Volume 17 - Número 1
EDITORIAL
Palavras do Prof. Fabio B. Jatene
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
Keywords:
SPECIAL ARTICLE
A new proposal of nomenclature system for congenital heart defects
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
The authors propose a new nomenclature system for congenital heart defects, based on the principles of the sequential segmental analysis. The short list of diagnosis is presented, and the importance of terminology uniformity is discussed, in order to facilitate the exchange of information among institutions.
Keywords: Congenital heart defects, classification; Congenital heart defects, nomenclature; Terminology, medical; Unimity system, medical terms
ORIGINAL ARTICLE
Surgical treatment of left ventricular free wall rupture after acute myocardial infarction
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
MATERIAL AND METHODS: Between January 1983 and May 1999, 12.405 patients were treated by the surgical team of the Heart Institute (InCor) with the diagnosis of acute myocardial infarction (AMI). From these patients, 127 (1.02%) had left ventricular free wall rupture as an ischemic complication of the myocardial infarction. The cardiac rupture was acute in 98 patients (77.1%) and sub-acute in 29 (22.9%).
RESULTS: Twenty-four patients were operated on, 5 on acute rupture with 80% of hospital mortality and 19 on sub-acute rupture with 15.8% of hospital mortality. The post-operative overall survival including both groups was 70.8%.
CONCLUSION: The conclusion was drawn that left ventricular free wall rupture is a severe complication of acute myocardial infarction that needs an immediate action. In acute ruptures, most patients develop hemodynamic deterioration without enough time to try to proceed any surgical correction. The sub-acute cases can be detected and monitored through periodic ecocardiographic exams after the AMI. In these cases the early surgical intervention, many times without using extra-corporeal circulation, has been increasing the chances of survival of the majority of these patients.
Keywords: Heart ventricle, surgery; Myocardial infarction, complications; Heart rupture, post-infartion
Efficacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left ventricular dysfunction
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
PURPOSE: Efficacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left ventricular dysfunction.
METHODS: This study evaluated clinical and hemodynamic results of endoventricular circular patch plasty in patients with either large akinetic scar (n=9) or large dyskinetic scar (n=11) and depressed left ventricular function (ejection fraction < 35%). The difference between akinetic and dyskinetic left ventricular aneurysms was diagnosed by gated radionuclide ventriculography. Groups were comparable for symptons and by echocardiography and by hemodynamic before and after the surgery.
RESULTS: Results showed an early improvement in New York Heart Association functional class. Statistically (the Student t test) an improvement occurred in left ventricle ejection fraction (from 25 ± 0.8% to 39 ± 1.6% in akinetic patients and from 27 ± 0.7% to 41 ± 1.6% in dyskinetic patients), decreased of capillary wedge pressure (20 ± 1.2 mmHg to 12 ± 1.2 mmHg in akinetics and 17 ± 0,5 mmHg to 11 ± 0.9 mmHg in dyskinetics patients), decrease end-diastolic volume index (226 ± 11 ml to 115 ± 7,8 ml in akinetics and 209 ± 11ml to 96 ± 5ml in dyskinetics) and end-systolic volume index (176 ± 9.2 ml to 77 ± 6.2 ml in akinetics and 160 ± 10ml to 66 ± 2ml in dyskinetics patients. Overall operative mortality was 10% (2 cases in akinetic group = 22.2%).
CONCLUSION: We find that endoventricular circular patch plasty technique allows an effective correction and provides a significant improvement in cardiac function in patients with large postinfarction akinetic scar and severe left ventricular dysfunction.
Keywords: Myocardial infarction, complications; Heart aneurysms, surgery; Heart ventricle, surgery; Ventricular function
Radial artery selection as coronary artery bypass graft: surgical correlation vs preoperative evaluation by using echocolor Doppler and digital photoplethysmography
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
INTRODUCTION: With the growing use of the radial artery as a coronary artery bypass graft, becomes necessary to revalue the criteria used for the selection of that vessel in the preoperative of the surgery of coronary artery bypass graft (CABG). The objective of this study was to correlate the evaluation of the viability of the vessel for the heart surgeon at surgery with the study of selection of the radial artery for the methods non invasivos, as EchocolorDoppler(ECD) and the digital photoplethysmography(PPG).
