Volume 15 - Número 1
ORIGINAL ARTICLE
Cardiac surgery in elderly patients
Braz J Cardiovasc Surg 15;
Publish in: 8/2/2025
BACKGROUND: Because of the increase in the life expectancy of the Brazilian population, elderly patients are being increasingly referred to cardiac surgery.
MATERIAL AND METHODS: Seventy-five patients, 70 years of age or older, who underwent cardiac surgery in the HC-UFPR, between 1995 and 1999 were studied. The purpose of this study was to analyze early and long-term results. Ages from 70 to 88 years, with 34 females (46.7%) and 41 males (53.3%). Symptoms included angina (81.3%), dyspnea (42.6%) and syncope (16%). There was 57.3% of patients in NYHA class I, 17.3% in class II, 18.6% in class III and 6.6% in class IV. The main risk factors listed were high blood pressure (61.3%), smoke (48%), diabetes mellitus (28%) and 9.3% had already had cardiac operations. Surgical procedures included 50 coronary artery bypass grafts - CABG (66.6%), 9 aortic valve replacements (12%), 5 aortic operations (6.6%), 4 CABG + valve replacement (5.2%) and other procedures (7%). The main postoperative complications were cardiovascular - ventricular arrhythmias (22.6%), supraventricular arrhythmias (21.3%), low cardiac output (16%) - infections (16%) and pulmonary problems (9.3%). The median stay in the ICU was 5 days.
RESULTS: Sixty-five (78.4%) survivors had complete follow-up. The mean follow-up time was 20.7 months and long-term survival was 92%. Only one of the late deaths was cardiac related.
CONCLUSION: Although this subgroup is associated with chronic diseases compromising other organs, advances in cardiac surgery and intensive care have made possible an intervention with safety and low morbidity and mortality.
Keywords: Aging, physiology; Cardiac surgical procedures; Heart disease, surgery; Cardiac surgical procedures, aged
Myocardial revascularization without cardiopulmonary bypass: experience and initial results
Braz J Cardiovasc Surg 15;
Publish in: 8/2/2025
BACKGROUND: Myocardial revascularization without cardiopulmonary bypass (CPB) has been used as an alternative for treatment of coronary insufficiency.
OBJECTIVE: To present our experience with this procedure describing the technique used and our initial results.
MATERIAL AND METHODS: Twenty-three patients were submitted to myocardial revascularization without CPB. The patients selected for this study had lesions in the coronary arteries of the anterodiaphragmatic cardiac region. The main surgical indication was chronic coronary insufficiency (78.3%). 65% of the patients were male, with age between 44-80 (mean - 59.6 years). The surgical approach in all patients was through median sternotomy. He grafts used were internal thoracic arteries, saphenous vein and radial artery.
RESULTS: Mean surgical time was 3:15 hours. There were no intra-operative occurences.
The number of grafts was 1 to 3 in each patient (mean 1.56 graft/patient) out of a total of 36 grafts. The left internal thoracic artery was the most used graft (41.7%). The most frequently revascularized coronary arteries were the anterior interventricular branch (52.8%) and the right coronary (30.5%). Hospital mortality and post-operative infarct were 4.3%. There were no neurological, pulmonary, renal, hemorragic or infectious complications. The mean hospital stay was 7 days.
CONCLUSION: Myocardial revascularization without cardiopulmonary bypass is an effective and safe technique that can be utilized in selected cases with low morbidity and mortality, reducing costs and hospital stay.
Keywords: Myocardial revascularization; Extracorporeal circulation; Heart disease, surgery
Gastroepiploic artery in coronary artery bypass grafting
Braz J Cardiovasc Surg 15;
Publish in: 8/2/2025
MATERIAL AND METHODS: From January 1996 to July 1999, the right gastroepiploic artery (RGA) has been used for coronary artery bypass grafting (CABG) in 26 patients (25 male, average age 55.2 years). The surgery was indicated in patients with occlusion or critical coronary disease in the right coronary artery, in the anterior descending coronary artery and in branches of the circumflex coronary artery. Some 15 (57.8%) patients had stable angina, 10 (38.4%) had unstable angina and one of them had no clinical signs. There were 5 (19.2%) reoperations, 2 of them were second reoperations. CABG was used in 24 patients; normothermic in 18 and hypothermic in six. Two, 5 and 19 patients had coronary artery disease in one, two and three vessels respectively. RGA was used "in situ" in 24 patients and as a graft in 3 to the anterior descending coronary artery, 11 to the right posterior descending coronary artery, 8 to the right coronary artery, 1 to the right posterior ventricular coronary artery and 1 to the descending posterior vessel of the circumflex coronary artery and as a free graft revascularized the coronary diagonal in 2. The left and the right internal thoracic artery, the left radial artery and the saphenous vein graft were used concomitantly.
RESULTS: Postoperative angiography was performed in 12 (46.7%) patients, in 10 (83.4%) of them the RGA was patent, in 1 it was impossible to catheterize the celiac trunk, hence the flow could not be evaluated and in the other patient the graft was occluded. There were no deaths and all patients had an excellent outcome.
