Volume 17 - Número 4
EDITORIAL
Words of Professor Dr. Domingo Braile Ph.D.
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
MY OPINION
A realistic view of the cardiothoracic surgery specialty
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
ORIGINAL ARTICLE
Coronary artery and myocardial inflammatory reaction induced by intracoronary stent
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
BACKGROUND: Intra-coronary stents have been extensively employed in percutaneous coronary revascularization. However, despite breakthroughs and developments associated to this new technology, novel complications and findings have emerged compelling the cardiac surgeon to cope with this new scenario. The presence of an intra-coronary foreign body (stent) might induce an inflammatory reaction carrying functional and structural repercussions of the coronary artery and surrounding cardiac muscle.
METHOD:Patients, who had previously undergone stent implantation (6 to 18 months) and were submitted to coronary artery bypass surgery, had biopsies taken from the grafted coronary artery distal to the stent and from the adjacent muscle. The collected samples were processed and stained with hematoxylin-eosin and histologically studied.
RESULTS:The histology of the coronary artery distal to the stent revealed chronic inflammatory processes and an intimal acute inflammatory infiltrate, with polymorphonuclear leukocytes even at long term follow-up, 12 months after stent implantation, disclosing an ongoing inflammatory process. The myocardium adjacent to the stent implantation site exhibited a significant chronic inflammatory infiltrate and fibrosis compatible with myocarditis.
CONCLUSION:The presence of an intra-coronary stent induces an acute and chronic inflammatory reaction, even over the long term, with involvement of the distal coronary artery and surrounding myocardium. Further studies are necessary to assess the inflammatory process extension and its consequences.
Keywords: stent, coronary artery bypass grafting , inflammation
Surgical treatment of mitral valve insufficiency by valve repair
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
OBJECTIVE: To analyze the short term results of mitral valve repair in a consecutive series of mitral insufficiency patients from different ethiologies.
METHODS: A retrospective study was made of 86 patients with mitral insufficiency operated on between May 1992 and May 2001 for mitral valve repair. Mitral insufficiency was severe in 77 patients and moderate in 9. The functional class of the patients was I in 4, II in 48, III in 29 and IV in 5 patients. The etiology was rheumatic in 47 (54.6%) cases.
RESULTS: Mitral valve repair was performed by only one procedure on the mitral valve in 6 patients, two procedures in 29, and three or more procedures in 51 (59.3%) patients. Mitral annuloplasty was performedin 81 patients, with the Braile posterior pericardial ring being the mostcommonly used (87.2%). Hospital mortality was 3.5%. There was improvement in the funcional class in 79 (91.8%) patients. Mitral valve function was normal in 80 (93%) patients and moderate mitral insufficiency occurred in 6 patients.
CONCLUSION: Mitral valve repair can be performed with low mortality (3.5%) and high probability of valve function recovery (93%). It should be the procedure of choice in patients with mitral insufficiency.
Keywords: Mitral valve insufficiency, surgery; Mitral valve, surgery
Technical modification for composite grafts in myocardial revascularization surgery
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
OBJECTIVE: In the last decade, the coronary artery bypass grafts (CABG) with arterial grafting had been remarkable, mainly the combined ones in Y or T form, which start from the left internal thoracic artery (LITA). Elaborating this kind of grafting, we identified a certain worry related to the anastomoses of the radial artery in LITA, principally when realized in T, since any small traction, angulations or spasms of the radial artery might impaired the flow of the distal anastomoses of LITA to the anterior interventricular artery.
METHOD: We modified the combined graft technique, by making anastomoses of the radial artery to the anterior interventricular artery, and, consequently the LITA is sewed above the anastomoses of the radial artery to the anterior interventricular artery, favoring therefore, the revascularization of the anterior interventricular artery with the LITA, transforming the radial artery into almost an extension of the LITA to the remaining branches of the left coronary artery.
CONCLUSIONS: This technical modification for these composite grafts is simple, safer and effective, and it will enable a larger number of surgeons to routinelyuse composite grafts in coronary artery bypass grafting.