METHODS: Between July of 1998 and January of 2000, 78 radial arteries and 78 arteries ulnares of 39 patients selected for CABG, were studied. The study was carried out bilaterally, using duplex ultrasound ATL - HDI 5000 and Acuson - Sequoia 512, and for the photoplethysmography an apparel Parks Vascular Mini - Lab Model 1052-C. The radial artery was considered susceptible to be used as coronary artery graft bypass, when it filled out the following criteria: ateromatose absence or occlusion of the radial artery and ulnar ipsilateral, internal diameter of the larger radial artery or equal to 2.5mm, appraised for ECD, and presence of pulse wave in two or more digits during the radial compression, appraised for the PPG.
RESULTS: Among the 78 studied radial arteries, 64 (82%) were considered appropriate for use as coronary artery graft bypass and 12 (18.7%), not appropriate. Of the 39 selected patients, 24 (61.5%) they were submitted to CABG with use of the radial artery and the correlation between the viability of the appraised radial artery for the surgeon at surgery with the evaluation preoperative for ECD and for the PPG for selection of the radial artery was of 100%. The contraindication of the harvest of 12 (18.7%) radial arteries took to the alteration of the surgical planning of two patients, owing to the bilateral compromising. In three patients that, for different reasons, they were not submitted to the study by ECD and for the PPG, the clinical evaluation of the patency of the radial artery using Allen's maneuver was not enough to move away the presence of calcification of the arterial wall found in the operative act, disabling the use of that artery as graft.
CONCLUSION: The selection of the radial artery for use as graft coronary artery bypass, appraised by non invasive tests, as ECD and the PPG, it is effective, because the association of those methods presents excellent correlation with the evaluation at surgery and it allows us, cardiovascular surgeons, besides the safety, a better surgical planning for each patient.
Keywords: Radial artery, ultrasonography; Echocardiography, Doppler color, utilization; Photoplethysmography, utilization; Myocardial revascularization
Mitral valve repair in rheumatic heart disease and mixomatous degeneration: a comparative study
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
RACIONALE: Most surgical intervention on the mitral valve in Brazil are due to rheumatic cardiac disease (RCD). Some advantages of the mitral valve repair over replacement are lower operative and late mortality, maintenance of geometry and left ventricular function. Nevertheless, the evolution of the RCD can jeopardize the late results of mitral reconstruction.
OBJECTIVE: The objective of this study is to compare the results of mitral valve repair for isolated regurgitation in our patients with RCD and myxomatous degeneration (MD).
MATERIAL AND METHODS: Charts from patients with RCD (n = 11), and MD (n = 9) submitted to mitral repair between July 1992 and August 1999 were reviewed. Twenty six mitral procedures were performed on patients with MD, and 31 on those with RCD. Bovine pericardial ring was used for anuloplasty on 18 patients, and rigid (Carpentier) ring on 2 (one in each group). The techniques were quadrangular ressection (n = 13), trench shortening (n = 5), comissurotomy (n = 4), leaflet extention (n = 3), chordal transposition (n = 3), chordal replacement (n = 2), papilotomy (n = 2), chordal plication (n = 1), and folding plasty (n = 1).
RESULTS: Mean follow-up was 41.5 months (6 to 96 months), and one patient was lost. There were no hospital or late deaths. One patient with RCD were reoperated for disease evolution. One patient was treated concervatively for endocaditis 3 months after surgery. The difference on left ventricular diameter, both systolic and diastolic, did not reach statistical significance (p = 0.20; p = 0.17, respectively).
CONCLUSION: In conclusion, the mid-term (3.4 years) results for mitral valve repair due to isolated regurgitation were satisfactory in both groups. Clinical follow-up of patiens with RCD was comparable to those with MD in respect to operative and late death, endocarditis, and valve related events.
Keywords: Mitral valve surgery; Mitral valve injuries; Rheumatic fever, complications; Rheumatic heart discase
Anterior and posterior enlargement of the aortic annulus for valve replacement
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
OBJECTIVES: To present a technique for anterior and posterior enlargement of the aortic anulus using individual patches and results in 26 patients.
METHOD: Aortic valve surgery is performed with conventional cardiopulmonary bypass. For posterior enlargement, the longitudinal aortotomy is extended inferiorly and posteriosly in the mean portion of the noncoronary sinus, until the anterior mitral leaflet. Anterior enlargement results from incision between the two coronary ostium, extended in the left side of the ventricular septum for 2 cm. Two patches of bovine pericardium are sutured in the distal portion of the anterior and posterior incisions and the aortic prosthesis is fixed. Aorta is reconstructed with the patchs. Combined cardiac defects are corrected.
