Volume 16 - Número 4

OBJECTIVE: The internal mammary artery (IMA) is the best conduit for use as a descending anterior artery bypass graft. The incidence of the IMA use in the elderly is widely variable. This study reviews the indications of the coronary artery bypass grafting with the internal mammary artery in the elderly and shows our experience with this procedure. METHODS: From July 1999 through December 2000, 163 patients underwent isolated coronary artery bypass grafting. Of these, 40 patients (24.53%) were 70 years or older (Group 2). The preoperative data included gender, coronary risk factors, NYHA functional class, angina class, history of previous myocardial infarction, and left ventricular function. Intraoperative information included the number of graft performed, whether the IMA was used, and incidence of surgical complications. The incidence of the postoperative complications was recorded in all patients. RESULTS: In the Group 1 all anterior interventricular branch was revascularized with IMA, and in the Group 2, 95% received the IMA graft. No significant differences were noted in the preoperative and postoperative data between the two groups. CONCLUSION: Although elderly patients requiring bypass grafting clearly are at increased risk of the surgical complications, an IMA graft does not increase the morbidity and appears to improve both early and late survival, making it a first selection graft for such a population. Keywords: Coronary disease, surgery; Myocardial revascularization, aged; Internal mammary artery, surgery; Cardiac surgical procedures, methods, aged

OBJECTIVE: Partial left ventriculectomy has been performed in patients with severe cardiomyopathies. The purpose of this investigation is to document the clinical effects of this procedure, associated with mitral insufficiency correction, in 43 patients with idiopathic dilated cardiomyopathy. METHODS: Eighteen patients were in New York Heart Association class III and 25 were in persistent class IV. Seven of these patients were operated on in cardiogenic shock. The procedure was associated with mitral anuloplasty in 32 patients and with mitral replacement in three. Ten patients were also submitted to De Vega tricuspid valve anuloplasty. Automatic cardioverter-defibrillators were implanted in 12 patients. RESULTS: Nine (20.9%) patients died during the hospital period. The follow-up time ranged from two to 57 months, with a mean of 28.3 months. At six months of follow-up, eight patients were in functional class I, 13 patients in class II, three patients in class III e one patient in class IV (p<0.001). On the other hand, nine patients died during the first six months and other ten in the later postoperative period. Actuarial survival rates were 58?(?7% at one year, 48?(?7% at two years and 32 (?8% at five years of follow-up. Stepwise logistic regression demonstrated that six-month survival was significantly affected by the degree of myocytes hypertrophy. The Cox proportional-hazards analysis showed that preoperative functional class and nor-epinephrine levels were significantly associated with a long-term unfavorable outcome. When that analysis also included anatomicopathological variables, the existence of apoptotic myocardial cells and of more important myocytes hypertrophy were identified as the unique independent predictors of poor outcome. Patients operated in functional class III or IV presented survival rates of 60 ±?11% and of 14 (?8% at five years, respectively. In the presence of myocardial cells apoptosis, the survival was 8?(?7% at the same period, where as it was 63 (11% in the absence of that alteration. CONCLUSION: Partial left ventriculectomy, associated, when necessary, with mitral insufficiency correction, improves LV function and ameliorates congestive heart failure in patients with idiopathic dilated cardiomyopathy. However, this procedure clinical application is limited by the high mortality observed in the first postoperative months and by the possibility of heart failure progression and of arrhythmia related events at the late follow-up. These facts seem to be influenced by myocardial cells compromise and by patients' preoperative condition. Keywords: Cardiomyopathy, congestive, surgery; Cardiac surgical procedures, methods; Heart ventricle, surgery