Keywords: coronary artery bypass grafting, methods; Mammary arteries, surgery; Radial artery
The transplant of cardiac cells and myoblast skeletal cells in myocardial infarction
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
OBJECTIVE: To analyze the functional results of adult skeletal muscle cell and cardiac cell transplantations in the hearts of rats that have suffered an infarct.
METHOD: An infarct of the anterolateral wall of the left ventricle was provoked, by left lateral thoracotomy and posterior legation of the left coronary artery. After five days the animals were submitted to a transthoracic echocardiography to evaluate the systolic (LVFSV) and diastolic volumes (LVFDV) of the left ventricle and the left ventricle ejection fraction (LVEF). After that, the animals were divided in three groups: 1) control (n=10), 2) adult cardiac cells (n=8) and 3) adult skeletal muscle cells (n=8). Seven days after the myocardium infarct, all the animals were operated on again by median sternotomy, identifying the region with fibrosis and conducting the injection of 0.15 ml of a culture in group I, 8.5x106/0.15 ml, of heterologous skeletal muscle cells in group III, and 8.5x106/0.15 ml of heterologous adult cardiac cells in group II. All animals received cyclosporin (15mg/kg/day). After two months, an echocardiography was conducted on all mice, assessing the same parameters.
RESULTS: Two months after transplantation, group I presented a decrease in the LVEF (48.18% + 9.95% vs. 33.25% + 12.41% p=0.0003), with an increase of the LVFSV and the LVFDV (0.308 ml + 0.072 ml vs. 0.536 ml + 0.228 ml p=0.0026 and 0.597 ml + 0.098 ml vs. 0.776 ml + 0.187 ml p=0.0540, respectively). In group II, there was an stabilization of the LVEF (42.48% + 7.83% vs. 41.31% + 8,46% p=0.4968, respectively) an increase in the LVFDV and LVFSV (0.602 ml + 0.203 ml vs. 0.771 ml + 0.110 ml p=0.0711 and 0.358 ml vs. 0.450 ml p=0.0400, respectively). Group III presented an increase on the LVEF, LVFSV and LVFDV (40% + 5.69% vs. 47.35% + 6.89% p=0.0142, 0.643 ml + 0.103 vs. 0.931 ml + 0.226 p=0.0026 and 0.388 ml + 0.082 vs. 0.491 ml + 0.149 ml p=0.0557, respectively).
CONCLUSION: Two months after cell transplantation, there was a significant improvement in the LVEF in group III, when compared to group I, and there was a preservation of the ventricular contractility and a stabilization of LVEF in group II.
Keywords: Cell transplantation; Heart; Myocardial infarction; Myocardium
Abdominal aorta morphometric study for endovascular treatment of aortic aneurysms: comparison between spiral CT and angiography
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
PURPOSE: To compare the computed tomography and angiography study of abdominal aortic aneurysms for posterior endograft implant.
METHOD: From June 1997 to March 2001, 113 patients with abdominal aortic aneurysm were submitted to study of the aorto-iliac axis with abdominal spiral computed tomography and angiography with calibrated catheter. The patient's ages ranged from 51 and 88 years (mean: 69). There were 104 males and nine females.
RESULTS: When comparing the mean computed tomography and angiography diameters, we observed that there was a statistical difference for the infra-renal neck (p<0.05) and for the aortic aneurysm diameters (p<0.001). There was no statistical difference for the iliac artery diameters (p>0.05). When comparing the mean lengths, we observed that there was a statistical difference for the aortic infra-renal neck (p<0.05), for the distance between the renal artery and the aortic bifurcation (p<0.05) and for the common iliac artery lengths (p<0.05). There was also a statistical difference for the length between the renal artery and the internal iliac artery (p<0.05).
CONCLUSIONS: In the AAA pre-procedure imaging study there were statistical differences between the computed tomography and angiographic measurement studies. We believe that computed tomography is a superior method for the evaluation of diameters and the angiography with a calibrated catheter for the length evaluation. We conclude, that both methods are complementary and must be undertaken for accurate evaluation of all candidates for aortic endograft implant.
Keywords: Abdominal Aortic Aneurysm; Blood vessel prosthesis; X-ray Computed Tomography; Angiography
Influence of tranexamic acid in postoperative bleeding of cardiac surgery with cardiopulmonary bypass
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
OBJECTIVE: To analyze the influence of tranexamic acid in postoperative bleeding of cardiac surgery with cardiopulmonary bypass.
