Volume 30 - Número 1

OBJECTIVE: To apply and to compare the Society of Thoracic Surgery score (STS), EuroSCORE (Eurosc1), EuroSCORE II (Eurosc2) and InsCor (IS) for predicting mortality in patients undergoing to coronary artery bypass graft and/or valve surgery at the Santa Casa Marilia.
METHODS: The present study is a cohort. It is a prospective, observational, analytical and unicentric. We analyzed 562 consecutive patients coronary artery bypass graft and/or valve surgery, between April 2011 and June 2013 at the Santa Casa Marilia. Mortality was calculated for each patient through the scores STS, Eurosc1, Eurosc2 and IS. The calibration was calculated using the Hosmer Lemeshow test and discrimination by ROC curve.
RESULTS: The hospital mortality was 4,6%. The calibration is generally adequate group P=0.345, P=0.765, P=0.272 and P=0.062 for STS, Eurosc1, Eurosc2, and IS respectively. The discriminatory power of STS score 0.649 (95% CI 0.529 to 0.770, P=0.012), Eurosc1 0.706 (95% CI 0.589 to 0.823, P<0.001), Eurosc2 was 0.704 (95% CI 0.590-0.818, P=0.001) and InsCor 0.739 (95% CI 0.638 to 0.839, P<0.001).
CONCLUSION: We can say that overall, the InsCor was the best model, mainly in the discrimination of the sample. The InsCor showed good accuracy, in addition to being effective and easy to apply, especially by using a smaller number of variables compared to the other models.

OBJECTIVE: To establish the determinants of the peak VO₂ in heart transplant recipients.
METHODS: Patient's assessment was performed in two consecutive days. In the first day, patients performed the heart rate variability assessment followed by a cardiopulmonary exercise test. In the second day, patients performed a resting echocardiography. Heart transplant recipients were eligible if they were in a stable condition and without any evidence of tissue rejection diagnosed by endomyocardial biopsy. Patients with pacemaker, noncardiovascular functional limitations such as osteoarthritis and chronic obstructive pulmonary disease were excluded from this study.
RESULTS: Sixty patients (68% male, 48 years and 64 months following heart transplantation) were assessed. Multivariate analysis selected the following variables: receptor's gender (P=0.001), receptor age (P=0.049), receptor Body Mass Index (P=0.005), heart rate reserve (P<0.0001), left atrium diameter (P=0.016). Multivariate analysis showed r=0.77 and r2=0.6 with P<0.001. Equation: peakVO₂=32.851 - 3.708 (receptor gender) - 0.067 (receptor age) - 0.318 (receptor BMI) + 0.145 (heart rate reserve) - 0.111 (left atrium diameter).
CONCLUSION: The determinants of the peak VO₂ in heart transplant recipients were: receptor sex, age, Body Mass Index, heart rate reserve and left atrium diameter. Heart rate reserve was the unique variable positively associated with peak VO₂. This data suggest the importance of the sympathetic reinnervation in peak VO₂ in heart transplant recipients.

INTRODUCTION: Acute myocardial infarction is a social health problem of epidemiological relevance, with high levels of morbidity and mortality. Stress is one of the modifiable risk factors that triggers acute myocardial infarction. Stress is a result of a set of physiological reactions, which when exaggerated in intensity or duration can lead to imbalances in one's organism, resulting in vulnerability to diseases.
OBJECTIVE: To identify the presence of stress and its phases in hospitalized and active labor market patients with unstable myocardial infarction and observe its correlation with the life of this population with stress.
METHODS: The methodology used was a quantitative, descriptive and transversal research approach conducted with a total of 43 patients, who were still active in the labor market, presenting or not morbidities. Data collection occurred on the fourth day of their hospitalization and patients responded to Lipp's Stress Symptom Inventory for adults.
RESULTS: Thirty-one patients (72.1%) presented stress and twelve (27.8%) did not. In patients with stress, the identified phases were: alert - one patient (3.2%); resistance -twenty-two patients (71.0%); quasi-exhaustion - six patients (19.4%) and exhaustion - two patients (6.5%). All women researched presented stress.
CONCLUSION: The results suggest a high level of stress, especially in the resistance phase, in the male infarcted population, hospitalized and active in the labor market.

