificar pacientes que quando submetidos a CRM com CEC têm chance de óbito aumentada significativamente.

OBJECTIVE: Remain controversies about the use of cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG). The aim of this study was to evaluate the impact of the 2000 Bernstein Parsonnet (2000BP) and EuroSCORE (EU) for choice CPB in CABG. METHODS: 1.551 consecutive patients underwent CABG. CPB was used in 1.121 (72.3%) patients. The performance of 2000BP and EU was assessed by calibration, discrimination and correlation tests. For both risk scores, increasing the value of the score and presence of CPB were directly related to a higher risk of death (P<0.05). Therefore with these two variables was constructed a logistic regression model for each risk score, in order to determine in which value of score the presence of CPB increases significantly the risk of death. RESULTS: The calibration, like the area under the ROC curve for the group with CPB [2000BP=0.80; EU=0.78] and without CPB [2000BP=0.81; EU=0.85] were appropriate. The Spearman correlation for groups with and without CPB was 0.66 (P<0.001) and 0.62 (P<0.001), respectively. Using the 2000BP, for a value>17.75 the presence of CPB increased the chance of death to 7.4 [CI 95% (4.4-12.3), P<0.0001]. With the EU, for a value >4.5 the presence of CPB increased the chance of death to 5.4 [CI 95% (3.3-9), P<0.0001]. CONCLUSION: In decision making, the 2000BP>17.75 or the EU>4.5 guide to identify patients who underwent CABG with CPB increases significantly the chance of death.

Mitral valve replacement with chordae tendineae preservation, traction and fixation in end-stage dilated cardiomyopathy.

OBJECTIVE: This study aimed at evaluating results of mitral valve replacement using a new technique of complete chordae tendineae adjustment for left ventricular remodeling. METHODS: Twenty end-stage idiopathic dilated cardiomyopathy patients with severe functional mitral valve regurgitation underwent mitral valve replacement. Seventeen (85%) were in functional class IV. Both anterior and posterior leaflets of the mitral valve were divided to obtain 4 pillars of chordae tendineae. These were displaced with traction toward the left atrium and anchored between the mitral annulus and a valvular prosthesis. To evaluate the left ventricular remodeling, Doppler echocardiography was performed. For statistical analysis, variance analysis and the Friedman's test were employed. RESULTS: Two (10%) early deaths occurred. Kaplan-Meyer showed survival at one year post-operative was 85%, 2 years it was 44%, at 3 years 44%, at 4 years 44% and at 5 years it was 44%. In the 48- and 54-month follow-ups, the McNemar test showed improvement in the functional class (p<0.001). In the third month of follow-up, variance analysis showed improvement in the ejection fraction (p=0.008) and reductions of the end diastolic diameter (p=0.038), end systolic diameter (p=0.008), end systolic volume (p=0.029) and end diastolic volume (p=0.009). No statistical differences were noted in the systolic volume. Comparing pre-operative and third- and six-month follow-ups, the Friedman test showed no statistical differences for all studied variables. Variance analyses between pre, three-month and final evaluations showed no significant differences. CONCLUSION: This technique of mitral valve replacement improved the left ventricle ejection fraction and decreased the end diastolic and systolic diameters and the end systolic diastolic volumes up to the third month of follow-up. From then on the variables stabilized.

Os escores 2000 Bernstein-Parsonnet e EuroSCORE são similares na predição da mortalidade no Instituto do Coração-USP / The 2000 Bernstein-Parsonnet score and EuroSCORE are similar in predicting mortality at the Heart Institute, USP