METHOD: 51 patients who underwent heart surgery with cardiopulmonary bypass were randomly divided in 2 groups: Group I - control, with 12 coronary artery disease patients and 14 valve disease patients. Group II - Tranexamic acid, with 14 coronary artery disease patients and 11 valve disease patients. The Group I after venous access, received 250 ml of 0.9% normal saline solution as a placebo, Group II received 100 milligram per kilogram of body weight of tranexamic acid diluted in 250 ml of 0.9% normal saline solution. Blood samples were taken and examined at entry to Intensive care unit and after 12, 24 and 36 hours in the postoperative period. The groups were compared concerning factors which might influence the postoperative bleeding and transfusion required: age, gender, creatinine, duration of Cardiopulmonary bypass, hematocrit, platelets and fibrinogen variations, number of saphenous vein grafts performed, mammary artery used and valve replacement or repair. The postoperative bleeding was evaluated from the 1st to 4th hours and the total. Data were analyzed by appropriate statistic methods (Student T-test, X2 test and Fischer's test); a p-value of less than 0.05 was the accepted level of significance.
RESULTS: Concerning the postoperative bleeding and transfusion required, there was a statistically significant reduction in its average in valve disease patients in Group II. In coronary disease patients there was only a slight tendency. There was no significant statistical difference as far as the thromboembolic or renal complications were concerned.
CONCLUSION: In valve disease patients, there was a reduction in bleeding and the need of transfusions of red blood cells, both of which had statistical differences. In coronary disease patients there was only a reduced tendency. The use of tranexamic acid was not related to further thromboembolic complications or renal insufficiency in the assessed groups.
Keywords: Tranexamic acid, therapeutic use; Cardiac surgical procedures; Fibrinogen
Iliac valve regurgitation disease: implications for the surgical approach of the venous insufficiency in the lower extremities
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
BACKGROUND: Varicose veins of the lower extremities is one of the most common circulatory diseases but no published reports describing the associated comparative rates of femoral and iliac valve regurgitation were found.
OBJECTIVE: To study the occurrence of selective valve regurgitation in the external iliac vein, associated or not with insufficiency of the valves in the femoral or great saphenous veins.
METHOD: With the approval of the Ethics Committee of the São Francisco de Assis Cardiovascular Foundation, the venous system of the lower limbs of twenty-four female (80%) and six male (20%) patients aged between 21 and 71 years old (mean 39 years old), with varicose veins in the lower extremities, were studied with Color Flow Duplex Scanning (Esaote array; 7.5 MHz transducer; 2-dimensional, pulsed Doppler and color flow techniques). The aim was to investigate the regurgitation in the iliac, femoral, popliteal and great saphenous veins. The results were statistically analyzed using variance analysis and student T-test with a significance level of 0.05.
RESULTS: Iliac regurgitation ³ 26.0 cm/s, which was present in 19 limbs, occurred isolated without reflux in the great saphenous ostium valve only in one case (5.3%). In the cases with iliac regurgitation < 26.0 cm/s, the absence of regurgitation in the great saphenous vein ostium occurred in four limbs (14.3%). Considering the total of 60 lower limbs studied, iliac regurgitation was observed in 47 (78.3%) cases and dysfunction of the saphenous ostium valve in 45 (75%) cases. Furthermore, saphenous ostium valve reflux without iliac regurgitation occurred only in three cases (6.3%), which in only one case was above 25.9 cm/s.
CONCLUSION: In conclusion anomalies of the valvular function in the iliac veins present a significant correlation with the intensity of the insufficiency in the great saphenous vein ostium valve and the gravity of varicose veins in the lower limbs.
Keywords: Varicose Veins; Iliac Vein, surgery; Iliac Vein, pathology; Venous Insufficiency
Risk factors to hospital mortality in valvar reoperations
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
OBJECTIVE: Analyze the risk factors for hospital mortality in valvar reoperations.
