Volume 33 - Número 6

Objective: To analyze the inflammation resulting from myocardial revascularization techniques with and without cardiopulmonary bypass, based on ultrasensitive C-reactive protein (US-CRP) behavior.
Methods: A prospective non-randomized clinical study with 136 patients was performed. Sixty-nine patients were enrolled for Group 1 (on-pump coronary artery bypass - ONCAB) and 67 patients were assigned to Group 2 (off-pump coronary artery bypass - OPCAB). All study participants had blood samples collected for analysis of glucose, triglycerides, creatinine, total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) and creatinephosphokinase (CPK) in the preoperative period. The samples of creatinephosphokinase MB (CKMB), troponin I (TnI) and US-CRP were collected in the preoperative period and at 6, 12, 24, 36, 48 and 72 hours after surgery. We also analyzed the preoperative biological variables of each patient (age, smoking, diabetes mellitus, left coronary trunk lesion, body mass index, previous myocardial infarction, myocardial fibrosis). All angiographically documented patients with >70% proximal multiarterial stenosis and ischemia, documented by stress test or classification of stable angina (class II or III), according to the Canadian Cardiovascular Society, were included. Reoperations, combined surgeries, recent acute myocardial infarction, recent inflammatory disease, deep venous thrombosis or recent pulmonary thromboembolism, acute kidney injury or chronic kidney injury were not included.
Results: Correlation values between the US-CRP curve and the ONCAB group, the treatment effect and the analyzed biological variables did not present expressive results. Laboratory variables were evaluated and did not correlate with the applied treatment (P>0.05).
Conclusion: The changes in the US-CRP at each moment evaluated from the postoperative period did not show any significance in relation to the surgical technique applied. Keywords: C-reactive protein; Myocardial Revascularization; Atherosclerosis; Coronary artery bypass, off-pump; Inflammation; Coronary artery bypass; Cardiopulmonary bypass

Which Method to Use for Surgical Ablation of Atrial Fibrillation Performed Concomitantly with Mitral Valve Surgery: Radiofrequency Ablation

Unsal Vural^I; Ahmet Yavuz Balci^I; Ahmet Arif Aglar^I; Mehmet Kizilay^I

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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Objective: The effects of energy source on the maintenance of sinus rhythm and the contribution of demographic characteristics to the case selection in patients submitted to ablation performed concurrently with mitral valve surgery were analyzed.
Methods: Cryothermal (n=42; 43.8%) and radiofrequency (n=54; 56.3%) energy were employed in 96 patients submitted to mitral valve replacement and Cox maze IV procedure. Patients were called for control visits between 15 days and 12 months after discharge. The causal relationship between recurrence of atrial fibrillation and factors such as left atrial diameter, C-reactive protein, hypertension, left ventricular ejection fraction, chronic obstructive pulmonary disease, and body mass index was determined.
Results: Maintenance rates of the sinus rhythm with radiofrequency and cryoablation were 97.6% and 96.3%, respectively, in the first postoperative month, whereas at the 12th postoperative month were 88.1% and 83.3%. No significant difference was found between groups in relation to the energy source. Sensitivity and specificity for left atrial diameter with a cut-off value of 50.5 mm were 85.7% and 70.7%, respectively. Sensitivity and specificity for C-reactive protein with a cut-off value of 12 mg/dL on the 15th postoperative day were 83.3% and 88.9%, respectively. The effect of body mass index on atrial fibrillation recurrence was 3.2 times. Sensitivity and specificity for left ventricular ejection fraction 37% cut-off value were 96.3% and 11.4%, respectively. Atrial fibrillation in hypertensive cases was 5.3 times more. In patients with chronic obstructive pulmonary disease, recurrence of atrial fibrillation was 40%. The causal relation between recurrence of atrial fibrillation and the studied factors was established.
Conclusion: Demographic characteristics have a significant impact on ablation efficiency, while the type of energy source does not. Keywords: Catheter ablation; Ablation; Cryosurgery; Mitral valve/surgery; Ablation techniques