From November 30, 1991 to August 31, 2000, 80 cardiac transplants have been analyzed retrospectively at Instituto Dante Pazzanese de Cardiologia. Seventy percent of the recipient were male, and the recipient average was 44.8 years(range: 7 to 69 years). Twelve patients(15%) were considered priority, receiving inotropic drug support at the moment of transplantation. The diagnosis of the recipients included primary dilated cardiomiopathy (37.5%), ischemic cardiomiopathy (33.75%), cardiomiopathy by Chagas disease (17.5% ) and others (11.25%). Seventy eight transplants were orthotopic, and two heterotopic. Surgical technique used was bicaval/bipulmonar (63.75%), atrial (27.5%), bicaval/unipulmonar (6.25%) and heterotopic (2.5%). The 30 day mortality for all patients was 18.75%. The survival after orthotopic transplant in one year was of 72.7%; in five years was 61.5%, and in seven years was of 56.4%. The survival after transplant was related to the following variables: age, cause of death and sex of the donor, and wheter the transplant was or not the patient's first cardiac surgery . Keywords: Heart transplantation, methods; Heart transplantation, mortality; Heart transplantation, statistics & numerical data

INTRODUCTION: This study analyzed the alterations in the pulmonary artery (PA) diameters after bilateral cavopulmonary derivation (BCPD). MATERIAL AND METHODS: Eighteen patients submitted to BCPD in the period from March 1990 to January 1997, with available cineangiographic examinations in the pre- and postoperative period, were included. Measurements in right pulmonary artery (RPA) and left pulmonary artery (LPA) were performed at three sites: at the origin, immediately before bifurcation and at the beginning of the inferior lobe artery. The diameters of each site were indexed with respect to body surface or diameter of the aorta at the level of the diaphragm. Angiographic and oximetric data were submitted to statistical analysis. RESULTS: On analyzing absolute diameters, it was observed that most suffered a non-significant increase in the postoperative period, while the LPA diameter presented a decrease. The total indexes I e III presented a significant decrease in the postoperative period, this reduction of the total index II being non-significant. Analysis of the postoperative follow-up variable showed a significant reduction in the total indexes in patients with a postoperative follow-up less than 23,6 months. Presence of additional blood flow elicited an increase in RPA I and III indexes and a small reduction in the other. The PA measurements indexed with respect to the diameter of the aorta showed a behavior similar to those with respect to body surface. In the absence of collateral venous circulation (CVC) a significant increase in O2 saturation was observed. On the other hand, its presence elicited a non-significant increase during the period of observation. Keywords: Heart defects, congenital, surgery; Pulmonary artery, anatomy & histology; Pulmonary artery, surgery; Pulmonary artery, growth & development; Heart bypass, right; Cardiovascular surgical procedures, methods

OBJECTIVE: To analyze the morphological aspects, the surgical results obtained according to the number of procedures, and the mortality in each group of Barbero-Marcial´s classification of the pulmonary atresia with ventricular septal defect. MATERIAL E METHODS: From January 1990 to November 1999, 73 patients submitted to cardiac catheterization and detailed pulmonary angiographic study before the first surgical intervention were analyzed. The anatomical characteristics of the pulmonary arteries and major aorticopulmonary collaterals, as the surgical techniques of definitive, palliative and "definitive palliative" were studied. The causes of mortality were also described. RESULTS: Nineteen patients had all the pulmonary segments supplied by pulmonary arteries (group A), 45 patients had pulmonary segments supplied by pulmonary arteries and major aorticopulmonary collaterals (group B) and 9 had only major aorticopulmonary collaterals (group C). The group A has the major incidence of definitive surgical repair, the group B more palliative procedures and the group C more "definitive palliative" procedures (p< 0.0001). There is no statistically significant difference of mortality among the groups (p=0.860), although the mortality of group B and C was more than twice that of group A. CONCLUSIONS: Barbero-Marcial´s classification allows to estimate the probability of definitive, palliative or "definitive palliative" treatment, as well as the risk of mortality in patients with pulmonary atresia with ventricular septal defect. Keywords: Heart defects, congenital, surgery; Pulmonary atresia, surgery; Pulmonary atresia, classification; Pulmonary atresia, anatomy & histology