OBJETIVO: Avaliar o desempenho do 2000 Bernstein-Parsonnet (2000BP) e EuroSCORE aditivo (ES) na predição de mortalidade cirúrgica no Instituto do Coração da Universidade de São Paulo (InCor-USP). MÉTODOS: Desenho prospectivo e observacional. Setecentos e quarenta e quatro pacientes consecutivos submetidos à cirurgia de revascularização miocárdica, valvar ou associada, entre maio e outubro de 2007, foram analisados. A mortalidade foi calculada com os escores 2000BP e ES. A correlação entre mortalidade estimada e mortalidade observada foi validada mediante testes de calibração e discriminação. RESULTADOS: Os pacientes foram estratificados em cinco grupos para o 2000BP e três para o ES. O teste de Hosmer Lemeshow para o 2000BP (P = 0,70) e para o ES (P = 0,39) indica uma boa calibração. A curva ROC para o 2000BP = 0,84 e para o ES = 0,81 confirma que os modelos são bons preditores (P < 0,001). CONCLUSÃO: Ambos os modelos são similares e adequados na predição de mortalidade cirúrgica no InCor-USP.

OBJECTIVE: To evaluate the performance of 2000 Bernstein-Parsonnet (2000BP) and additive EuroSCORE (ES) for predicting surgical mortality at the Heart Institute, University of São Paulo. METHODS: A prospective observational design. Seven hundred and seventy four patients were operated for coronary artery bypass graft, valve or combined procedure between May and October, 2007, were analyzed. The mortality was estimated with the 2000BP and ES. The correlation between expected mortality and observed mortality was validated through calibration and discrimination test. RESULTS: The patients were stratified into five groups for the 2000BP and three for the ES. The Hosmer-Lemeshow test for 2000BP (P = 0.70) and for ES (P = 0.39) indicate a good calibration. The ROC curve for the 2000BP = 0.84 and for the ES = 0.81 confirms that the models are good predictors (P<0.001). CONCLUSION: Both models are similar and adequate in predicting surgical mortality at the InCor-USP.

Coronary artery bypass grafting in acute myocardial infarction. Analysis of preoperative predictors of mortality.

OBJECTIVE: To assess preoperative predictors of mortality in patients undergoing coronary artery bypass grafting (CABG) within the first 30 days of acute myocardial infarction (AMI). METHODS: Between March 1998 and July 2002, 753 AMI patients were consecutively and prospectively entered into a database, 135 (17.9%) of whom underwent isolated CABG and were enrolled in this study. The following prognostic factors were assessed by multivariate analysis: age, gender, diabetes, history of previous AMI, CABG or coronary angioplasty (PTCA), anterior infarct location, Q-wave AMI, the use of fibrinolytics, elapsed time from AMI to the procedure, and presence of complications in the preoperative period. RESULTS: Overall in-hospital mortality was 6.7%, ranging from 12.5% in patients with preoperative complications to 1.4% in those with no complications. Only history of previous angioplasty (p = 0.037) and cardiogenic shock (p = 0.002) showed a statistically significant correlation with postoperative mortality. The use of thrombolytics, on the other hand, in the initial management of AMI showed a negative correlation with mortality (p = 0.035). CONCLUSION: CABG in the acute phase of MI is associated with distinct operative mortality, depending on the patients preoperative clinical condition. Among those factors analyzed, preoperative cardiogenic shock and history of previous angioplasty were predictive of worse prognosis in this group of patients.

Dura mater mitral and tricuspid bioprostheses: 30 years of follow-up.

PURPOSE: The dura mater bioprosthesis was developed in the Department of Cardiopneumology of the Hospital das Clínicas of the University of São Paulo Medical School in 1971. Here, we present the clinical results of the dura mater bioprosthesis over 30 years of follow-up. METHODS: We studied 70 consecutive patients who underwent mitral or tricuspid valve replacement with a dura mater bioprosthesis between January 1971 and August 1972. RESULTS: The early mortality was 10% (7 patients). The follow-up was 87% complete (9 patients were lost to follow-up). Two patients were alive and asymptomatic 30 years after valve replacement; 33 patients underwent reoperations due to valve dysfunction, and 19 died during the follow-up period. At 30 years, the actuarial survival was 49.2 +/- 8.6%; freedom from rupture, 27.0 +/- 10.2%; freedom from calcification, 78.8 +/- 8.6%; and freedom from reoperation, 18.8 +/- 7.5%. CONCLUSIONS: The dura mater bioprosthesis played an important role in the treatment of patients with mitral and tricuspid valve disease. The low rate of thromboembolism and the long period of follow-up without evidence of valve dysfunction, which occurred for several of our patients, are important characteristics of these bioprosthesis.