Vasodilatory Efficacy and Impact of Papaverine on Endothelium in Radial Artery Predilatation for CABG Surgery: in Search for Optimal Concentration

Piotr Wegrzyn^I; Grzegorz Lis^II; Pawel Rudzinski^I; Jacek Piatek^I; Grazyna Pyka-Fosciak^II; Ryszard Korbut^III; Boguslaw Kapelak^I; Krzysztof Bartus^I; Radoslaw Litwinowicz^I

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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Objective: The aim of this study was to compare the efficacy of two different papaverine concentrations (0.5 mg/ml and 2 mg/ml) for vasospasm prevention and their impact on endothelium integrity.
Methods: We have studied distal segments of radial arteries obtained by no-touch technique from coronary artery bypass graft (CABG) patients (n=10). The vasodilatory effect of papaverine (concentrations of 0.5 mg/ml and 2 mg/ml) was assessed in vitro, in isometric tension studies using ex vivo myography (organ bath technique) and arterial rings precontracted with potassium chloride (KCl) and phenylephrine. The impact of papaverine on endothelial integrity was studied by measurement of the percentage of vessel's circumference revealing CD34 endothelial marker.
Results: 2 mg/ml papaverine concentration showed stronger vasodilatatory effect than 0.5 mg/ml, but it caused significantly higher endothelial damage. Response to KCl was 7.35±3.33 mN for vessels protected with papaverine 0.5 mg/ml and 2.66±1.96 mN when papaverine in concentration of 2 mg/ml was used. The histological examination revealed a significant difference in the presence of undamaged endothelium between vessels incubated in papaverine 0.5 mg/ml (72.86±9.3%) and 2 mg/ml (50.23±13.42%), P=0.002.
Conclusion: Papaverine 2 mg/ml caused the higher endothelial damage. Concentration of 0.5 mg/ml caused better preservation of the endothelial lining. Keywords: Papaverine; Graft occlusion, vascular; Radial artery; Coronary artery bypass; Vasodilation

The Negative Effect of Mean Perfusion Pressure on the Development of Acute Kidney Injury after Transcatheter Aortic Valve Implantation

Ilker Gül^I; Levent Cerit^I; Bihter Senturk^II; Mustafa Zungur^III; Mustafa Beyazit Alkan^IV; Hatice Kemal^I; Zeynep Cerit^V; Belma Yaman^I; Songul Usalp^I; Hamza Duygu^I

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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Objective: To evaluate the predictive value of mean perfusion pressure (mPP) in the development of acute kidney injury (AKIN) after transcatheter aortic valve implantation (TAVI).
Methods: One hundred and forty seven consecutive patients with aortic stenosis (AS) were evaluated for this study and 133 of them were included. Mean arterial pressure (mAP) and central venous pressure (CVP) were used to calculate mPP before TAVI procedure (mPP = mAP-CVP). The occurrence of AKIN was evaluated with AKIN classification according to the Valve Academic Research Consortium-2 recommendations. The patients were divided into two groups according to the receiver operating characteristic (ROC) analysis of their mPP levels (high-risk group and low-risk group).
Results: The AKIN prevalence was 22.6% in this study population. Baseline serum creatinine level, glomerular filtration rate, amount of contrast medium, and the level of mPP were determined as predictive factors for the development of AKIN.
Conclusion: The occurrence of AKIN is associated with increased morbidity and mortality rates in patients with TAVI. In addition to the amount of contrast medium and basal kidney functions, our study showed that lower mPP was strongly associated with development of AKIN after TAVI. Keywords: Transcatheter Aortic Valve Replacement; Kidney; Acute kidney injury; Perfusion

Does Moderate Coronary Stenosis Affect the Fate of the Left Internal Thoracic Artery Graft?