RESULTS: Procedure resulted in increase of the annulus diameter from 18.0 + 2.6 mmHg to 24.5 + 2.1 mmHg (p<0.01). During operation, one patient required coronary revascularization owing to ostial obstruction. After the operation, one patient was reoperated owing bleeding (3.8 % morbidity) and one died with sepsys (3.8% hospital mortality). In the late post-operative period (mean follow up: 24 months) there were no deaths or reoperations. Functional class improved for all followed up patients and 22 (84.3 %) are in class I (NYHA). For patients with stenosis of the native valve or prosthesis, mean peak systolic transvalvar gradient (measured by Doppler echocardiography) decreased from a preoperative value of 87.3 + 20.8 mmHg to 25.9 + 10,3 mmHg (p<0.01).
CONCLUSION: Increase in diameter of the aortic annulus results from anterior and posterior enlargement using individual patches. The procedure should be considered for enlargement of the aortic annulus and reconstruction of the left ventricular outflow tract.
Keywords: Aortic valve, surgery; Aortic valve stenosis, surgery; Heart valve prosthesis, implantation
Comparative study of low-dose aprotinin x placebo during cardiopulmonary bypass
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
BACKGROUND: The use of aprotinin, a antifibrinolytic agent, has been shown to decrease damaging effects on cardiopulmonary bypass in fibrinolytic system, which may improve hemostasis.
OBJECTIVE: To study the effect of low dose aprotinin in patients undergoing extracorporeal circulation.
METHOD: Seventeen patients, underwent cardiopulmonary bypass to mitral valve replacement, was ramdomized in two groups: I (control) ¾ 9 patients received placebo after anesthesia induction and each hour in the priming; II (aprotinin) ¾ 8 patients received after anesthesia induction 30,000 KIU/kg and 7.500 KIU/kg each hour in the priming during the perfusion. The blood loss was observed through the first 24 hours postoperatively. Arterial blood samples were taken after anesthesia induction and after administration of protamina in order to analyse: prothrombin activity (PA), partial thomboplastin time (PTT), thrombin time (TT), euglobulin lysis time (ELT) and to measure levels of fibrinogen (F), d-dimer (dD) and antithrombin III (ATIII).
RESULTS: Mean postoperative bleeding at the 24th hours was 690.67±377 in the control group and 248,.75±105 in the aprotinin group (p=0.0017). The results taken from the blood samples were shown above.
CONCLUSION: It follows that aprotinin, in low dose, was able to inhibit fibrinolysis and reduced bleeding after cardiopulmonary bypass.
Keywords: Aprotinin, therapeutic use; Extracorporeal circulation, adverse effects
CONCLUSION: It follows that aprotinin, in low dose, was able to inhibit fibrinolysis and reduced bleeding after cardiopulmonary bypass.
Keywords: Aprotinin, therapeutic use; Extracorporeal circulation, adverse effects
Evaluation of the protamine in the neutralization of heparin after cardiopulmonary bypass
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
INTRODUCTION: The protamine is the antidote universally used to neutralize the heparin at the end of the cardiopulmonary bypass; however there isn't a consensus about the ideal necessary dosage so far.
OBJECTIVE: To evaluate the effectiveness of the neutralization of heparin, with variable dosages of protamine after cardiopulmonary bypass, using three different protocols.
MATERIAL AND METHODS: From April to August 2000, 45 patients were randomized prospectively, and divided into three Protocols: I, II e III with 15 patients each. The protocol I evaluates the neutralization of heparin, with dosage of protamine calculated by the initial dosage of heparin. The protocol II evaluates the neutralization of the full dosage of heparin used during cardiopulmonary bypass.The protocol III evaluates the neutrlization of the full dosage of heparin, plus a reinforcement of 30% of this dosage, administered in peripheral vein during four hours.
RESULTS: In the protocol I, 60% of the patients had necessity of reinforcement of the dosage of protamine and 20% showed hemorrhagics complications, requiring reoperation. From these 20%, one patient passed away and another had cerebrovascular accident; 53% of the patients of the protocol II had necessity of reinforcement of the dosage of protamine. The patients from protocols II and III didn't have neither hemorrhagics complications nor necessity of reoperation.