Spondylodiscitis and infectious endocarditis: a round-trip to be considered

The association between spondylodiscitis and endocarditis was first reported in 1965 by de Sèze et al. The most common clinical picture of this association is musculoskeletal symptoms preceding endocarditis diagnosis, but we report here a case of spondylodiscitis complicating endocarditis in its late course. A 70-year-old man, with an established diagnosis of mitral valve endocarditis caused by Streptococcus intermedius, early submitted to surgical treatment because of heart failure, who had an uneventful recovery up to the 12th day of antibiotic therapy when he presented intensive backache, with tenderness in the two lower lumbar vertebras. Spondylodiscitis was confirmed by a magnetic resonance imaging and the treatment was non-esteroidal anti-inflamatory and analgetics drug, with good results, and prolongation of antibiotic treatment up to 3 months. Appropriate diagnosis of this association has important consequences, as the need of a longer antibiotic therapy course, which can range from 6 weeks to 3 months.

Revascularização híbrida do miocárdio: uma alternativa para reduzir o tempo de perfusão / Hybrid CABG: an alternative for perfusion time decrease

OBJETIVO: Avaliar a possibilidade da redução do tempo de circulação extracorpórea (CEC) e das complicações relacionadas a esta variável na revascularização do miocárdio (RM), utilizando o método híbrido como alternativa. MÉTODOS: Noventa pacientes foram analisados, retrospectivamente, entre março/2000 e agosto/2006. Todos foram revascularizados com três ou mais enxertos e divididos em doisgrupos: híbrido - 45 pacientes que foram operados pela técnica híbrida; total - 45 pacientes operados com CEC. RESULTADOS: No grupo híbrido, o tempo de CEC variou de 20 a 81 minutos e, no grupo total, de 60 a 210 minutos (p<0,001). O tempo de pinçamento aórtico variou de 7 a 70 minutos no primeiro grupo e de 34 a 100 minutos (p<0,001) no segundo grupo. Foi encontrada diferença estatisticamente significativa entre os grupos em relação à incidência de fibrilação atrial e à disfunção renal. CONCLUSÃO: Utilizando-se a técnica híbrida é possível reduzir o tempo de CEC e a incidência de algumas complicações pós-operatórias. Provavelmente, esta redução nas incidências de fibrilação atrial e disfunção renal podem ser explicadas por uma redução na resposta da inflamatória conseqüente a um tempo de CEC menor.

OBJECTIVE: To evaluate the decrease of CPB time and its related complications in CABG using a hybrid alternative method. METHODS: Ninety patients were retrospectively analyzed between March 2000 and August 2006. All were treated with three or more grafts and divided into two groups: Group 1 was the hybrid group - 45 patients who had been operated by the hybrid technique; Group 2 was the total group - 45 patients operated in on-pump. RESULTS: In the hybrid group, the CPB time varied from 20 min. to 81 min. In the total group, the CPB time varied from 60 min. to 210 min. (p<0.001). The aorta cross-clamping time varied in the first group from 7 min. to 70 min. In Group 2, from 34 to 100 min. (p<0.001). A statistically significant difference was found between these two groups in relation to the occurrence of postoperative atrium fibrillation and renal dysfunction. CONCLUSION: Using the hybrid technique it is possible to reduce the CPB time, as well as the occurrence of some postoperative complications. Probably, this decreasing in atrial fibrillation and renal dysfunction incidences could be explained due to a less significant inflammatory activation, which is a consequence of a shorter CPB time.

