Volume 21 - Número 2
EDITORIAL
The future of cardiovascular surgery
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Is the best option of treatment being offered to patients with multiple coronary artery diseases?
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
The necessity of a public register of clinical trials
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
SPECIAL ARTICLE
Vulnerability of atherosclerotic carotid disease: from laboratory to operating room - Part 1
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
ORIGINAL ARTICLE
Effects of inhaled nitric oxide on pulmonary hypertension in patients after mitral valve surgery
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: Cardiac surgery in patients with pulmonary hypertension may present severe postoperative complications. The study consists of verifying the effects of using inhaled nitric oxide (iNO) in patients during the postoperative period of mitral valve surgery.
Methods: The effects of iNO were measured mainly by verifying changes in pulmonary artery pressure (PAP). Other measures performed included mean arterial pressure (MAP), mean central venous pressure (CVP), mean left atrial pressure (LAP), oxygen saturation by pulse oxymetry, and static pulmonary compliance.
Results: In the 20 patients studied, a median time of iNO use of 19.1 hours was obtained. The mean PAP was significantly reduced from 33.8 ± 6.17 mmHg (pre-iNO) to 29.1 ± 6.46 mmHg in the initial 30 minutes and to 28.4 ± 5.22 mmHg considering the mean of all post-iNO measures (p< 0.05). No significant changes occurred in the other hemodynamic measures.
Conclusion: The findings indicate that the use of iNO, in post-operative period of mitral valve operation associated with pulmonary hypertension, reduces PAP without systemic effects, demonstrating a selective vasodilator effect on the pulmonary vascular system.
Keywords: Nitric oxide; Hypertension, pulmonary; Mitral valve, surgery
Remodeling of the right internal thoracic artery: new method of analysis using the coronary area grafted
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: To analyze angiographic factors related to remodeling of the right internal thoracic artery (RITA) using a new quantitative technique of the target coronary grafting area.
Method: In the period from January 1992 to 2002, 452 consecutive patients were submitted to coronary artery bypass grafting (CABG) with RITA "in situ" through the transverse sinus. In this sample, 32 patients were submitted to at least one postoperative coronariography study after receiving RITA grafts. The studies were analyzed by the CASS II® software. The angiographic criteria assessed were the proximal and distal diameters of the RITA, coronary area irrigated by the target vessel, TIMI flow score, quantitative coronary angiography(QCA), dominant flow grade and the existence of patent lateral branches of the RITA.
Results: The mean follow-up period was 42 months, ranging from 6 to 204 months. The mean proximal diameter of the RITA was of 2.639 mm ± 0.09 and the distal diameter was 2.159 mm ± 0.1 (p < 0.001). The coronary irrigated by the target marginal branch presented a ß coefficient of 0.424 (p=0.001) and diameter of the stenosis (QCA) of the marginal branch gave a ß coefficient of 0.55 (p=0.001) adjusted by weight, height, time surgery/study, TIMI flow score, angina functional class and systemic hypertension. Multiple regression modeling demonstrated an adjusted R2 of 0.696 (p<0.0001).
Conclusion: This study, using angiographic evaluation, demonstrated that the coronary area and proximal diameter (QCA) of the marginal branch stenosis were independent factors in RITA remodeling in the postoperative of CABG.
Keywords: Internal mammary-coronary artery anastomosis; Heart catheterization; Image processing, computer-assisted
Medication in relation to complications after endovascular abdominal aortic aneurysm repair
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: This observational study was undertaken to explore the influence of medication on the occurrence of complications following endovascular repair of abdominal aortic aneurysms.
Methods: Clinical data concerning 70 consecutive patients undergoing elective EVAR in two vascular surgical centres over a 3 year period were analysed retrospectively. Complications were graded according to the recommendations of the Ad Hoc Committee on Reporting Standards. A distinction was made between device-related and non-related complications. An adjusted regression analysis was used to assess the association between 12 different medication groups and EVAR outcome.
