[Show abstract][Hide abstract] ABSTRACT: Patients with congenital heart disease who underwent pulmonary valvotomy or surgery to open the pulmonary valve ring are prone to develop residual pulmonary insufficiency or stenosis that may lead to right heart failure with clinical deterioration. These children require multiple interventions throughout their lives, which impose a high rate of morbidity and mortality.
To develop a less invasive technique for implantation of a valved prosthesis through the right ventricle.
The valved prosthesis consists of an auto expanding metal stent built with nitinol, surrounded with polyester, where the three leaflets of bovine pericardium were mounted. Twelve pigs were used to perform the implants. Echocardiographic control was performed immediately after implantation and one, four, eight and 12 weeks.
One animal showed reflux of moderate to severe and three mild reflux. Transvalvular gradients measured before implantation ranged from 3 to 6 mmHg and that soon after the implant was increased, ranging from 7 to 45 mmHg. There was a decrease in these gradients during follow up and in only four of the twelve animals the gradients were above 20 mmHg. Thrombus formation occurred in the prosthesis of six animals, and this was the most frequent complication.
These findings highlight the need for studies with the use of anticoagulants and antiplatelet, an attempt to reduce this event. The study aims to contribute for the start of the use of prosthetic heart valves that could be implanted through minimally invasive techniques without the use of cardiopulmonary bypass.
Full-text · Article · Sep 2011 · Brazilian Journal of Cardiovascular Surgery
[Show abstract][Hide abstract] ABSTRACT: A cirurgia de revascularização do miocárdio (CRM) é um procedimento bem estabelecido com indicações atuais precisas. O advento e a disseminação dessa técnica foram possíveis após a introdução do angiograma coronário. Embora muitos métodos de avaliação tenham evoluído nos últimos anos, nenhum conseguiu substituir o angiograma coronário invasivo como exame pré-operatório. A tomografia computadorizada (TC) emergiu como uma alternativa ao angiograma coronário invasivo. O presente relato descreve dois casos de CRM realizadas usando-se apenas a TC como técnica de avaliação anatômica das artérias coronárias pré-operatória.
[Show abstract][Hide abstract] ABSTRACT: Coronary artery bypass graft (CABG) is a well established procedure with current precise indications. The advent and spread of this technique was possible after the introduction of the coronary angiogram. Although many evaluation methods have been developed in the past years, to date, none have been able to replace the invasive coronary angiogram as a pre-operative exam. Computed tomography angiography (CTA) has emerged as an alternative to invasive coronary angiogram. In this report we describe two CABG cases that were performed using only this technique as a pre-operative anatomic coronary arteries evaluation.
[Show abstract][Hide abstract] ABSTRACT: Neoplasms are among the most common solid-organ transplant complications, occurring in 11.7% of all transplant recipients and in 6% to 15% of heart transplant recipients, according to early studies. The skin and lips are the most common sites for neoplasms, but they also appear in the setting of post-transplant lymphoproliferative disease. Post-transplant lymphoproliferative disease (PTLD) is one of the most serious complications of long-term immunosuppression after transplantation. Herein we report the case of a 53-year-old man who underwent orthotopic heart transplantation for Chagas cardiomyopathy and had developed a mass in the left ventricle with symptomatic ventricle outflow obstruction. The patient was initially treated with anti-coagulation but his condition worsened and he was given emergency surgery to remove the mass. The patient recovered well and histologic assessment revealed PTLD as the etiologic culprit. Lymphoproliferative disorders are the second most frequently identified malignant neoplasm after heart transplantation. B-cell tumors are the most common histologically and are associated with infection by Epstein-Barr virus in 80% to 90% of cases.
