Volume 4 - Número 3
ORIGINAL ARTICLE
Internal mammary artery free graft: immediate and late results
Braz J Cardiovasc Surg 4;
Publish in: 8/2/2025
In the surgical treatment of coronary artery disease, the graft of choice is the internal mammary artery (IMA), used in our Service in 93% of the patients younger than 65 years old, during the last year. When, by anatomic reasons, it is not possible the "in situ" use, we have employed the free graft of IMA in the aorto-coronary position. Between April 1986 and September 1988, 58 patients, who underwent surgical myocardial revascularization, we treated with this procedure. Fifty five (95%) were males and the mean age was 49 years old, ranging from 35 to 69. The preoperative clinical findings were: stable angina 43%, unstable angina 36%, post-infarction angina 17%, and 4% were asymptomatics. We performed 179 grafts (3 grafts/patient) with: saphenous vein 67, "in situ" IMA 53, IMA free graft 59. The arteries treated with free grafts were: right coronary 18, circunflex marginal branch 17, diagonal 10, left anterior descending 10, "en passant" to LAD-Dgl 2, and double free graft to LAD and Dgl 1. Perioperative myocardial infarction diagnosed by electrocardiographic changes occurred in one circunstance (1,7%). Two patients (3,4%) died during the hospitalization. One late death occurred in the second postoperative year due to a sudden death. Between 55 survivors, 51 cases (92,7%) were analized and 94% were asymptomatic in a two year-follow up period.
Keywords: internal mammary artery, free graft; myocardial revascularization, surgery
Treatment of the aneurysms of descending aorta for intraluminal prosthesis (elephant trunk)
Braz J Cardiovasc Surg 4;
Publish in: 8/2/2025
Aneurysms of descending aorta still cause great morbidity and mortality even in modern cardiac surgery days. In this paper, we describe the use of a recente technique which consists in the insertion of an intraluminal Dacron prosthesis, sutured only in its proximal end, just after the left subclavian artery. The prosthesis goes beyoud the aneurysm area and stays free in its distal aortic segment (elephant trunk). The operation is performed with bypass and profound hypothermia at 19ºC with circulatory arrest for just enough time to insert the prosthesis and make the proximal suture. Since May 1988 eight patients underwent this kind of surgery: six cases of acute type B dissection and two cases of saccular aneurysms. The procedure is very simple and fast and the post-operative results obtained make clear that our experience should go on. We recommend this procedure as a tactical alternative, specially for type B dissections.
Keywords: aneurysms of descending aorta, surgery; intraluminal prosthesis
Aortic valve replacement in patients with depressed left ventricular ejection fraction
Braz J Cardiovasc Surg 4;
Publish in: 8/2/2025
To evaluate the prognostic value of resting left ventricular ejection fraction (LVEF) a series of 210 consecutive patients with aortic valve disease operated upon between May 1981 and October 1988 was studied retrospectively. All patients had their aortic valve replaced by Omniscience or Meditronic prosthesis; 112 formed the study group because they have complete follow up and cineangiocardiographic data. Based on pre-operatory left ventricular ejection fraction the patients were divided in two groups: Group 1 = 52 patients with LVEF > 40%, 39 ± 12 years, NYHA functional class 2.8, and EF 58 ± 10%. Group 2 = 60 patients with LVEF < 40, 48 ± 17 years, NYHA functional class 3.6, and LVEF of 27 ± 12%. During surgery moderate hypothermia and hemodilution were utilized, with dubble oxygenator and cardioplegia With St. Thomas cardioplegic solution. Mean extracorporeal circulation and cardiac arrest time were respectively 82 ± 18 and 49 ± 7 minutes in Group 1 and 96 ± 11 and 55 ± 6 minutes in Group 2. The size of the prosthesis were 25.2 ± 1.8 mm in Group 1. The short term mortality was 3.8% in Group 1 and 5.8 in Group 2. The long-term mortality was 4.0% in Group 1 and 8.7% in Group 2. In Group 1 there was a significant association between mortality and left ventricular systolic function. In the follow-up evaluation, among patients in Group 1, 65% were in class I, 28% were in functional class II, 5% in class III, and 2% in class IV. Among patients in group II 46% were in class I, 25% in class II, 13% in class III, and 16% in class IV. The 7 year survival rate was 88 ± 2% in Group 1 and 76 ± 4% in Group 2. Thus, patients with LVEF less than 40% had higher short and longterm mortality and worse clinical course. For better surgical results patients with aortic valve disease should be operated upon before the reduction of left ventricular systolic function.
