Volume 18 - Número 2
EDITORIAL
Words of Professor Dr. Domingo M. Braile
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025
SPECIAL
Ways of searching for scientific information
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025
ORIGINAL ARTICLE
Experience with utilization of auto-expandable stents introduced through the femoral artery for treatment of thoracic aortic diseases
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025
INTRODUCTION: The authors describe their experience with the implantation of endovascular self-expanding stent-grafts for the treatment of descending aortic thoracic diseases.
METHOD: From June 1996 to April 2002, 14 endovascular self-expanding stent-grafts were implanted, 10 in acute type B dissections, 3 in atherosclerotic aneurysms and 1 in a penetrating aortic ulcer. The patient's ages varied between 43 and 77 years (mean = 63.3 years). In the majority of cases the procedure was performed under general anesthesia. The delivery of the stent-graft endoprostheses was performed using the trans-femoral system.
RESULTS: There was one death on the sixth postoperative day by pulmonary thromboembolism. One patient was operated on for the implantation of an endovascular self-expanding stent-graft through the aortic arch under deep hypothermia and circulatory arrest, and died eight months after operation. All the survivors were well and imaging studies showed adequate correction of the aortic disease.
CONCLUSION: Preliminary results suggest that this technique will contribute to improve surgical results in the treatment of descending thoracic aortic diseases.
Keywords: Aneurysm dissecting, surgery; Aortic aneurysm, surgery; Femoral artery, surgery
Off-pump coronary artery bypass surgery in left main coronary artery disease: the last frontier?
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025
OBJECTIVE: Our aim is to demonstrate the possibility of applying the alternative tactic of off-pump coronary artery bypass surgery to left main coronary artery disease and to assess the long-term results over a 5-year follow-up period.
METHODS: Among 210 subjects submitted to off-pump coronary artery bypass, 119 (56.7%) were male. Their ages ranged from 32 to 81 years with a mean age of 59.7. A left coronary artery branch lesion of at least 70% was demonstrated in 48 (22.8%) of the individuals and a right coronary lesion was associated in 10 (20.8%) of the cases.
RESULTS: A breakdown of the number of grafts per patient was: 2 for 52.1%, 3 for 43.5% and 4 for 4.4% of the surgeries. All of the patients were extubated in the intensive care unit after a 6-hour stay. No left ventricular dysfunction was evidenced after a seven-day total hospitalization period. One death, due to cardiac problems, occurred after one month. Follow-up with clinical cardiac evaluation was total until 60 months with a survival rate at 5 years of 96.0% ± 3.9%.
CONCLUSION: In left main coronary artery disease, which is feared by cardiac surgeons, we believe that the technique of off-pump coronary artery bypass could be very useful. If the patients are hemodynamically stable and undergo an elective operation, the operative period can be passed in a safe and tranquil manner.
Keywords: Myocardial revascularization; Coronary disease; Left main coronary artery
Carotid artery inflow in operations to correct aortic diseases (ascending, arch and descending)
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025
OBJECTIVE: Femoral artery cannulation has been used as the preferred option in operations to correct ascending aorta and aortic arch aneurysms and dissections. The axillary artery is an alternative site for cannulation. We have used arterial inflow via the common carotid artery in nine patients.
METHOD: Nine patients were operated on with ages ranging from 46 to 80 years (mean 62.1 ± 12.54), six were male. Four patients had true aneurysms, three had aortic dissections and two a combination of dissections and true aneurysms. Five patients had undergone previous cardiovascular operations. Deep hypothermia with circulation arrest was used in two patients and in seven, antegrade cerebral perfusion was used.
RESULTS: All nine patients awoke from the operation without cerebral damage. Two patients died, one on the 7th postoperative day due to respiratory failure and the other one on the third postoperative day due to a rupture of a thoracoabdominal aortic aneurysm.
CONCLUSION: The carotid artery can be a safe alternative of arterial inflow in operations to correct ascending aorta and aortic arch diseases. This strategy allows antegrade cerebral perfusion during the operation even during arch resection and reconstruction.