OBJECTIVE: A retrospective cohort study was preformed aiming to verify the presence of transient dysfunction of gas exchange in the postoperative period of cardiac surgery and determine if this disorder is linked to cardiorespiratory events.
METHODS: We included 942 consecutive patients undergoing cardiac surgery and cardiac procedures who were referred to the Intensive Care Unit between June 2007 and November 2011.
RESULTS: Fifteen patients had acute respiratory distress syndrome (2%), 199 (27.75%) had mild transient dysfunction of gas exchange, 402 (56.1%) had moderate transient dysfunction of gas exchange, and 39 (5.4%) had severe transient dysfunction of gas exchange. Hypertension and cardiogenic shock were associated with the emergence of moderate transient dysfunction of gas exchange postoperatively (P=0.02 and P=0.019, respectively) and were risk factors for this dysfunction (P=0.0023 and P=0.0017, respectively). Diabetes mellitus was also a risk factor for transient dysfunction of gas exchange (P=0.03). Pneumonia was present in 8.9% of cases and correlated with the presence of moderate transient dysfunction of gas exchange (P=0.001). Severe transient dysfunction of gas exchange was associated with patients who had renal replacement therapy (P=0.0005), hemotherapy (P=0.0001), enteral nutrition (P=0.0012), or cardiac arrhythmia (P=0.0451).
CONCLUSION: Preoperative hypertension and cardiogenic shock were associated with the occurrence of postoperative transient dysfunction of gas exchange. The preoperative risk factors included hypertension, cardiogenic shock, and diabetes. Postoperatively, pneumonia, ventilator-associated pneumonia, renal replacement therapy, hemotherapy, and cardiac arrhythmia were associated with the appearance of some degree of transient dysfunction of gas exchange, which was a risk factor for reintubation, pneumonia, ventilator-associated pneumonia, and renal replacement therapy in the postoperative period of cardiac surgery and cardiac procedures.

INTRODUCTION: The knowledge of the prevalence of risk facors and comorbidities, as well as the evolution and complications in patients undergoing coronary artery bypass graft allows comparison between institutions and evidence of changes in the profile of patients and postoperative evolution over time.
OBJECTIVE: To profile (risk factors and comorbidities) and clinical outcome (complications) in patients undergoing coronary artery bypass graft in a national institution of great surgical volume.
METHODS: A retrospective cohort study of patients undergoing coronary artery bypass graft in the hospital Beneficência Portuguesa de São Paulo, from July 2009 to July 2010.
RESULTS: We included 3,010 patients, mean age of 62.2 years and 69.9% male. 83.8% of patients were hypertensive, 36.6% diabetic, 44.5% had dyslipidemia, 15.3% were smokers, 65.7% were overweight/obese, 29.3% had a family history of coronary heart disease. The expected mortality calculated by logistic EuroSCORE was 2.7%. The isolated CABG occurred in 89.3% and 11.9% surgery was performed without cardiopulmonary bypass. The most common complication was cardiac arrhythmia (18.7%), especially acute atrial fibrillation (14.3%). Pneumonia occurred in 6.2% of patients, acute renal failure in 4.4%, mediastinites in 2.1%, stroke in 1.8% and AMI in 1.2%. The in-hospital mortality was 5.4% and in isolated coronary artery bypass graft was 3.5%. The average hospital stay was 11 days with a median of eight days (3-244 days).
CONCLUSION: The profile of patients undergoing coronary artery bypass graft surgery in this study is similar to other published studies.

OBJECTIVE: To analyze a cardiac rehabilitation adapted protocol in physical therapy during the postoperative hospital phase of cardiac surgery in a service of high complexity, in aspects regarded to complications and mortality prevalence and hospitalization days.
METHODS: This is an observational cross-sectional, retrospective and analytical study performed by investigating 99 patients who underwent cardiac surgery for coronary artery bypass graft, heart valve replacement or a combination of both. Step program adapted for rehabilitation after cardiac surgery was analyzed under the command of the physiotherapy professional team.
RESULTS: In average, a patient stays for two days in the Intensive Care Unit and three to four days in the hospital room, totalizing six days of hospitalization. Fatalities occurred in a higher percentage during hospitalization (5.1%) and up to two years period (8.6%) when compared to 30 days after hospital discharge (1.1%). Among the postoperative complications, the hemodynamic (63.4%) and respiratory (42.6%) were the most prevalent. 36-42% of complications occurred between the immediate postoperative period and the second postoperative day. The hospital discharge started from the fifth postoperative day. We can observe that in each following day, the patients are evolving in achieving the Steps, where Step 3 was the most used during the rehabilitation phase I.
CONCLUSION: This evolution program by steps can to guide the physical rehabilitation at the hospital in patients after cardiac surgery.