Aytac Caliskan^I; Ertekin Utku Unal^II; Emre Kubat^III; Bahadir Aytekin^II; Basak Soran Turkcan^II; Erman Sureyya Kiris^II; Muharrem Tola^IV; Hakki Zafer Iscan^II

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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Introduction: In this study we try to observe the fate of the left internal thoracic artery grafts that were bypassed to left anterior descending artery with moderate stenosis identified with fractional flow reserve (FFR) technique. Doppler ultrasonography was chosen as a noninvasive screening method.
Methods: A total of 30 patients who underwent coronary artery bypass grafting depending on results of the fractional flow reserve between January 2007 and January 2012, were subjected to transthoracic color Doppler ultrasonographic evaluation irrespective of the presence of symptoms, and the presence of a systolic-diastolic flow pattern was investigated using the supraclavicular approach.
Results: The left internal thoracic artery graft was found to be functional in 63.3% of patients within a mean period of 35.1±19.7 months between coronary bypass and color Doppler ultrasonography. This period was found to be 29.4±19.6 months in the functional graft group, and 44.7±16.6 months in the dysfunctional graft group (P=0.046). Preoperative complaints of angina were reported to fall from 88.9% to 16.7% in the functional graft group, when compared to the postoperative period (P<0.001), but fell from 90.9% to 36.4% in the dysfunctional graft group (P=0.034).
Conclusion: Functional left internal thoracic artery graft rates of the study population were found to be lower than the studies reported in the literature. Keywords: Coronary angiography; Coronary artery bypass; Internal mammary-coronary artery anastomosis; Ultrasonography; Coronary Stenosis

Should Sinus of Valsalva be Replaced in Patients with Dilated Ascending Aorta and Aortic Valve Diseases?

Salih Salihi^I; Emir Canturk^II; Cengiz Koksal^II; Hizir Mete Alp^I

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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Introduction: The aim of this study is to investigate the change in the dimension of sinus of Valsalva in patients who underwent supracoronary ascending aorta replacement with aortic valve replacement.
Methods: A total of 81 patients who underwent supracoronary ascending aorta replacement with aortic valve replacement were included. Ten of 81 patients died during the follow-up. The patients were divided into three groups according to the aortic valve diseases. Group I (n=17) included patients with bicuspid valves, group II (n=30) included patients with stenotic degenerative valves, and patients with aortic regurgitation constituted group III (n=24). In preoperative and follow-up periods, the sinus of Valsalva diameter of the patients was evaluated by echocardiographic examination. The mean age was 54.1±15.1 years. Twenty-eight (34.6%) patients were female and 12 (14.8%) patients were in New York Heart Association functional class III.
Results: There was no early mortality. Late mortality was developed in 10 (12.4%) patients, 8 (9.9%) due to non-cardiac reasons. Late follow-up was obtained in 71 patients with a mean of 60±30.1 months postoperatively. During follow-up, the increase in the diameter of the sinus of Valsalva was significant in Group I (P<0.01), while in Group II and III it was insignificant (P>0.05).
Conclusion: To avoid the risks associated with sinus of Valsalva dilatation, it is reasonable to replace the sinus of Valsalva in the setting of aortic valve replacement and ascending aorta replacement for bicuspid aortic valve with a dilated ascending aorta and relatively normal sinuses of Valsalva in young patients. Keywords: Aortic aneurysm, thoracic/surgery; Aorta/surgery; Aortic aneurysm; Aortic Valve/Abnormalities; Bicuspid Aortic Valve

The Importance of Intra-aortic Pulse Pressure After Anterior ST-segment Elevation Myocardial Infarction

Ilker Gül^I; Levent Cerit^I; Bihter Senturk^II; Mustafa Beyazit Alkan^III; Hatice Kemal^I; Zeynep Cerit^IV; Belma Yaman^I; Songul Usalp^I; Hamza Duygu^I