Keywords: Aortic aneurysm, surgery; Aneurysm, Dissecting, surgery; Extracorporeal circulation, methods; Carotid artery
Gene therapy with VEGF 165 for angiogenesis in experimental acute myocardial infarction
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025
OBJECTIVE: Evaluate coronary angiogenic response to transmural injection of plasmid encoding VEGF 165 in acute myocardial infarction (AMI) zones in a canine model.
METHODS: The heart of eleven dogs was exposed and AMI was induced by occlusion of the diagonal branch of anterior descending coronary artery. For each of 10 selected points in the infarction area and its peripheral zone injections of 1 ml of saline solution (control group: five dogs) or 1 ml of plasmid encoding VEGF 165 solution (200 µg/ml) (VEGF group: six dogs) were introduced. Tecnecium myocardial scintigraphy was performed immediately after animal recovery and 14 days later to evaluate the myocardial perfusion. The animals were sacrificed and the hearts were submitted to a histological study of the infarcted area, peripheral zone and normal posterior ventricular wall, to evaluate the number of arterioles and capillaries.
RESULTS: Immediate modifications in myocardial perfusion found in scintigraphic studies were similar in both groups. In the second evaluation at 14 days, hypoperfusion of ischemic area had recovered by 70% to 90% when compared to the day of AMI. Histologic evaluation of the peripheral area of AMI indicated a larger number of vessels in the VEGF group when compared to controls (mean: 123.81 + 21.48 and 40 + 6.13, p < 0.01, respectively). This increase resulted mainly from an increase in the number of capillaries (97.5 + 16.04 in the VEGF group and 22.18 + 3,25 in control group, p < 0.01), as the number of arterioles did not increase significantly. In the VEGF group, a comparison in the number of vessels of the AMI peripheral area and normal myocardium revealed a non-significant increase of vessels in the ischemic area (123.81 + 21.48 and 95.14 + 41.19).
CONCLUSION: An intramural injection of plasmid VEGF 165 resulted in a significant increase in the number of capillaries in the peripheral AMI area. This increase may have a beneficial effect in the reduction and recovery of the ischemic area secondary to AMI.
Keywords: Gene therapy; Angiogenesis; VEGF; Acute myocardial infarction
Molecular evaluation of the great vessels of patients with bicuspid aortic valve disease
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025
PURPOSE: Bicuspid aortic valve (BAV) is associated with increased prevalence of annulo-aortic ectasia, dissection and ascending aortic aneurysm. This study was undertaken to compare the amount of fibrillin-1 and elastin in the media of great vessels of patients with bicuspid and tricuspid aortic valve disease.
METHOD: Tissue samples of ascending aorta and pulmonary artery were obtained from 22 patients with bicuspid aortic valve disease (BAV) and 17 patients with tricuspid aortic valve disease (TAV), including 6 normal valves from the transplant program. Indirect immunofluorescence and computerized image analyses were used to quantify fibrillin-1 and elastin of the media of the arteries. The results were expressed as the mean integrated optical density (IOD).
RESULTS: In the ascending aorta, the IOD for fibrillin-1 was 15 ± 8 in the BAV group and 24 ± 7 in the TAV group (p = 0.001). In the pulmonary artery, the IOD for fibrillin-1 was 18 ± 10 in the BAV group and 25 ± 9 in the TAV group (p = 0.07). In respect to the elastin measurements of the aorta, the specific IOD was 34 ± 13 in the BAV group and 29 ± 14 in the TAV group. In the pulmonary artery the IOD for elastin was 30 ± 12 in the BAV group and 29 ± 14 in the TAV group (p = 0.34).
CONCLUSIONS: Patients with BAV were found to have less fibrillin-1 in the ascending aorta and pulmonary artery than patients with TAV. These findings may explain aortic root dilation and ascending aortic dissection in patients with BAV disease.