CONCLUSION: The RGA is a safe graft for CABG.
Keywords: Myocardial revascularization, methods; Thoracic arteries, transplantation; Stomach, blood supply
Mediastinitis after cardiac surgery: treatment using omental flap
Braz J Cardiovasc Surg 15;
Publish in: 8/2/2025
MATERIAL AND METHODS: Twenty-two patients with mediastinitis were analyzed out of 1,006 cardiac surgeries with sternotomy performed in "Felício Rocho Hospital" in Belo Horizonte, Minas Gerais, between 1993 and 1998. The complication occurred in 3.2% patients submitted to Coronary Artery Bypass Grafting (CABG), 3.1% in transplantations, 1.1% in valve diseases and none in congenital corrections.
RESULTS: The general infection rate was 2.1% and the identified was Staphylococcus aureus (39.1%). Different treatments performed during this period are presented: simple drainage, debridment and rotation of the pectoralis and omental flaps.
CONCLUSION: The omental flap rotation started on the Service in 1995, considerably improved the results and mortality due to this complication has been eliminated the past 2.5 years.
Keywords: Mediastinitis, surgery; Cardiac surgical procedures, adverse effects; Sternum, surgery; Surgical flaps; Omentum, transplantation
Simplified implantation technique of stentless aortic bioprosthesis
Braz J Cardiovasc Surg 15;
Publish in: 8/2/2025
OBJECTIVE: Probably the major drawback to a stentless porcine xenograft is the complexity of the technical demands required for inserting a competent aortic valve (usually two suture rows).
MATERIAL AND METHODS: Fifteen patients underwent aortic valve replacement with the Labcor stentless porcine heterograft using a simplified technique for implantation - single interrupted suture row on the aortic anulus and commissure attachment to the aortic wall. Twelve patients were male and 3 female, with ages ranging from 9 to 56 years. The aortic valve lesion was stenosis in 8 (53.3%) cases, mixed lesion in 4 (26.7%) and insufficiency in 3 (20%). Ten (66.7%) patients were in functional class III (NYHA) and 5 (33.3%) were in class IV.
RESULTS: There was no hospital death or valve related morbidity. The ColorDoppler echocardiography revealed mild central aortic regurgitation in 2 (13.3%) cases before discharge. One patient died 14 months after operation due to bacterial endocarditis and septic shock . The actuarial survival was 93.3% at a mean follow-up of 23.5 months, ranging from 17 to 29 months. Twelve (85.7%) patients are in functional class I and 2 (14.3%) patients in functional class II, without any report of tromboembolic events, paravalvular leakage or hemolysis in the observed period.
CONCLUSIONS: We conclude that this simplified technique for stentless aortic bioprosthesis implantation is easy to execute, reproducible and with low incidence of morbidity-mortality.
Keywords: Bioprosthesis; Blood vessel prosthesis implantation, methods; Aortic valve stenosis, surgery
Initial study in ministernotomy and mini-incision Dante Pazzanese Institute of Cardiology
Braz J Cardiovasc Surg 15;
Publish in: 8/2/2025
OBJECTIVE: Ministernotomy and mini-incision are options to approach the heart. The latter, is a small incision on the skin with complete division of the sternum. The goal of this study was to evaluate the two approaches regarding viability, reproducibility and the final estetic effect.
MATERIAL AND METHODS: "H" and "L" miniesternotomies and mini-incision surgeries had been realized for the treatment of valve defects (mitral and aortic), congenital heart defects (IAC and IVC) and three myocardial revascularizations. Thirty-five pacients were assessed: 10 submitted to ministernotomy (40%) and 24 to mini-incision (60%). Average age was 23.4 years (range 3 months to 52 years) with females predominating (54%).
RESULTS: The surgeries included: implant of aortic prostetic valve - 9 (25.7%), 8 were biological valves and one a mechanical valve; implant of mitral valve - 6 (17.1%) utilizing biological valves and one plastic mitral valve (2.9%); two mitro-aortic valve replacements (5.8%), correction of atrial septal defect 13 (37.1%) and correction of ventricular septal defect, 1 (2.9%) and 3 (8.5%) myocardial revascularizations, one without extracorporeal circulation. "H" ministernotomy had been done in 7 (20%) cases and in "L" in 3 (8.5%) cases and via mini-incision in the remaining cases (25). The size of the incisions ranged from 7 to 14 cm with an avarege of 9.9 cm.
CONCLUSION: This two approaches to the heart for cardiac surgery are perfectly viable and reproducible without changing surgical time, or extracorporeal circulation time without greater risks to the patient, and resulting in a better final estetic effect than conventional sternotomy.
Keywords: Sternotomy, surgery; Thoracotomy, methods
Right ventricular bifocal stimulation in treatment of heart failure with dilated cardiomyopathy
Braz J Cardiovasc Surg 15;
Publish in: 8/2/2025
BACKGROUND: Widening of QRS by ventricular conventional pacing (CP) impairs ventricular contractility and mitral performance.