No preview · Article · Mar 2009 · The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation
[Show abstract][Hide abstract] ABSTRACT: OBJETIVO: Analisar o resultado de uma alternativa operatória que envolve a correção da regurgitação mitral pelo implante de uma prótese de diâmetro menor do que o anel mitral e redução da esfericidade do ventrículo esquerdo com tração dos músculos papilares em direção ao anel, em portadores de miocardiopatia terminal e regurgitação mitral secundária. MÉTODO: Entre dezembro de 1995 e setembro de 2005, 116 pacientes foram operados com a técnica proposta. Os pacientes foram analisados de acordo com critérios clínicos, dados ecocardiográficos e aspectos morfológicos do ventrículo esquerdo. RESULTADOS: A mortalidade hospitalar foi 16,3% (19/116). O tempo médio de acompanhamento foi 38±16 meses. Após a alta hospitalar, a curva atuarial de sobrevida permaneceu estável com aceitável taxa de mortalidade tardia. Observou-se importante melhora clínica dos pacientes e de alguns parâmetros ecocardiográficos, especialmente redução da esfericidade do ventrículo esquerdo. CONCLUSÃO: Apesar da alta mortalidade operatória, a técnica apresentada representa uma alternativa aceitável no tratamento de portadores de miocardiopatia terminal com insuficiência cardíaca refratária associada à regurgitação mitral secundária.
Preview · Article · Sep 2006 · Revista Brasileira de Cirurgia Cardiovascular
[Show abstract][Hide abstract] ABSTRACT: Surgical myocardial revascularization without cardiopulmonary bypass (CPB) is not new, with the first consecutive series of patients appearing in the early eighties. There has been increased interest in this alternative approach, especially in patients with comorbidities. There is controversy regarding advantages, risks, and usefulness of this method of myocardial revascularization. We herein report a consecutive series of 3,866 patients, from the first case in September 1981 to the last in November 2004, analyzing applicability, mortality, morbidity, and surgical technique.
From September 1981 to November 2004, 3,866 consecutive patients were revascularized without CPB. This figure represents an overall applicability of 30.8% considering a total of 12,553 revascularization procedures performed during this time. There were 2,822 males (73%) with ages from 12 to 93 years (median, 62 +/- 14). Mean grafts per patient was 1.9, and the internal mammary artery was used in 87.3% of cases. The main indications for surgery were chronic coronary insufficiency (89% of cases) and failure of angioplasty or stenting.
Hospital mortality was 1.9%, with low incidence of cerebrovascular accident (5 cases in the entire series). Morbidity, considering major postoperative complications, occurred in 12.5% of the patients. The applicability of the off-pump technique was 18% of cases in the beginning of our experience, increasing to 49% in the last 5 years with the use of stabilizers and maneuvers to expose posterior coronary branches.
Off-pump coronary surgery is an alternative method of myocardial revascularization that should be considered for every patient. The preference of this technique over conventional revascularization should be based on the surgeon's own experience, on the patient's preoperative condition and on the coronary anatomy. Off-pump myocardial revascularization represents an important development in coronary artery surgery. Over the years it has evolved into a valid form of surgery with the same safety as the conventional operation and with more advantages in high risk patients.
Preview · Article · Feb 2006 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: Objective: To present a new surgical approach that consists of the implantation of a mitral prosthesis smaller than the annulus with traction of the papillary muscles to reduce the sphericity of the left ventricle. Method: Between December 1995 and September 2005, 116 heart disease patients were operated, all of whom were at end-stage despite of full medication. The patients were analysed according to clinical criteria, echocardiographic findings and morphology of the left ventricle. Results: Hospital mortality was 16.3% (19/116) and midterm follow-up (38 ± 16 months) showed evidence of improvement in the clinical status and some echocardiographic parameters, in particular reduction of the sphericity of the left ventricle. Conclusion: This technique, despite of the high mortality rate, offers a promising therapeutic alternative for the treatment of patients in refractory heart failure with cardiomyopathy associated to moderate or severe secondary mitral regurgitation.
No preview · Article · Jan 2006 · Brazilian Journal of Cardiovascular Surgery
[Show abstract][Hide abstract] ABSTRACT: Neurologic and neuropsychologic dysfunctions remain important complications of coronary artery bypass grafting (CABG)  and have largely been attributed to adverse effects of cardiopulmonary bypass (CPB); nonetheless, patients undergoing CABG are intrinsically at a higher risk of developing neurologic injuries. Microemboli are thought to be one of the major causes of neurologic and neuropsychologic complications after CABG. Transcranial Doppler (TCD) and transesophageal echocardiography (TEE) monitoring became useful tools to detect and quantify emboli , and their occurrence has been particularly related to CPB techniques (bubble oxygenators and nonfiltered bypass) [3–6] and also to specific operative events mainly attributable to aortic atheroma, such as insertion of aortic cannula, bypass onset and discontinuation, aortic cross-clamping and declamping [2, 7, 8].