Keywords: Aortic valve, pathology; Aorta, aneurysm, dissection, surgery; Fibrillin; Elastin; Marfan syndrome
Prescribility of generic microemulsion Cyclosporine A in heart transplant patients
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025
OBJECT: This paper aims to define the prescribility (therapeutic efficacy and bio-safety) of generic microemulsion Cyclosporin (Sigmasporin Microral®).
METHOD: Casuistic: Twenty heart transplantation patients, 13 males and 7 females, with a mean age of 49.6 years, began immunosuppression treatment with generic microemulsion cyclosporin (Sigmasporin Microral®). They underwent clinical and laboratory evaluation during a minimum of three months. Procedures included clinic evaluation with electro and echocardiogram, endomyocardial biopsy, routine biochemical and hematological tests.
RESULTS: The mean follow-up was 10 months with a maximum of 16 months. A total of 151 endomyocardial biopsies were evaluated: 31.7% were degree 0, 43.7% 1a and 23.1% 1b. We had only one case of acute clinical rejection confirmed by biopsy as IIIa, and one patient with mediastinitis, both of whom had a good evolution. The mean cyclosporin blood level was 303 Ng/mL. All other parameters also showed a good evolution.
CONCLUSION: Generic microemulsion cyclosporin (Sigmasporin Microral®) shows therapeutic efficacy and an excellent bio-safety profile. Its Prescribility is confirmed.
Keywords: Cyclosporine, pharmacokinetics; Cyclosporine, toxicity; Cyclosporine, therapeutic use; Immunossupressives; Heart transplantation
Risk factors of mortality in nine years of follow-up after dynamic cardiomyoplasty
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025
PURPOSE: To retrospectively evaluate the survival rate of patients that underwent dynamic cardiomyoplasty, determining the influence of pre-, intra- and post-operative factors and the evolution of left ventricle ejection fraction according to the stimulation mode.
METHOD: Forty-three patients that underwent dynamic cardiomyoplasty between May 1988 and September 1997 were analyzed. Functional class III was predominant (81.4%). The mean left ventricle ejection fraction was 19.37 ± 3.48%. Hospital death was 2.2% and 39 patients who completed the conditioning period had a mean follow up of 46 ± 26 months. Twenty-eight patients were predominantly maintained under stimulation mode 1:1 and 11 under 1:2 stimulation mode.
RESULTS: Survival rate at nine years of follow up was 9%. The causes of death were progression of the heart failure and sudden cardiac death. Functional class, the pulmonary vascular-resistance index and stimulation mode were identified as risk factors. The maintenance of the increase of the left ventricle ejection fraction when compared to the preoperative values was more consistent during the studied period when the graft was stimulated in the 1:2 mode.
CONCLUSION: Late results of dynamic cardiomyoplasty are limited by the high incidence of deaths by progression of the heart failure and sudden cardiac death. Survival rate is influenced by the preoperative clinical condition and by the stimulation mode. Muscle graft performance is higher at late follow up with the 1:2 stimulation mode.
Keywords: Cardiomyopathy; Cardiomyoplasty, risk factors, prognosis; Heart failure, surgery
Surgical treatment of active infectious endocarditis: a study of 361 surgical cases
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025
OBJECTIVE: To report on the experience achieved with the surgical treatment of 361 patients with acute infectious endocarditis who were operated on in the Heart Institute of the University of São Paulo.
METHOD: The ages of the patients ranged from 3 to 81 years, with an average age of 38 ± 8.3 years. There were 230 male patients. It was possible to identify the etiologic agent in 311 (86.20%) patients. The diagnosis of acute infectious endocarditis was obtained by clinical, echocardiographic and microbiological evaluations. Two hundred and five patients had lesions of heart valves and 156 patients had lesions of cardiac valvular prostheses. Ninety had annular abscesses and 11 had fistulae. Of the group of diseased native valves, 104 (50.73) were operated on because of severe heart failure and 87 (42.44%) because of progressive sepsis. All natural aortic valves (136) were replaced by artificial valves. There were 107 diseased native mitral valves. In this group partial resections of infected tissue (vegetations) were carried out in 13 patients while maintaining the valvar apparatus. Of the 16 infected tricuspid valves, 8 were replaced. All the prostheses were substituted. The abscesses were cleaned and closed when their diameter was less than 10 mm. The larger abscesses were cleaned and closed with a pericardial graft, which was the support for the artificial valve.