METHOD: A prospective analysis was performed of 194 patients that underwent valvar reoperations between July 1995 and June 1999. The following variables were analyzed: gender, age, functional class, number and type of previous operations, cardiac rhythm, urgency at operation, creatinine level, left ventricular ejection fraction, left ventricular systolic and diastolic diameters, right ventricular systolic pressure, prothrombin activity, activated partial thromboplastin time relation, platelet count, cardiopulmonary bypass time, aortic cross-clamp time, number and position of valves, type of procedure, associated procedures and intraoperative bleeding volume. Univariate and multivariate statistical analyses were performed to determine the risk factors for hospital mortality.
RESULTS: The overall hospital mortality was 8.8% (17 patients). Univariate analysis showed that the following variables were associated with higher mortality rates: advanced New York Heart Association functional class, decreased left ventricular ejection fraction, decreased prothrombin activity, increased creatinine level, longer aortic cross-clamping time, prolonged cardiopulmonary bypass time, concomitant associated procedures, and higher intraoperative bleeding volume. Logistic multivariate analysis identified advanced New York Heart Association functional class, creatinine level higher than 1.5 mg/dl, and cardiopulmonary bypass time longer than 120 minutes as independent predictors of hospital mortality.
CONCLUSIONS: The variables functional class IV, creatinine level > 1.5 mg/dl and cardiopulmonary bypass time > 120 min were independent predictors of hospital mortality in valvar reoperations.
Keywords: Heart valves, surgery, risk factors
HOW I DO IT
Re-implant of the right coronary artery: a surgical technique for the treatment of ostial lesions
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
Previously described surgical treatment for ostial coronary artery stenosis relied on either venous or arterial bypasses or ostial patch angioplasty. These surgical procedures are performed with bovine pericardium, saphenous vein or internal thoracic artery. We describe a technique of right coronary artery re-implantation into the aorta. The procedure was performed in four patients with right coronary artery ostial stenosis along with other left coronary artery lesions.
Keywords: Myocardial revascularization, methods; Coronary disease, surgery
CASE REPORT
Mitral-aortic annular enlargement: modification of Manouguian's technique
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
We hereby present a technical modification for mitral-aortic annular enlargement. The mitral valve is replaced through the retro-septal approach, avoiding patches for left atrial roof closure. We report a mitral-aortic valve replacement in a patient whose original annuli would preclude adequate prostheses. The simultaneous annular enlargement may be necessary for avoiding patient-prosthesis mismatch and for reconstructing destroyed mitral and aortic annuli. The technique may minimize the risk of bleeding and of paravalvular leakage, using an approach well known to cardiac surgeons.
Keywords: Cardiac surgical procedures, methods; Heart valves, surgery; Aortic valve; Mitral valve
Myocardial revascularization in patient with situs inversus totalis: case report
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
This is a report of an unusual case of a patient, with dextrocardia and a "situs inversus totalis". She presented angina pectoris during an ECG stress test. The coronary arteriography revealed severe obstruction in the main left coronary artery. The patient underwent coronary artery bypass grafting surgery. We did not find a similar case in the national medical literature. The myocardial revascularization performed utilizing the right mammary artery for anterior descending artery and saphenous vein grafts for first diagonal branch and first marginal branch.
Keywords: Dextrocardia, surgery; Situs Inversus; Myocardial revascularization
Mitral valvuloplasty without support in children - Modified De Vega technique: case reports
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025
We report on three cases of mitral regurgitation in children at ages of 7 months, 5 months and 10 years old. In two of them, the etiology was congenital and the other it was rheumatic. The surgical technique used was valvuloplasty without support using the modified De Vega technique isolated or associated with other procedures. One of the children was re-operated seven years after the first surgery. All the patients were rated New York Association Class III before surgery. Following the surgery they were at Class I with good outcomes. All patients survived, without complications. According with the literature, mitral regurgitation can be treated with mitral valvuloplasty without support or using other surgical techniques, with excellent outcomes. We report here on one more option for its treatment especially in children and adolescents. This technique is easily performed and it permits growth of mitral valve during life.
Keywords: Mitral valve insufficiency, surgery; Mitral valve, surgery; Heart valve disease, surgery
Heterologous valve implantation in the infra-renal vena cava for treatment of the iliac venous valve regurgitation disease: experimental study
Braz J Cardiovasc Surg 17;
Publish in: 8/2/2025