CONCLUSIONS: 1- The dosage of protamine to neutralize heparin in the proportion less than 1:1, isn't sufficient. The patients that need of doses of reinforcement, have more hemorrhagics complications and greater necessity of blood transfusions. 2 - The neutralization of heparin, with dosage of protamine in the proportion of 1:1 isn't totaly effective; 53% of the pacients needed complementary doses in the frist hours affter surgery. 3 - An additional dose of 30% in the dosage of protame in the proportion of 1:1 in continual infuse in the frist hours after surgery, decreases the loss of blood and the necessity of transfusions.
Keywords: Protamines, administration and dosage; Heparin, adverse effects; Extracorporeal circulation
Comparative study of right ventricular and biventricular stimulations in post-operative of myocardial revascularization
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
OBJECTIVE: In recent years, the ventricular resynchronization has been proposed as an assisting therapy in congestive heart failure. This study objective is to compare the electrocardiographic changing and the acute hemodynamics effects of right ventricular (RVS) and biventricular stimulation (BVS), in post-operative of myocardial revascularization with cardiopulmonary bypass.
MATERIAL AND METHODS: In a cross-over trial, thirteen patients with multiarterial coronary disease and ejection fraction lower than 50%, were submitted to right ventricular and biventricular epicardial temporary stimulation, in 5th post-operative day. The variables researched were lenght of time of the QRS complex, diameter of left atrium (LA) and left ventricle (LV), the LV shortening fraction and LV ejection fraction. The results from two groups were compared through the Student's t test for paired observations and the value p<0.05 was considered significant.
RESULTS: The duration of QRS complex was 185±26 ms during RVS, and 126±37 ms with BVS (p<0.001). The left atrium diameter with RVS was 40±4 mm, and 35±4 mm during BVS (p<0.001). The end systolic and dyastolic LV diameters were respectivelly 49±13 mm and 59±11 mm during RVS, and 42±12 mm and 52±10 mm with BVS (p<0.001). The LV shortening fraction established by RVS was 18±7 %, and with BVS was 22±8 % (p=0.017). The LV ejection fraction during RVS was 33±14 %, and with BVS was 46±17 % (p<0.001).
CONCLUSION: In the studied pattern, biventricular artificial stimulation determined a significant improvement of the hemodynamic performance in comparison to the right ventricular stimulation, and a QRS complex with duration close to the physiological.
Keywords: Myocardial revascularization, postoperative period; Cardiac pacing, artificial; Pacemaker, artificial
Cardiac pacing with frequency variation in closed loop system and myocardial contractility sensor: late evaluation in multicenter study
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
INTRODUCTION: The treatment of bradycardias with bicameral pacemakers (PM) with frequency response (DDD,R) has motivated the search of an ideal sensor. We did a late re-evaluation (3 years) the frequency response of those PM with myocardial contractility sensor in closed loop system.
MATERIAL AND METHODS: Thirty patients (pts) of the initial study done in 1997, who presented binodal disease and 3-year implantation were evaluated, being 60% male, ages between 17-87 (average = 61). Their heart frequency (HF) was observed through a 24 Holter monitoring and MP frequency histogram on the daily activities, plus 6-minute walk and going up and downstairs tests. Chronic pacing thresholds were determined as well as atrial (A) and ventricular (V) sensitivity, checking them against those obtained in the implantation and immediate post-operative periods.
RESULTS: The average threshold in the intra-operative, 30 days and 3 years were as follows: A pacing (0.8, 1.4 and 1.1V) and V (0.5, 1.1 e 1.0V), A sensitivity (2.3, 2.8 e 2.6mV) and V (10.6, 6.3 and 6.3mV). The HF at the 3rd year increased for daily activities (physical and mental) from 33 to 91%, and for physical exercises tests from 21 to 130%, similarly to the results obtained in 30 days (test t student and variation analysis). This contractility sensor kept at the 3rd year the same good results obtained at the 30th day, presenting the following adverse effects: high-energy consumption in 2 pts and difficulty of sensor adjustment in other 2.
Keywords: Cardiac pacing, artificial; Pacemaker, artificial; Myocardial contraction
Experimental study of the protection provided by a cardioplegic solution of lidocaine and potassium in dogs
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
INTRODUCTION: The action of a cardioplegic solutions with lidocaine and potassium. Was studied experimentally in dogs.
MATERIAL AND METHODS: Fourteen dogs, divided en two groups, were operated.