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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Objective: To evaluate the association of pulse pressure (PP) with mortality and major adverse cardiac events (MACE) in one-year period after anterior ST-elevation myocardial infarction (A-STEMI).
Methods: A total of 261 consecutive patients whose blood pressure was measured with the aid of a catheter before primary percutaneous coronary intervention (PPCI) between August 2016 and February 2017 were included in the study. The patients were divided into three groups according to pulse pressure (PP) (Group 1, PP<35 mmHg; Group 2, 35=PP=50 mmHg; Group 3, PP>50 mmHg).
Results: The mean age of the patients was 63.4±14.1 years, and 206 of them were male. The groups were similar in terms of age and diastolic blood pressure (DBP). The ratio of female patients in Group 1 was higher, and their systolic blood pressure (SBP) was lower than those from the other groups (P=0.005 vs. P=0.042). The rates of MACE and mortality were higher in Group 1. The predictive PP values were calculated to be 42.5 mmHg for development of MACE and 41.5 mmHg for mortality. One-year survival ratio was worse in Group 1 than in the others according to Kaplan-Meier analysis (P<0.001).
Conclusion: The values of PP which was measured intra-aortically in patients with A-STEMI were associated with mortality and MACE in the one-year follow-up period. Keywords: Treatment outcome; Cardiac catheterization; Myocardial infarction; ST Elevation Myocardial Infarction

ACT Values after Neutralization Lower than Pre-heparinization ACT Leads to Lower Operative Times, Bleeding, and Post-Operative Transfusions in CABG Patients: an Observational Study

Weitie Wang^I; Yongwang Wang^III; Jinshan Wang^IV; Rihao Xu^II; Junwu Chai^I; Wei Zhou^I; Honglei Chen^I; Fenlong Xue^I; Xiangrong Kong^I; Wang Kai^I

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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Objective: To evaluate if lower activated coagulation time (ACT) value after neutralization than preoperative ACT value was effective in reducing bleeding, operative times, and post-operative transfusions in patients underwent coronary artery bypass grafting (CABG).
Methods: Retrospective selection of 398 patients from January 2014 to May 2017. Patients were divided into 2 groups according to final ACT after neutralization: A - final ACT lower than preoperative ACT; and B - final ACT higher than or equal to preoperative ACT. Hemostatic time, intraoperative blood loss, ACT after final neutralization, mediastinal blood loss, and transfusion requirements were observed.
Results: The hourly blood loss in the Group A was generally lower than in the Group B at first 3 hours, which has significant difference (P<0.05). However, there was no difference after 3 hours between the two groups. Operative time, intraoperative blood loss, mediastinal blood loss, transfusion requirements, and drainage in the first postoperative 12 hours in the Group A were lower than in Group B, which has significant difference (P<0.05).
Conclusion: As a result, final ACT values lower than pre-heparinization ACT values are safe and lead to lower operative times, bleeding, and post-operative transfusions. Keywords: Protamines; Coronary artery bypass; Thromboelastography; Whole blood coagulation time; Cardiopulmonary bypass

Expressions of Transforming Growth Factor β₁ Signaling Cytokines in Aortic Dissection

Shi-Min Yuan^I; Hong Lin^I

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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Objective: To demonstrate the underlying mechanisms of aortic dissection compared to those of coronary artery disease in terms of the transforming growth factor-beta (TGF-ß) signaling pathway.
Methods: Twenty consecutive aortic dissection patients and 20 consecutive coronary artery disease patients undergoing a surgical treatment in this hospital were enrolled into this study. The aortic tissues were sampled and the TGF-ß1 and its receptor TGF-ß receptor I (TßRI) were detected by Western blotting assay.
Results: TGF-ß1 and TßRI were positively expressed in the aortic tissues in both groups by Western blotting assay. The expressions of the two proteins were significantly higher in the aortic tissue of patients with aortic dissection than in those with coronary artery disease. The quantitative analyses of the relative gray scales of the proteins disclosed close correlations between the expressions of TGF-ß1 and TßRI in both the study and control group patients.
Conclusions: The aortic remodeling of aortic dissection might differ from that of coronary artery atherosclerosis concerning the nature, mechanism, mode, and activities of TGF-ß signaling pathway. The development of aortic dissection could be associated with a significantly enhanced function of TGF-ß1/Smad signaling transduction as a result of aortic remodeling incorporating both vascular injury and repair. Keywords: Aneurysm, dissecting; Coronary Artery Disease; Intercellular Signaling Peptides and Proteins; Blotting, Western