INTRODUCTION: The intraoperative atrial compartmentalization was done in 27 patients, utilizing ultrasound energy (US). This source has been more effective in creating deeper and uniform atrial line lesions, without causing carbonization. MATERIAL AND METHODS: From March 1999 to June 2000, 27 patients (19 females) averaging 36 years old were submitted to this operation. Five were operated for the second time due to mitral valve disorders, 2 for mixomatose valve degenerations, 1 for congenital defect and 1 for lone atrial fibrillation. RESULTS: The procedure takes 166.6 minutes on average, in each surgery, that is 69.2 minutes for the cardiopulmonary bypass, 39.7 minutes for cardiac arrest by aorta clamping, 12.5 minutes for the right atrial lesion lines and 14 minutes for the left one. The reversion to sinus rhythm was achieved in 24 patients. In 2 the reversion was not obtained and in 1 transient total atrium-ventricular block was observed. No explanation was found for the failure to revert the 2 patients, since both were primarily phase submitted to valve repair operation and the atrium was not very enlarged. In the postoperative phase, atrial fibrillation recurrence was observed in 2 patients and two deaths occurred cuased by pulmonary problem and cardiogenic shock unrelated to the technique. The success rate at the hospital discharge was 81.4%. To all patients were given verapamil or amiodarone for electrical atrium remodeling. CONCLUSION: The use of US during mitral valve operation to compartmentalize the atrium, in patients with CAF, makes the reversion to sinus rhythm so easy and fast that is possible to consider employing this technique in patients having CAF associated to other surgical cardiac diseases. The use of US, during cardiac operation, to create the atrial line lesion, modifies and makes easier the Maze procedure, causes less tissue damage, decreases the surgical time and the chance for postoperative complications. Keywords: Atrial fibrillation, surgery; Arrhythmia, therapy; Cardiac surgical procedures, methods

OBJECTIVE: To compare the efficacy of two therapeutical protocols using low doses of betablockers for prevention of atrial fibrillation in the immediate postoperative period of coronary artery bypass surgery (CABS). METHODS: 154 patients, submitted to coronary artery bypass surgery, were randomised into two groups: Group I (n = 72) received Sotalol (80 mg/daily) and group II (n = 82) received Propranolol (40 mg/daily), both starting in the first postoperative day. Patients were observed by continuous electrocardiographic bedside monitoring in the intensive care unit. Additionally, standard 12-lead electrocardiograms were made preoperatively, on 1st, 3rd and 6th postoperative days and in patients with complaints of palpitations or whenever signs of arrythmias appeared (i.,e., irregular pulse or a pulse rate exceeding 100 beats/min). RESULTS: Atrial fibrillation was documented in 3 (4.2%) patients of group I (Sotalol) and in 8 (9.8%) of group II (Propranolol). CONCLUSION: The overall incidence of atrial fibrillation in patients receiving low doses of Sotalol and Propranolol after CABS was low (7.1%) and, although not statistically significant (p = 0.221), it was even lower (4.2%) in patients receiving Sotalol. Keywords: Myocardial revascularization, adverse effects; Atrial fibrillation, prevention & control; Sotalol, therapeutic use; Propranolol, therapeutic use

OBJECTIVE: The aim of this investigation was to analyze the behavior of the mitral valve anulus and of the left ventricle (LV) in dilated cardiomyopathy (DCM). MATERIAL AND METHODS: Sixty-eight hearts of adults males suffering from ischemic or idiopathic DCM were analyzed after formaldehyde fixation and 20 hearts from in former patients without cardiopathy. Images were obtained after digitalization of the perimeter of mitral anulus, insertion of the anterior and posterior cusps and of the fibrous and muscular portion, as well as of the internal perimeter of the LV, distance from the septum to the anterior and posterior papillary muscle and of the septum interventricular length. RESULTS: The analysis of the results showed proportionality, both of the fibrous portion (r2 = 0.98) and of the muscular portion (r2 = 0.99) of the anulus as related to the dilatation degree of the mitral valve. Linear regression revealed a proportion relationship between the perimeter of the anterior (r2 = 0.96) and posterior (r2 = 0.99) cusps. The LV dilation occurred in global and spherical shape in all segments. No proportional relationship was observed between the degree of dilation of the mitral anulus and of the LV. CONCLUSIONS: Contrary to previous thinking, the DCM of ischemic or idiopathic etiology, the dilation of the anulus occurs in a proportional form and not only in its posterior portion. The degree of LV dilation does not determine the degree of mitral anulus dilation as they occur independently. Such obeservations open new perspectives for the techniques of correction of mitral valve insuficiency in DMC. Keywords: Mitral valve, pathology; Mitral valve, anatomy & histology; Cardiomyopathy, complications; Cardiomyopathy, pathology; Heart ventricle, anatomy & histology; Heart ventricle, pathology