INTRODUCTION: Perioperative myocardial infarction adversely affects the prognosis of patients undergoing coronary artery bypass graft and its diagnosis was hampered by numerous difficulties, because the pathophysiology is different from the traditional instability atherosclerotic and the clinical difficulty to be characterized.
OBJETIVE: To identify the frequency of perioperative myocardial infarction and its outcome in patients undergoing coronary artery bypass graft.
METHODS: Retrospective cohort study performed in a tertiary hospital specialized in cardiology, from May 01, 2011 to April 30, 2012, which included all records containing coronary artery bypass graft records. To confirm the diagnosis of perioperative myocardial infarction criteria, the Third Universal Definition of Myocardial Infarction was used.
RESULTS: We analyzed 116 cases. Perioperative myocardial infarction was diagnosed in 28 patients (24.1%). Number of grafts and use and cardiopulmonary bypass time were associated with this diagnosis and the mean age was significantly higher in this group. The diagnostic criteria elevated troponin I, which was positive in 99.1% of cases regardless of diagnosis of perioperative myocardial infarction. No significant difference was found between length of hospital stay and intensive care unit in patients with and without this complication, however patients with perioperative myocardial infarction progressed with worse left ventricular function and more death cases.
CONCLUSION: The frequency of perioperative myocardial infarction found in this study was considered high and as a consequence the same observed average higher troponin I, more cases of worsening left ventricular function and death.

INTRODUCTION: Complete denervation of transplanted heart exerts protective effect against postoperative atrial fibrillation; various degrees of autonomic denervation appear also after transection of ascending aorta during surgery for aortic aneurysm.
OBJECTIVE: This study aimed to evaluate if the level of cardiac denervation obtained by resection of ascending aorta could exert any effect on postoperative atrial fibrillation incidence.
METHODS: We retrospectively analysed the clinical records of 67 patients submitted to graft replacement of ascending aorta (group A) and 132 with aortic valve replacement (group B); all episodes of postoperative atrial fibrillation occurred during the 1-month follow-up have been reported. Heart Rate Variability parameters were obtained from a 24-h Holter recording; clinical, echocardiographic and treatment data were also evaluated.
RESULTS: Overall, 45% of patients (group A 43%, group B 46%) presented at least one episode of postoperative atrial fibrillation. Older age (but not gender, abnormal glucose tolerance, ejection fraction, left atrial diameter) was correlated with incidence of postoperative atrial fibrillation. Only among a subgroup of patients with aortic transection and signs of greater autonomic derangement (heart rate variability parameters below the median and mean heart rate over the 75^th percentile), possibly indicating more profound autonomic denervation, a lower incidence of postoperative atrial fibrillation was observed (22% vs. 54%).
CONCLUSION: Transection of ascending aorta for repair of an aortic aneurysm did not confer any significant protective effect from postoperative atrial fibrillation in comparison to patients with intact ascending aorta. It could be speculated that a limited and heterogeneous cardiac denervation was produced by the intervention, creating an eletrophysiological substrate for the high incidence of postoperative atrial fibrillation observed.

INTRODUCTION: In spite of its importance as an experimental model, the information on the great cardiac vein in pigs is sparse.
OBJECTIVE: To determine the morphologic characteristics of the great cardiac vein and its tributaries in pigs.
METHODS: 120 hearts extracted from pigs destined to the slaughterhouse with stunning method were studied. This descriptive cross-over study evaluated continuous variables with T test and discrete variables with Pearson χ square test. A level of significance P<0.05 was used. The great cardiac vein and its tributaries were perfused with polyester resin (85% Palatal and 15% Styrene) and then subjected to potassium hydroxide infusion to release the subepicardial fat. Calibers were measured, and trajectories and relations with adjacent arterial structures were evaluated.
RESULTS: The origin of the great cardiac vein was observed at the heart apex in 91 (76%) hearts. The arterio-venous trigone was present in 117 (97.5%) specimens, corresponding to the open expression in its lower segment and to the closed expression in the upper segment in the majority of the cases (65%). The caliber of the great cardiac vein at the upper segment of the paraconal interventricular sulcus was 3.73±0.79 mm. An anastomosis between the great cardiac vein and the middle cardiac vein was found in 59 (49%) specimens.
CONCLUSION: The morphological and biometric characteristics of the great cardiac vein and its tributaries had not been reported in prior studies, and due to their similitude with those of the human heart, allows us to propose the pig model for procedural and hemodynamic applications.