Seguimento a longo prazo de pacientes submetidos à revascularização do miocárdio com uso exclusivo de enxertos arteriais / Long-term follow-up of patients undergone coronary artery bypass grafting with exclusive use of arterial grafts

OBJETIVO: Avaliar os resultados a longo prazo da cirurgia de revascularização do miocárdio com o uso exclusivo de enxertos arteriais em pacientes com doença coronariana triarterial. MÉTODOS: Avaliamos 136 pacientes submetidos a cirurgia de revascularização do miocárdio isolada, no período janeiro de 1995 e dezembro de 1997. Utilizaram-se 353 enxertos para revascularizar 449 artérias (média: 3,30 por paciente). Foram utilizadas a artéria torácica interna esquerda (99,2 por cento), artéria torácica interna direita (56,6 por cento), artéria radial (87,5 por cento), artéria gastroepiplóica direita (20,5 por cento) e uma artéria epigástrica inferior. Setenta e seis (55,8 por cento) pacientes receberam enxertos compostos (em "Y") e 66 (48,5 por cento) receberam anastomoses seqüenciais. RESULTADOS: A mortalidade hospitalar foi de 4,4 por cento. No seguimento a longo prazo, (9,5 a 12,8 anos), 82,1 por cento dos pacientes não apresentaram nenhum evento cardíaco. Vinte (17,9 por cento) pacientes necessitaram de reinternação por eventos cardiovasculares; 15 com angina e cinco com infarto agudo do miocárdio, sendo que três apresentaram insuficiência cardíaca associada. Oito (7,1 por cento) pacientes necessitaram de reintervenção por doença coronariana, sendo um reoperado e os demais submetidos a angioplastia com stent. A probabilidade estimada livre de eventos cardíacos foi de 98,2 por cento, 95,4 por cento e 84,2 por cento em 1, 5 e 10 anos, respectivamente. Ocorreram 16 (14,2 por cento) óbitos tardios, sendo quatro deles (3,6 por cento) de causa cardíaca. Sobrevida actuarial em 12,8 anos por todas as causas foi de 85 por cento neste grupo. CONCLUSÃO: Revascularização do miocárdio com o uso exclusivo de enxertos arteriais em pacientes com doença coronariana triarterial é um procedimento seguro, com bons resultados a longo prazo.

OBJECTIVE: To evaluate the long-term results of the coronary artery bypass grafting with exclusive use of arterial grafts for patients with triple vessel disease. METHODS: We evaluated 136 patients who underwent isolated coronary artery bypass grafting between January 1995 and December 1997. 353 grafts were used for revascularization of 449 arteries (mean: 3.30 per patient). Grafts used were left internal thoracic artery (99.2 percent), right internal thoracic artery (56.6 percent), radial artery (87.5 percent), right gastroepiploic artery (20.5 percent) and one inferior epigastric artery. 76 (55.8 percent) patients received composite grafts ("Y" shape) and 66 (48.5 percent) patients received sequential anastomoses. RESULTS: Hospital mortality was 4.4 percent. In the long-term follow-up (9.5 to 12.8 years), 82.1 percent of the patients were free of cardiac events. 20 (17.9 percent) patients had hospital readmission due to cardiac events: 15 presented angina and five presented acute myocardial infarction, and three of them presented associated heart failure. Eigth (7.1 percent) patients needed coronary reintervention: one of them underwent coronary bypass reoperation and the others underwent coronary angioplasty with stent. Estimated probability of cardiac event-free was 98.2 percent, 95.4 percent e 84.2 percent at 1, 5 and 10 years follow-up respectively. There were 16 (14.2 percent) late deaths and four of them (3.6 percent) were cardiac-related. Actuarial 12.8-year-survival of all deaths was 85 percent in this group. CONCLUSION: Coronary artery bypass grafting with exclusive use of arterial grafts is a safe procedure for patients with triple vessel coronary disease with good long-term results.