No preview · Article · Nov 1999 · Cerebrovascular Diseases
[Show abstract][Hide abstract] ABSTRACT: A new form of postperfusion manifestation is detailed, a vasoplegic syndrome presenting in the postoperative period after cardiopulmonary bypass (CPB) heart surgery.
This retrospective study included sixteen patients who underwent cardiovascular surgery using CPB and exhibited clinical and hemodynamic features compatible with vasoplegic syndrome. The technique of CPB was hypothermic (28 degrees C) in 15 and normothermic in 1 patient, and hypothermic blood cardioplegia was employed in all patients, except 1. The mean CPB time was 121 minutes, ranging from 80 to 210 minutes.
The patients presented a severe feature comprising hypotension, tachycardia, normal or elevated cardiac output, low systemic vascular resistance and decreased filling pressures. Fluid administration alone was not capable of restoring hemodynamic parameters. Physical examination revealed normal capillary filling at the extremities although oliguria and hypotension were observed. These patients needed a high dosage of vasoconstrictor drugs (norepinephrine) for blood pressure control but even high dose norepinephrine did not produce the classical situation of cool extremities and weak peripheral pulses, with increased morbidity and mortality. Severe systemic complications could develop if the vasoplegic syndrome persisted 36-48 hours after its onset. All patients, except 3, presented associated postoperative complications and 4 patients died. The characteristics of vasoplegic syndrome are similar to those observed in septic shock, where the alterations are mediated by cytokines and tumor necrosis factor-alpha.
The appearance of vasoplegic syndrome augmented operative morbidity with a consequent increased risk to the patient in the early postoperative period.
No preview · Article · Nov 1998 · The Journal of cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: To analyze the results of myocardial revascularization through small left anterior thoracotomy utilizing the left thoracic internal artery (LTIA) to left anterior descending coronary artery (LAD) without cardiopulmonary bypass, in order to simplify the operative procedure.
From September/95 till August/96 we operated on 45 patients with lesions in LAD or LAD and diagonal arteries that were revascularized with an anastomoses of the LTIA to LAD or LAD and diagonal as composite grafts, through left anterior small thoracotomy. In the second postoperative day 43 out of 45 patients were restudied with arteriography and/or transthoracic echocardiography that showed excellent patency in 39 of them.
Six patients with obstruction or stenoses were reoperated through median sternotomy without complications. We did not observe flow through intercostal arteries in these restudies except in cases of obstructed anastomosis, showing that it is not necessary to ligate these branches. We observed too, excellent correlation between angiographic patterns and diastolic flows detected in the thoracic internal artery with transthoracic echocardiography.
These initial results suggest that this approach may be good to a subset of patients with lesions in LAD and/or diagonal arteries and if associated with complementary angioplasties of other coronary arteries may be the best choice of invasive treatment of coronary insufficiency in a near future.
No preview · Article · Mar 1997 · Arquivos Brasileiros de Cardiologia
[Show abstract][Hide abstract] ABSTRACT: Myocardial revascularization in elderly patients (i.e., over 70 years of age) is associated with higher incidence of morbidity and mortality compared with younger patients. We herein report our experience on myocardial revascularization in the elderly comparing the results between 2 groups; one operated on with the aid of cardiopulmonary bypass and the other group in whom extracorporeal circulation was not used. The records of 265 elderly patients ( at or above 70 yrs) undergoing myocardial revascularization were prospectively analyzed between January 1994 and December 1995. Mean age was 74 Â+/- 6 years (range 70-95 yrs), with 83 (31.3%) females and 182 (68.7%) males. The following were the preoperative diagnoses: chronic ischemia and angina (186 patients), reoperation (28 patients), unstable angina (26 patients), failed angioplasty (13 patients), post-thrombolytic therapy (7 patients), cardiogenic shock (2 patients), evolving myocardial infarction (2 patients), and aortic dissection (1 patient). Extracorporeal circulation was used in 204 (76.9%) patients (Group I) and no extracorporeal circulation was used in 61 (23.1%) patients (Group II). The overall mortality was 6.4%, with 7.8% (16/204) in Group I and 1.6% (1/61) in Group II. Hospital stay was 11.4 days in Group I and 7.1 in Group II. Transfusion requirements were 1.4 and 0.6 units for Groups I and II, respectively. The use of extracorporeal circulation in the elderly is a major cause of morbidity and mortality following myocardial revascularization. Whenever possible, myocardial revascularization in the elderly should be performed without the use of extracorporeal circulation.