OBJECTIVE: An unclear issue is whether gender may influence at cardiac remodeling after myocardial infarction (MI). We evaluated left ventricle remodeling in female and male rats post-MI.
METHODS: Rats were submitted to anterior descending coronary occlusion. Echocardiographic evaluations were performed on the first and sixth week post-occlusion to determine myocardial infarction size and left ventricle systolic function (FAC, fractional area change). Pulsed Doppler was applied to analyze left ventricle diastolic function using the following parameters: E wave, A wave, E/A ratio. Two-way ANOVA was applied for comparisons, complemented by the Bonferroni test. A P<0.05 was considered significant.
RESULTS: There were no significant differences between genders for morphometric parameters on first (MI [Female (FE): 44.0±5.0 vs. Male (MA): 42.0±3.0%]; diastolic [FE: 0.04±0.003 vs. MA: 0.037±0.005, mm/g] and systolic [FE: 0.03±0.0004 vs. MA: 0.028±0.005, mm/g] diameters of left ventricle) and sixth (MI [FE: 44.0±5.0 vs. MA: 42.0±3.0, %]; diastolic [FE: 0.043±0.01 vs. MA: 0.034±0.005, mm/g] and systolic [FE: 0.035±0.01 vs. MA: 0.027±0.005, mm/g] of LV) week. Similar findings were reported for left ventricle functional parameters on first (FAC [FE: 34.0±6.0 vs. MA: 32.0±4.0, %]; wave E [FE: 70.0±18.0 vs. MA: 73.0±14.0, cm/s]; wave A [FE: 20.0±12.0 vs. MA: 28.0±13.0, cm/s]; E/A [FE: 4.9±3.4 vs. MA: 3.3±1.8]) and sixth (FAC [FE: 29.0±7.0 vs. MA: 31.0±7.0, %]; wave E [FE: 85.0±18.0 vs. MA: 87.0±20.0, cm/s]; wave A [FE: 20.0±11.0 vs. MA: 28.0±17.0, cm/s]; E/A [FE: 6.2±4.0 vs. MA: 4.6±3.4]) week.
CONCLUSION: Gender does not influence left ventricle remodeling post-MI in rats.

INTRODUCTION: Previous studies have demonstrated that thymoquinone has protective effects against ischemia reperfusion injury to various organs like lungs, kidneys and liver in different experimental models.
OBJECTIVE: We aimed to determine whether thymoquinone has favorable effects on lung, renal, heart tissues and oxidative stress in abdominal aorta ischemia-reperfusion injury.
METHODS: Thirty rats were divided into three groups as sham (n=10), control (n=10) and thymoquinone (TQ) treatment group (n=10). Control and TQ-treatment groups underwent abdominal aorta ischemia for 45 minutes followed by a 120-min period of reperfusion. In the TQ-treatment group, thymoquinone was given 5 minutes. before reperfusion at a dose of 20 mg/kg via an intraperitoneal route. Total antioxidant capacity, total oxidative status (TOS), and oxidative stress index (OSI) in blood serum were measured and lung, kidney, and heart tissue histopathology were evaluated with light microscopy.
RESULTS: Total oxidative status and oxidative stress index activity in blood samples were statistically higher in the control group compared to the sham and TQ-treatment groups (P<0.001 for TOS and OSI). Control group injury scores were statistically higher compared to sham and TQ-treatment groups (P<0.001 for all comparisons).
CONCLUSION: Thymoquinone administered intraperitoneally was effective in reducing oxidative stress and histopathologic injury in an acute abdominal aorta ischemia-reperfusion rat model.