Substituição da valva mitral com tração dos músculos papilares em pacientes com miocardiopatia dilatada / Mitral valve replacement with chordae tendineae preservation, traction and fixation in end-stage dilated cardiomyopathy

OBJETIVO: Avaliar a geometria e a função do ventrículo esquerdo (VE) após a troca mitral com tração e fixação dos papilares, em portadores de insuficiência cardíaca terminal com insuficiência mitral secundária. MÉTODO: Dos 20 pacientes avaliados, 70 por cento eram homens, com idade média de 50,2 anos e 55 por cento recebiam inotrópicos. A fração de ejeção (FEVE) foi menor que 30 por cento em todos; 85 por cento estavam em classe funcional (CF) IV. Dezoito receberam próteses de pericárdio bovino e dois, mecânicas. Os períodos considerados foram: 3, 6, 12 e 18 meses. As variáveis consideradas: volume sistólico do VE (VS), a FEVE, os diâmetros sistólico e diastólico finais (DSF e DDF) e os volumes sistólico e diastólico finais (VSF e VDF). No estudo estatístico, empregou-se da análise de variância (AV) e o teste de Friedmann (F). A sobrevida foi aferida pelo método de Kaplan-Meyer. RESULTADOS: Dois (10 por cento) faleceram no período imediato. A sobrevida no primeiro ano foi de 85 por cento, no segundo, 44 por cento, no terceiro, 44 por cento, no quarto, 44 por cento e no quinto, 44 por cento. A comparação entre pré e 3 meses, empregando-se a AV, não revelou alteração significativa para o VS (p=0,086). Houve acréscimo da FEVE (p=0,008) e decréscimo do DDF (p=0,038); do DSF (p=0,008); do VDF (p=0,029) e do VSF (p=0,009). Os momentos pré, 3 e 6 meses, com o teste F, não revelaram alterações. Entre os momentos pré, 3 meses e final, empregando-se a AV, não houve significância. CONCLUSÃO: Há melhora da FEVE, dos VDF, VSF, DDF e DSF; até o terceiro mês. A partir de então, as variáveis permanecem estáveis.

OBJECTIVE: This study aimed at evaluating results of mitral valve replacement using a new technique of complete chordae tendineae adjustment for left ventricular remodeling. METHODS: Twenty end-stage idiopathic dilated cardiomyopathy patients with severe functional mitral valve regurgitation underwent mitral valve replacement. Seventeen (85 percent) were in functional class IV. Both anterior and posterior leaflets of the mitral valve were divided to obtain 4 pillars of chordae tendineae. These were displaced with traction toward the left atrium and anchored between the mitral annulus and a valvular prosthesis. To evaluate the left ventricular remodeling, Doppler echocardiography was performed. For statistical analysis, variance analysis and the Friedman's test were employed. RESULTS: Two (10 percent) early deaths occurred. Kaplan-Meyer showed survival at one year post-operative was 85 percent, 2 years it was 44 percent, at 3 years 44 percent, at 4 years 44 percent and at 5 years it was 44 percent. In the 48- and 54-month follow-ups, the McNemar test showed improvement in the functional class (p<0.001). In the third month of follow-up, variance analysis showed improvement in the ejection fraction (p=0.008) and reductions of the end diastolic diameter (p=0.038), end systolic diameter (p=0.008), end systolic volume (p=0.029) and end diastolic volume (p=0.009). No statistical differences were noted in the systolic volume. Comparing pre-operative and third- and six-month follow-ups, the Friedman test showed no statistical differences for all studied variables. Variance analyses between pre, three-month and final evaluations showed no significant differences. CONCLUSION: This technique of mitral valve replacement improved the left ventricle ejection fraction and decreased the end diastolic and systolic diameters and the end systolic diastolic volumes up to the third month of follow-up. From then on the variables stabilized.