Risk Factors for Mortality in Children with Congenital Heart Disease Delivered at a Brazilian Tertiary Center

Luciane Alves Rocha^I; Sthefane Catib Froio^I; Célia Camelo Silva^II; Simone de Araujo Negreiros Figueira^III; José Cícero Stocco Guilhen^IV; Ruth Guinsburg^III; Edward Araujo^I

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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Objective: This study aims to investigate the incidence of postnatal diagnosis of congenital heart disease (CHD) and the predictive factors for hospital mortality.
Methods: This retrospective cohort study was conducted at a Brazilian tertiary center, and data were collected from medical records with inclusion criteria defined as any newborn with CHD diagnosed in the postnatal period delivered between 2015 and 2017. Univariate and multivariate analyses were performed to determine the potential risk factors for mortality.
Results: During the 3-year period, 119 (5.3%) children of the 2215 children delivered at our institution were diagnosed with CHD. We considered birth weight (P=0.005), 1st min Apgar score (P=0.001), and CHD complexity (P=0.013) as independent risk factors for in-hospital mortality. The most common CHD was ventricular septal defect. Indeed, 60.5% cases were considered as "complex" or "significant" CHDs. Heart surgeries were performed on 38.9% children, 15 of whom had "complex" or "significant" CHD. A mortality rate of 42% was observed in this cohort, with 28% occurring within the initial 24 h after delivery and 38% occurring in patients admitted for heart surgery.
Conclusion: The postnatal incidence of CHD at our service was 5.3%. Low 1st min Apgar score, low birth weight, and CHD complexity were the independent factors that affected the hospital outcome. Keywords: Mortality; Risk Factors; Heart Defects, Congenital; Infant, newborn

REVIEW ARTICLE

Combined Mitral Valve Replacement and Ravitch Procedures in a Patient with Previous Pneumonectomy: Case Report and Review of the Literature

Ilyas Kayacioglu^I; Ahmet Can Topcu^I; Kamile Ozeren^I; Yasin Ozden^I; Ahmet Bolukcu^I; Mehmet Yildirim^II

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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Introduction: Significant anatomical and functional changes occur following pneumonectomy. Mediastinal structures displace toward the side of the resected lung, pulmonary reserve is reduced. Owing to these changes, surgical access to heart and great vessels becomes challenging, and there is increased risk of postoperative pulmonary complications.
Methods: We performed a mitral valve replacement combined with a Ravitch procedure in a young female with previous left pneumonectomy and pectus excavatum.
Results: She was discharged on postoperative day 9 and remains symptom-free 3 months after surgery.
Conclusion: Thorough preoperative evaluation and intensive respiratory physiotherapy are essential before performing cardiac operations on patients with previous pneumonectomy. Keywords: Chest Wall/surgery; Heart valve prosthesis implantation; Mitral valve/surgery; Pneumonectomy; Funnel Chest

Perioperative Management of the Diabetic Patient Referred to Cardiac Surgery

Camila Perez de Souza Arthur^I; Omar Asdrubal Vilca Mejia^I; Gisele Aparecida Lapenna^I; Carlos Manuel de Almeida Brandão^I; Luiz Augusto Ferreira Lisboa^I; Ricardo Ribeiro Dias^I; Luís Alberto Oliveira Dallan^I; Pablo Maria Alberto Pomerantzeff^I; Fabio B. Jatene^I