Keywords: ventricular function; heart valves, aortic, surgery
Surgical treatment of mitral insufficiency in children: ten years of reparative techniques
Braz J Cardiovasc Surg 4;
Publish in: 8/2/2025
From April 1979 through January 1989, 71 patients with mitral insufficiency were surgically treated, 53 of them (74,6%) submitted to valvuloplasty. From this group 21 patients had associated mitral estenosis. Rheumatic fever was the major cause of the mitral lesions (79,2%). All patients, but 3, were situated in funcional class III and IV (NYHA). Anuloplasty (Carpentier ring and Gregori-IMC) were made associated to plastic procedures at the leaflet and the subvalvar set. In the postoperative period, we observed: no hospital mortality; early postoperative evolution was better in patients subjected to surgery in the period from 84 through 89, in comparison to the anterior period (79-83); reoperation index very acceptable at the late postoperative (5,7%); satisfactory clinical and hemodynamic late evolution; better evolution in the group of patients in the functional class postoperative II and III; better evolution in the group of patients with mitral insufficiency without associated stenosis.
Keywords: heart valves, mitral, surgery, children
Development and construction of a balloon-pump for aortic counterpulsation
Braz J Cardiovasc Surg 4;
Publish in: 8/2/2025
The present paper presents the project and construction of a balloon-pump for aortic counterpulsation. Three experimental models were developed, the first two using hospital air and vacuum lines for inflation and deflation of the balloon catheter. These two inicial models diffères among themselves in the mechanism used to capture the light signal corresponding to the R wave of the ECG, which was used to sincronize the pumping. The solenoid valve and electronic components were of higher resolution in the second model. The third and present model recieves the R wave signal from the cardioversor adaptor of ECG monitor and the hospital vacuum and air lines along with the solenoid valve were substituted by an electromagnetic pump. The problems related to late deflation that have ocurred in the system are still in study. Emphasis is given on the importance of this research, which has incremented knowledge for the construction of other medical equipment, mainly in the area of respiratory care.
Keywords: aortic balloon-pump; counterpulsation; assisted circulation, mechanic
Hemolysis in extracorporeal circulation: a comparative study between roller and centrifugal pumps
Braz J Cardiovasc Surg 4;
Publish in: 8/2/2025
The utilization of centrifugal pumps as circulatory support in patients with cardiogenic shock after cardiac surgery and as support in patients waiting for cardiac transplant has been progressively extended. Some centers utilize the centrifugal pump in routine extracorporeal circulation as a substitute for roller pump. At INCOR, we operared upon 2 groups of triple vessel disease patients submitted to coronary arterial bypass graft (CABG). They were operated upon by the same surgeon, with the same perfusionist and with the same perfusionist and the same myocardial protection method (cristaloid cardioplegia, systemic hipotermia at 28C and topic hipotermia with NaCI 0,9%). All pre-operatory parameters in both groups were statistically similar: age, sex, corporeal surface and analized hematologic parameters). Twenty-seven patients were consecutively and alternatively operated, 13 with centrifugal pump and 14 with roller pump. We utilized the Macchi bubble oxygenator. The average perfusion time was 105 minutes in the roller pump group and 103 minutes in the centrifugal pump group. We analized protrombin time, haptoglobin, activated partial tromboplastin time, trombin time and platelet number in the pre and pos extracorporeal circulation time, comparing both groups. There was no statistical significant difference between the several parameters. We conclude that in habitual duration extracorporeal circulation there is no hematological difference between centrifugal and roller pumps.
Keywords: hemolysis in extracorporeal circulation; extracorporeal circulation, roller pump; extracorporeal circulation, centrifugal pump
Practical aspects in the recommendation for reoperation in immediate postoperative phase of cardiac surgery
Braz J Cardiovasc Surg 4;
Publish in: 8/2/2025
Blood coagulation of 65 patients that needed reoperation to control excessive bleeding after cardiopulmonary bypass surgery was evaluated by hematologist that didn't know the reoperation findings. Forty-six (90.2%) of 51 patients with normal tests before the reintervention had localizated bleeding, and five (9.8%) had difuse hemorrhage. From 14 patients with abnormal coagulation tests, eight (57.2%) had difuse bleeding and six (42.8%) had a localizated bleeding. The authors concluded that with normal coagulation tests and excessive bleeding after cardiopulmonary bypass surgery a new reoperation is indicated. Otherwise, patients with abnormal coagulation tests can receive initial clinical treatment.