INTRODUCTION: The pulmonary trunk (PT) banding has been used to promote rapid left ventricular (LV) hypertrophy in patients with transposition of the great vessels (TGV) with intact septum, treated after the neonatal period. This procedure carries a high morbidity and mortality rates. Genetic alterations of the cardiomyocytes resulting from acute hypertrophy have not been evaluated in models of variable systolic overload of the subpulmonary ventricle. In order to evaluate the activity of angiotensin converting enzyme (ACE) in acute right ventricular (RV) hypertrophy, a balloon catheter was implanted in the PT of six young goats. MATERIAL AND METHODS: Systolic overload was carried out throughout progressive balloon insufflations for a period of 96 hours. Hypertrophy was followed by daily hemodynamic and echocardiographic evaluations. At the end of the 96 hours, the animals were killed to harvest the heart. The ventricles and septum were weighted separately. Samples of each cardiac muscle were collected for ACE analysis. Eight goats (with similar age and weight) were used as control for weight and ACE activity. RESULTS: At the end of the protocol, the following parameters were increased: RV/PT gradient (p=0.001), RV to LV ratio (p=0.005), thickness of the free wall of RV (p=0.002) and RV weight (p=0.002). The evaluation of ACE activity showed an increase only in the hypertrophied RV muscle (p=0.002), indicating a high correlation with the increase in the RV to LV ratio (r=0.87). CONCLUSION: The progressive systolic overload in the RV of goats induces ventricular hypertrophy. This hypertrophy is related to a significant increase in ACE activity, an important molecular marker of this process. Keywords: Hypertrophy right ventricle, physiopathology; Hypertrophy right ventricle, enzymology; Transposition of great vessels; Cardiac surgical procedures, methods

The systemic inflammatory response syndrome (SIRS) occurs in the cardiac surgery more often with the use of CPB. It is due to the contact of the blood with non-endothelial surfaces and, later to reperfusion. This contact leads to the release of substances such as anaphylotoxins, which are activated by the complement factor, and stimulate the production of pro-inflammatory cytokines (IL-1, IL-6, TNF-a). Cytokines are responsible for induction of fever, neutrophilia with increase of adhesiveness between neutrophils and mocytes and, they act synergetically stimulating the production of other interleukins (IL-6, IL-8). It is observed that intestinal ischemia secondary to CPB, causes the production of IL-6, TNF-a, IL-1 in the intestinal epithelium and, reperfusion post CPB induces the expression of IL-1 and TNF-a in the vascular endothelium that can generate a dysfunction able to injure cardiomyocytes. Following the post-CPB cascade of reactions, the adult respiratory distress syndrome is mediated by IL-8, found the at alveolar level. The brain and the liver can also be affected by ischemia/reperfusion phenomena and, once more, it is shown that interleukins (IL-8 and IL-13, respectively) have an important role in the course of SIRS- related events. CPB and anesthesia techniques can influence interleukin activity. There is not a consensus regarding preventive or treatment therapies for complications from SIRS. Possible choices are: intervention at the level of inflammation mediators, digestive decontamination procedures, use of drugs such as indometacin or steroids. The regulation of the inflammatory process, generally depends on the balance between anti- and pro- inflammatory cytokines. These later are detectable in normal individuals whereas the others only manifest locally or are almost inexistent. We conclude that the increase of the concentration of pro-inflammatory interleukins in the organism is expected during important surgical intervention. Such an increase will bring complications if it is exacerbated and, the organism is debilitated. Keywords: Extracorporeal circualtion, adverse effects; Interleukins; Cardiac surgical procedures, adverse effects

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