PURPOSE: To study an alternative mode of cardiac stimulation with narrower QRS, using 2 leads in the right ventricle and to test it, compared to CP.
MATERIAL AND METHODS: 5 dilated cardiomyopathy patients (3 Chagas´ disease, 2 unknown) with cardiac failure (NYHA III/4) and pacemaker (PM) indication, 4 male/1 female, mean age 52.2. years, cardiac shape 3+/4+, chronic AF with AVB, were submitted to endocardial PM implants with 2 right ventricular leads. The first in the His bundle area (septal) and the second, conventional, in the right ventricular apex. The generator was Biotronik Dromos DR (the short programmable AV = 15ms). The septal lead was connected to the atrial outflow and the one of the apex to the ventricular exit. After 2 weeks, they were studied by echocardiogram, in 3 stimulation modes in the same session with same cardiac rate: mode "AAI" (septal), mode VVI (conventional) and mode "DDT" with AV interval=15ms (almost simultaneous bifocal stimulation).
RESULTS: The averages of the parameters studied were:
CONCLUSION: The echocardiographic evaluation for the immediate comparison in the same patient with 3 stimulation modes, revealed: 1. The conventional mode showed the worse hemodynamic performance; 2. the bifocal mode showed the best result with mean increase of the EF of 6.8% and of CO in 0.6 l/min, mean reduction of LA in 7.5 cm2, mean reduction of the area of mitral regurgitation in 7.6 cm2 and mean reduction in the QRS duration of 61ms, (p < 0.03). It was the best stimulation in cardiomyopathy with heart failure, functional mitral regurgitation and pacemaker indication.
Keywords: Cardiomyopathy, congestive, therapy; Pacemaker, artificial; Cardiac output, low therapy
CONCLUSION: The echocardiographic evaluation for the immediate comparison in the same patient with 3 stimulation modes, revealed: 1. The conventional mode showed the worse hemodynamic performance; 2. the bifocal mode showed the best result with mean increase of the EF of 6.8% and of CO in 0.6 l/min, mean reduction of LA in 7.5 cm2, mean reduction of the area of mitral regurgitation in 7.6 cm2 and mean reduction in the QRS duration of 61ms, (p < 0.03). It was the best stimulation in cardiomyopathy with heart failure, functional mitral regurgitation and pacemaker indication.
Keywords: Cardiomyopathy, congestive, therapy; Pacemaker, artificial; Cardiac output, low therapy
UPDATES
Expression of nitric oxide synthases in coronary artery disease after heart transplantation
Braz J Cardiovasc Surg 15;
Publish in: 8/2/2025
A major complication that can limited the evolution of a cardiac transplantation over the long term is the development of accelerated coronary arteriosclerosis. This form of coronary disease is different from the atherosclerotic coronary disease of patients not submitted to cardiac transplantation. Current evidence obtained by intravascular ultrasound, has demonstrated that the occurrence of a precocious endothelial dysfunction, mainly mediated by the inducible isoform of the nitric oxide synthase (iNOS) expression, is associated with the development of atherosclerosis in cardiac allografts during the first year of the transplant. This review was developed starting with basic concepts (description of the enzyme and its known isoforms; a brief comparison between them), reviewing the coronary endothelial dysfunction after cardiac transplantation, from the specific point of view of the NOS enzymatic function. In cardiac transplantation iNOS promotes acute rejection but prevents chronic episodes. The relationship between these opposing effects remains unknown we only know that they are different mechanisms which are time-dependent.
Keywords: Nitro-oxide synthese, metabolism; Endothelium, vascular, enzymology; Heart transplantation, physiology; Graft rejection, enzymology
CASE REPORT
Surgical correction of left ventricle aneurysm in a patient with Chagas disease utilizing prosthesis of bovine pericardium
Braz J Cardiovasc Surg 15;
Publish in: 8/2/2025
The authors describe the surgical correction of left ventricle aneurysm in a female patient with Chagas disease that presented heart failure. A prosthesis of bovine pericardium was used to reconstruct the aneurysmatic wall of the left ventricle, thus obtaining marked reduction of symptoms. They believe that the benefits of this type of surgery in patients with left ventricle aneurysm of ischemic etiology, can be extended to patients with Chagas disease.
Keywords: Chagas cardiomyopathy, surgery; Heart ventricle, surgery; Heart valve prosthesis
Pulmonary resection after orthotopic heart transplantation
Braz J Cardiovasc Surg 15;
Publish in: 8/2/2025
OBJECTIVE: The purpose of this study is to present and discuss the clinical evolution of 2 patients who after orthotopic heart transplantation presented complicated pulmonary infection, resulting in the formation of abscess.
MATERIAL AND METHODS: In both cases lobectomy was indicated due to failure to respond to conventional clinical treatment. At operation classical rules of pulmonary resection were strictly adhered to avoid the appearance of bronchopleural fistulas.
RESULTS: The patients presented a good postoperative course with definitive resolution of infections and at follow-up are in stable condition.
Keywords: Heart transplantation, effect adverse; Lung abscess, surgery; Pneumonectomy; Graft rejection, etiology