Keywords: blood coagulation; bleeding in cardiac surgery; reoperation, cardiac surgery
Comparative study of fluid dynamic characteristics in high and low biological prosthetic heart valves from bovine pericardium
Braz J Cardiovasc Surg 4;
Publish in: 8/2/2025
The fluid dynamic performance and lifetime of a prosthetic heart valve are one of the most important characteristics to determine the choice of what prosthesis must be applied to a patient. Because of this, two different biological prosthetic heart valves profiles (one high profile and other low profile) were studied, to verify possible alterations of working life, pressure gradient and reverse flux debt to this profiles difference. With a Pulse Duplication, ten valves sixe 29 were analysed , manufactured by Institute Dante Pazzanese de Cardiologia, being five low profile and five high profile. With a working frequency of 1000 ppm (pulses per minute) and a differential pressure of 1000 mmHg, we verified the same working life in both cases. With a Cardiac Simulator, the prosthesis was submitted to similar physiologic human cardiac conditions, with an equivalent 75 ppm heart pulse. The results show that the reverse flux volume necessary to close the low profile valve is lower than with the high profile valve. The loss head of these valves were compared though the maximum pressure gradient of them. It was noticed that the low profile, biological prosthetic valves are lower flux resistant than the high profile valves, being then more indicated to its implant function.
Keywords: heart valves prostheses, tests; heart valves prostheses, biologic
Desferoxamine and its protective effect in pulmonary preservation
Braz J Cardiovasc Surg 4;
Publish in: 8/2/2025
There is increasing evidence that oxygen derived free radicals are involved in the injury that occurs following the reperfusion of ischaemic tissue. Deferoxamine by preventing hydroxyl radical production and scavenging superoxide anion may attenuate this injury and its effects were evaluated following 4 hours of static hypothermic pulmonary preservation. Left lung autotransplantation was performed in 12 mongrel dogs. The autograft was initially flushed with 1000 cc of modified Collins solution and then stored in an inflated state for 4 hours in 4ºC saline. Six dogs received deferoxamine 500 mg intravenously infused before and immediately after the time of reperfusion. Following reimplantation, contralateral pulmonary artery ligation was performed and the animals were then maintained on a fixed FiO2 (40%) and monitored for 6 hours. During the first hour of reperfusion arterial pO2 was significantly better in the deferoxamine treated dogs (p < 0.05). Alveolar-arterial oxygen gradients were also lower (p < 0.05). Pulmonary vascular resistance was not different between groups. We conclude that deferoxamine improves gas exchange in the immediate reperfusion period and that further investigation of its use is warranted.
Keywords: pulmonary preservation, deferoxamine; free radicals
CASE REPORT
Cardiac fibroma mimicking hypertrophic cardiomyopathy
Braz J Cardiovasc Surg 4;
Publish in: 8/2/2025
A 33 year-old woman was seen, for the first time, ten years ago, for evaluation of a recurrent chest pain, dyspnea and arrhythmia. She was submitted to echocardiographic studies and a cardiac catheterization. The diagnoses was endomyocardial fibrosis at first, and hypertrophic cardiomyopathy after. Despite treatment with propranolol and quinidine, the episodes of dyspnea and tachyarrhythmias became more frequent and severe, and the patient was guided to our Service. Cardiac re-catheterization, echocardiographic and computed tomography studies identified in traumural cardiac fibroma and the patient was referred for surgical treatment. The cardiac fibroma was successfully resected on extracorporeal bypass and with cardioplegic arrest of the heart. Repair of the heart was accomplished with a patch placed to close the left ventricular cavity. The postoperative course was uncomplicated, and she remains assymptomatic two years later. We have emphazied tha this tumor often produces clinically obscure disease, simulating particularly the left ventricle hypertrophic cardiomiopathy.
Keywords: tumors of the heart; cardiomiopathy, hypertrophic