No preview · Article · Feb 1997 · The American Journal of Geriatric Cardiology
[Show abstract][Hide abstract] ABSTRACT: Myocardial revascularization without cardiopulmonary bypass is now a subject of increasing interest. The purpose of this paper is to present the results obtained during 15 years of experience. From September 1981 till March 1996,1549 patients we operated on without the use of cardiopulmonary bypass with an applicability of this alternative around 18% of the total revascularized patients in this period. The ages varied from 28 to 86 years (medium 57) with 1126 males and 423 females. The number of grafts varied from 1 to 5 (medium 1.7 grafts/patient). The technique did not constitute special limitation to use arterial grafts. The thoracic internal arteries were used 1140 times. In 1515 patients the revascularization was achieved through medsternotomy and in 34 through a minor left anterior thoracotomy. The mortality rate was 2.4% (38/1549) the main primary cause of death, low cardiac output in patients operated under acute ischemia after failed angioplasty or evolving mycardial infarction. In 8 patients the revascularization was performed under intraaortic balloon pump. The results of this 15 years experience permit the conclusion that myocardial revascularization without extracorporeal circulation is an excelent alternative of surgical treatment of coronary artery disease for a subset of patients with lower mortality and morbidity being specially indicated in high risk patients.
Preview · Article · Dec 1996 · Revista Brasileira de Cirurgia Cardiovascular
[Show abstract][Hide abstract] ABSTRACT: A new form of postperfusion syndrome, termed vasoplegic syndrome and presenting in the postoperative period of heart surgery with cardiopulmonary bypass (CPB) is described. The patients exhibit hipotension, normal or elevated cardiac output, low systemic vascular resistance and decreased filling pressures. Physical examination revealed normal capillary filling atthe extremities, but oliguria and hipotension. These patients needed a high dosage of vasoconstrictor drugs (norepinephrine) for blood pressure control and even high dose of norepinephrine did not produce the classical situation of cool extremities. Twelve patients who presented signals and symptoms of vasoplegic syndrome are shown. The characteristics of vasoplegic syndrome are similar to those observed in the septic shock. In sepsis, the alterations are mediated by cytokines and TNF-α. The appearance of vasoplegic syndrome augments operative morbidity, with an increased risk to the patient.
Preview · Article · Mar 1996 · Revista Brasileira de Cirurgia Cardiovascular
[Show abstract][Hide abstract] ABSTRACT: Coronary artery bypass grafting without cardiopulmonary bypass is now an accepted technique of myocardial revascularization. We herein report our total experience with this procedure.
In a consecutive series of 8,751 patients operated on in our institution for coronary artery disease from 1981 to 1994, 1,274 patients received coronary artery bypass grafting without cardiopulmonary bypass.
Results indicate that the operation can be performed with an acceptable mortality (2.5%), and that all types of arterial conduits can be used. Most commonly the left anterior descending and right coronary arteries were bypassed. The incidence of arrhythmias and of pulmonary and neurologic complications were significantly lower in this group of patients compared with patients receiving coronary artery bypass grafting with cardiopulmonary bypass. Most importantly, there was decreased cost when the procedure was used because no extracorporeal circulation, cardioplegia sets, or other cannulas were used.
We conclude that the continuing use of coronary artery bypass grafting without cardiopulmonary bypass is justified and that, with proper selection of patients, the procedure is safe and cost-effective.
No preview · Article · Feb 1996 · The Annals of Thoracic Surgery