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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Currently there is a progressive increase in the prevalence of diabetes in a referred for cardiovascular surgery. Benefits of glycemic management (< 180 mg/dL) in diabetic patients compared to patients without diabetes in perioperative cardiac surgery. The purpose of this study is to present recommendations based on international evidence and adapted to our clinical practice for the perioperative management of hyperglycemia in adult patients with and without diabetes undergoing cardiovascular surgery. This update is based on the latest current literature derived from articles and guidelines regarding perioperative management of diabetic patients to cardiovascular surgery. Keywords: Perioperative Management of the Diabetic Patient; Cardiac surgery

CASE REPORT

Lateral Costal Artery: Clinical Importance of an Accessory Thoracic Artery

Unsal Vural^I; Ahmet Arif Aglar^I; Sinan Sahin^I; Mehmet Kizilay^I

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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The lateral costal artery has sometimes been identified as the culprit for the “steal phenomenon” after coronary artery bypass grafting, besides being occasionally used for myocardial revascularization. Its branches make anastomoses with the internal thoracic artery through lateral intercostal arteries. We aim to report, on three cases, the clinical significance of a well-developed lateral costal artery after coronary artery bypass grafting. Two out of three patients who underwent coronary artery bypass graft surgery in our center between June 2010 and August 2017, applied to us with stable angina pectoris, while the third one was diagnosed with acute coronary syndrome after applying to the emergency department. In coronary cineangiography, in all three cases, a well-developed accessory vessel arising from the proximal 2.5 cm segment of the left internal thoracic artery coursed as far as the 6th rib was detected, and it was confirmed to be the lateral costal artery. A stable angina pectoris in two of the patients was thought to be the result of steal phenomenon caused by the well-developed lateral costal artery. In the two cases with stable angina pectoris the lateral costal artery was obliterated via coil embolization. In the other case with the proximal left anterior descending artery stenosis, before percutaneous coronary intervention, the lateral costal artery was obliterated via coil embolization and the occluded subclavian artery was stented. Routine visualization in cineangiography and satisfactory surgical exploration of the left internal thoracic artery could be very helpful to identify any possible accessory branch of the left internal thoracic artery like the lateral costal artery. Keywords: Mammary arteries; Subclavian Steal Syndrome; Thoracic Wall/blood supply; Internal mammary-coronary artery anastomosis

Gradual Treatment of Arteriovenous Fistula in Femoral Vessels as a Complication of Coronary Angiography

Mehmet Isik^I; Omer Tanyeli^I; Yuksel Dereli^I; Volkan Burak Taban^I; Özgür Altinbas^II; Niyazi Gormus^I

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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Arteriovenous fistula due to coronary angiography intervention is rarely seen. Arteriovenous fistulas may be asymptomatic according to the size of the shunt, as well as to the heart failure. In this case report, we aimed to share gradual transition from endovascular methods to surgery and why surgical treatment is required for a patient who developed arteriovenous fistula after coronary angiography. Keywords: Coronary Angiography/Adverse Effects; Endovascular procedures; Arteriovenous Fistula

Correction of Left Ventricular Outflow Tract Obstruction Caused by Anomalous Papillary Muscle and Subaortic Membrane

Mário Augusto Cray da Costa^I; Ana Caroline Wippich^I

Braz J Cardiovasc Surg 33; Publish in: 8/2/2025

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This paper presents a case study of a 30-year-old male patient with dyspnea on exertion had echocardiographic diagnosis of aortic subvalvar stenosis. Discrete mitral regurgitation and aortic valve dysplasia with mild to moderate insufficiency and hypertrophic cardiomyopathy were also noted. During surgery, a rare condition was identified: presence of papillary muscle anomaly associated with the subaortic membrane as a cause of obstruction of the left ventricular outflow tract. With the resection of these structures and a mitral valve annuloplasty, the patient evolved with a significant improvement of clinical condition and heart failure, with no residual mitral insufficiency. Keywords: Aortic valve/surgery; Papillary muscles; Heart valve prosthesis implantation; Cardiomyopathies

LETTER TO THE EDITOR