RESULTS: There were 75 (20.78%) hospital deaths, most of which caused by heart problems and their complications. There were 15 cases of postoperative endocarditis, 10 of which were re-operated on. The late follow-up showed good functional and clinical results, with 222 (77.62%) patients as NYHA Class I.
CONCLUSIONS: When indicated, the surgical treatment must be instituted as early as possible. All diseased and infected tissue must be removed to achieve good results.
Keywords: Endocarditis, surgery; Heart valves, surgery; Abscess, heart valves
The transvalvar gradient after the aortic porcine stented valve replacement can be predicted?
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025
OBJECTIVE: This work aimed at establishing scientific criteria using the valve size mismatch to predict the transvalvar gradient resultant of aortic valve replacement.
METHOD: Thirty-one consecutive patients who survived aortic valve replacement surgeries using Labcor porcine stented prosthesis, in the period from March 1993 to June 2002 were studied. Each patient was submitted to an echocardiogram within three postoperative months at the same institution. The mean transvalvar gradient pressure was compared with the diameter of the prosthesis and the patient's body surface area.
RESULTS: The p-value for the diameter of the prosthesis was 0.81 and 0.59 for the R Index.
CONCLUSION: No relation at all was found to help to predict the postoperative pressure gradient, based on the prosthesis size and the body surface area of the patients.
Keywords: Heart valve prosthesis implantation; Heart valve diseases; Aortic valve, surgery
REVIEW ARTICLE
The surgical treatment of traumatic rupture of aortic valve and atrial septum after blunt chest trauma: literature review and presentation of a rare case
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025
The case of a 49-year-old man who suffered a car accident responsible for several chest injuries including fractures of the left ribs, large subcutaneous emphysema and left hemopneumothorax arrived in shock in the Emergency Room of the Real Hospital Português de Beneficência in Pernambuco (RHPBPE). He was hospitalized for 30 days including some time in the intensive care unit and but did not show signs of diastolic murmur or heart failure. He was submitted to an echocardiography examination that diagnosed slight aortic incompetence, good left ventricular function and was discharged after clinical improvement. Three months later he started to feel symptoms of heart failure and returned to cardiac Emergency Room of the same Hospital. He repeated transthoracic and transesophageal echocardiography examinations presenting severe aortic incompetence due to leaflet disruption, rupture of atrial septum with enlargement of the right cardiac chambers and poor left ventricular function. He underwent surgical treatment of these lesions, with direct approach of the atrial septum and the aortic valve was replaced with a mechanical prosthesis, with a good result.
Keywords: Heart injuries; Wounds and injuries, heart; Aortic valve, surgery; Heart septum, surgery
CASE REPORT
Coronary sinus iatrogenic lesion during repeated mitral valve replacement: case report of an immediate transmitral annulus repair
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025
We report a case and evolution of a patient in whom the coronary sinus was damaged and reconstructed through the mitral annulus. The surgical accident happened during a degenerated biological valve prosthesis instrumentation. An almost complete left circumflex coronary artery division was our first hypothesis. A coronary probe introduced through the vascular injury was distally detected inside the right atrium confirming a coronary sinus lesion. The surgical correction was performed using running polypropylene 7-0 sutures through the mitral ring. After fourteen months, a coronary sinus angiographic image was taking observing the venous phase of selective left coronary arteriography. The image demonstrated an acceptable narrowing of the local venous repair. In our opinion the single coronary sinus division or its repair, in this iatrogenic situation, is a matter of speculation.
Keywords: Coronary sinus; Mitral valve; Cardiac surgery; Heart valve diseases; Heart valve prosthesis; Mitral valve annulus
LETTERS TO THE EDITOR
Reumatic fever: it is still among us
Braz J Cardiovasc Surg 18;
Publish in: 8/2/2025