The group 1 was composed of 5 dogs, who were submitted to 120 minutes of myocardial anoxia, through cross clamping of the ascending aorta under cardiopulmonary bypass, without any myocardial protection. The group 2 were treated in the same way, but received cardioplegic protection. The technique of cardioplegia consisted of two phases: a) Induction phase the induction was achieved by the injection of 100mg of lidocain and 2.5 mEq of potassium, diluted in 60 ml of blood from the arterial line. This first injection was in bolus. After this, blood was injected from the arterial line during 30 seconds. The heart immediately had an arrest. b)The second phase was called maintaining phase. This phase consisted of repeated injections of blood from the arterial line, during 30 seconds each, and repeated every 20 minutes during the ischemic period.
RESULTS: All animals of this protected group survived after the release of the cross clamping of the aorta and all the dogs of the non protected group died after the end of the ischemic time. Echocardiographic evaluation were performed in 3 different moments of the experiment. The first was control, before cardiopulmonary bypass and the measures of delta D and ejection fraction were normal in all animals. The second was done about one hour after the reperfusion, in the group 2 animals. This measurement showed a decrease of 30% when compared with the control values. The third echocardiographic evaluation was done 5 hours after the end of the perfusion and showed a restoring to normal values in all 9 dogs of the group 2 dogs. All 14 hearts were studied with optical and electronic morphological exams. The group 1 dogs showed intense myocardial damage, while the group 2 animals showed inexpressive morphological findings.
CONCLUSION: It was concluded that the cardioplegia technique utilized in group 2 animals was effective in myocardial protection action, with good echocardiographic performance after perfusion and almost no morphological alterations in anatomopathological studies.
Keywords: Cardioplegic sulutions; Lidocaine, therapeutic use; Potassium, use
A juvenile sheep model for the stentless bioprostheses implanted as aortic root replacements
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
INTRODUCTION: Often, studies on aortic prosthetic valves analyze their performance not at the primitive position, but using tricuspid and mitral ones or inserting it in the descending aortic area. Taking that into account, it would be relevant to observe results in those studies in which the conclusions are based on their original implantation.
MATERIAL AND METHODS: Thirty young sheep, 28 males and 2 females, were operated on. Ages ranged 4.4 to 6.3 months and weights 25 to 37 Kg. Extra corporeal circulation (ECC) was applied to all the animals, always guided by the conventional criteria, that is to say, the arterial cannula was inserted in the thoracic aorta just past the arterious ducts and the venous cannulae, a single one, was placed in the right atrium. The operation was performed according to the principle of moderately low body temperature- 29oC- and cold cristalloid cardioplegia, in the aortic root, to induce; but otherwise was utilized blood to the maintenance. Following with the technique proposed, the aortic valve of the animal heart was completely excised and finally implanted the valved tube stentless, not forgetting the refixation of the coronary main. The sheep were kept in clinical and laboratorial observation during thirty days in what was included a echocardiogram in the end.
RESULTS: The results demonstrated 8 intraoperatory deaths (26.6%), and 6 during the following (27.7%). The mean time of ECC was 98 minutes. The dimension of the majority prothetics valves were 21 and 23. Only two valves evoluted with mild insufficiency, none denoted evidences of the endocarditis neither of leaflets perfuration, the mean fraction of ejection was 74%, the left ventricle had its wall preserved in all cases.
CONCLUSION: This experimental model can certainly reproduce nearly the reality, confirming good parameters of prothetics stentless evaluation in the aortic position. And the sheep declared itself to be pleasant, which helps us its control during the whole study.
Keywords: Aortic valve surgery; Blood vessel prosthesis, implantation; Bioprosthesis
CASE REPORT
Quadricuspid aortic valve with aortic regurgitation
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
This article is a case report of a 56 years old man, without known cardiac abnormality, presented signs of cardiac insufficiency. Transthoracic echocardiography revealed a quadricuspid aortic valve (QAV) with a moderated regurgitation. The clinical treatment was initiated with a good evolution. After one year, a new echocardiography revealed huge aortic regurgitation, pulmonary hypertension and lower ejection fraction. After that, the surgery for changing the valve was indicated in order to prevent the pathology progression. QAV is a rare pathology (0.003% to 0.043%). Usually is not associated with other cardiovascular pathologies. It can be an incidental finding but in general it carries aortic regurgitation in adulthood due to bad closure of the four cusps. There are different anatomical variations for the aortic valve cusps: four unequal cusps, three equal cusps and one smaller cusp (majority) and up to four equal cusps. Transthoracic and transoesophageal echocardiography can easily asses the morphological and functional status of such a valve.
Keywords: Aortic valve, surgery; Aortic valve, insuffiency; Aortic valve, pathology