OBJECTIVE:This study was conducted to reassess the concepts established over the past 20 years, in particular in the last 5 years, about the use of methylene blue in the treatment of vasoplegic syndrome in cardiac surgery.
METHODS: A wide literature review was carried out using the data extracted from: MEDLINE, SCOPUS and ISI WEB OF SCIENCE.
RESULTS: The reassessed and reaffirmed concepts were 1) MB is safe in the recommended doses (the lethal dose is 40 mg/kg); 2) MB does not cause endothelial dysfunction; 3) The MB effect appears in cases of NO up-regulation; 4) MB is not a vasoconstrictor, by blocking the cGMP pathway it releases the cAMP pathway, facilitating the norepinephrine vasoconstrictor effect; 5) The most used dosage is 2 mg/kg as IV bolus, followed by the same continuous infusion because plasma concentrations sharply decrease in the first 40 minutes; and 6) There is a possible "window of opportunity" for MB's effectiveness. In the last five years, major challenges were: 1) Observations about side effects; 2) The need for prophylactic and therapeutic guidelines, and; 3) The need for the establishment of the MB therapeutic window in humans.
CONCLUSION: MB action to treat vasoplegic syndrome is time-dependent. Therefore, the great challenge is the need, for the establishment the MB therapeutic window in humans. This would be the first step towards a systematic guideline to be followed by possible multicenter studies.

OBJECTIVE: A systematic analysis was made in view of the epidemiology, clinical features, diagnosis, treatment and main outcomes of mycobacterial endocarditis.
METHODS: The data source of the present study was based on a comprehensive literature search in MEDLINE, Highwire Press and Google search engine for publications on mycobacterial endocarditis published between 2000 and 2013.
RESULTS: The rapidly growing mycobacteria become the predominant pathogens with Mycobacterium chelonae being the most common. This condition has changed significantly in terms of epidemiology since the 21^st century, with more broad patient age range, longer latency, prevailed mitral valve infections and better prognosis.
CONCLUSION: Mycobacterial endocarditis is rare and the causative pathogens are predominantly the rapidly growing mycobacteria. Amikacin, ciprofloxacin and clarithromycin are the most frequently used targeted antimicrobial agents but often show poor responses. Patients with deep infections may warrant a surgical operation or line withdrawal. With periodic multidrug therapy guided by drug susceptibility testing, and surgical managements, patients may achieve good therapeutic results.

Why some countries have failed to create democracy, wealth and happiness for their people is one of the great questions of our time. This essay encompasses a description of the multiple barriers to development that may have different characteristics, according to the context and the social structures that maintain these conditions. It would be arrogant to pretend to have all the solutions for these problems.

The dehiscence after median transesternal sternotomy used as surgical access for cardiac surgery is one of its complications and it increases the patient's morbidity and mortality. A variety of surgical techniques were recently described resulting to the need of a classification bringing a measure of objectivity to the management of these complex and dangerous wounds. The different related classifications are based in the primary causal infection, but recently the anatomical description of the wound including the deepness and the vertical extension showed to be more useful. We propose a new classification based only on the anatomical changes following sternotomy dehiscence and chronic wound formation separating it in four types according to the deepness and in two sub-groups according to the vertical extension based on the inferior insertion of the pectoralis major muscle.

OBJECTIVE: To evaluate the behavior of castor oil-derived polyurethane as a hemostatic agent and tissue response after abdominal aortic injury and to compare it with 2-octyl-cyanoacrylate.
METHODS: Twenty-four Guinea Pigs were randomly divided into three groups of eight animals (I, II, and III). The infrarenal abdominal aorta was dissected, clamped proximally and distally to the vascular puncture site. In group I (control), hemostasis was achieved with digital pressure; in group II (polyurethane) castor oil-derived polyurethane was applied, and in group III (cyanoacrylate), 2-octyl-cyanoacrylate was used. Group II was subdivided into IIA and IIB according to the time of preparation of the hemostatic agent.
RESULTS: Mean blood loss in groups IIA, IIB and III was 0.002 grams (g), 0.008 g, and 0.170 g, with standard deviation of 0.005 g, 0.005 g, and 0.424 g, respectively (P=0.069). The drying time for cyanoacrylate averaged 81.5 seconds (s) (standard deviation: 51.5 seconds) and 126.1 s (standard deviation: 23.0 s) for polyurethane B (P=0.046). However, there was a trend (P=0.069) for cyanoacrylate to dry more slowly than polyurethane A (mean: 40.5 s; SD: 8.6 s). Furthermore, polyurethane A had a shorter drying time than polyurethane B (P=0.003), mean IIA of 40.5 s (standard deviation: 8.6 s). In group III, 100% of the animals had mild/severe fibrosis, while in group II only 12.5% showed this degree of fibrosis (P=0.001).
CONCLUSION: Polyurethane derived from castor oil showed similar hemostatic behavior to octyl-2-cyanoacrylate. There was less perivascular tissue response with polyurethane when compared with cyanoacrylate.