Results: During 70 person years of follow-up 14 mild (20%), 23 moderate (33%) and 7 severe (10%) complications were recorded. Thirty patients (43%) who used coumarin derivates showed significantly less non-device-related complications (OR 0.21; 95%CI 0.05-0.90) compared to non-users. Twenty patients (29%) on anti-emetic drugs during hospital stay showed a fourfold more non-device-related complications (OR 4.37; 95%CI 1.10-17.3) and in-hospital use of analgesics in 25 patients was associated with more device-related complications (OR 3.81; 95%CI 1.32-11.0).
Conclusion: Medication seems to be associated with the occurrence of complications following endovascular therapy of abdominal aortic aneurysms. Patients who used coumarin-derivatives experienced fewer non-device-related complications. Patients who used anti-emetic drugs during hospital-stay showed a fourfold number of non-device-related complications. Patients using analgesics during hospital stay were associated with significantly more device-related complications
Keywords: Aortic aneurysm, abdominal, complications; Vascular surgical procedures; Stents, complications
Ten years experience of aortic valve replacement with aortic homograft root replacement
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: To evaluate the imediate and late results of 10 years of aortic valve root replacement with aortic homografts and to identify possible risk factors related with homograft primary tissue failure.
Methods: Between May 1995 and January 2006, 282 patients with a mean age of 52.8±16.6 years were submitted to aortic valve root replacement with an aortic homografts. The most prevalent etiologies were calcified bicuspid aortic valves and senile degeneration, corresponding to 49% of the cases. Forty-seven patients were reoperations and acute bacterial endocarditis were present in 26. Associated procedures were necessary in 113 patients. The homograft was implanted as a root replacement in all. Follow-up time varied between 1 and 129 months (mean= 41±25 months).
Results: Early overall mortality was 7%, with only 2.6% for cases of aortic valve replacement in isolation. Of the 262 patients discharged from hospital, it was possible to obtain clinical and echocardiographic evaluations in 209. Fifty-one patients (20%) were lost in the follow-up. There were 17 late deaths between the 2nd and 81st postoperative months, which resulted in an actuarial survival rate of 90% and 80.1% at 5 and 10 years respectively. There were eight thromboembolic events (four early and four late), for a linearized incidence of 0.3% events/100 patients/year. Bacterial endocarditis occurred in three occasions (0.4%/100 patients/year). Nine patients were re-operated, of which only three were related to the homograft (one case of primary tissue failure and two of bacterial endocarditis), corresponding to a probability of 94% of the patients free from this complication at 10 years of follow-up. Late echocardiographic analysis demonstrated maximum gradients varying between 3 and 47 mmHg (mean= 14.5 mmHg), with only two patients having a maximum gradient greater than 40 mmHg. Moderate valvar insufficiency was present in four cases.
Conclusions: The early and late results of aortic valve root replacement with aortic valve homografts were excellent, with a good functional recovery and low late morbimortality. The only risk factor for primary tissue failure was age below 20 years at the time of the operation. Aortic homografts are an excellent option for over 40-year-old patients, especially for those who have contraindications or do not warrant anticoagulation.
Keywords: Aortic valve, surgery; Prostheses and implants; Transplantation, homologous
Incidence of atherosclerosis in radial arteries of cadavers
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: To verify the incidence of atherosclerotic obstructions and microscopic atherosclerotic lesions in radial arteries dissected from cadavers of over 34-years-olds.
Methods: Twenty-nine cadavers had both radial arteries dissected as if they were going to be utilized as a coronary artery bypass grafts. An angiogram was performed to determine atherosclerotic obstruction of the radial arteries Subsequently, three fragments of the artery (proximal, medial, distal) were prepared on microscopic slides using hematoxylin-eosin in order to identify microscopic atherosclerotic lesions. Results were compared with risk factor found in patient's records: age, gender, hypertension, diabetes, history of smoking, myocardial infarctation, stroke, peripheral vascular disease, obesity, family history.
Results: No obstructive lesions were found in the angiograms. Four cadavers presented with microscopic atherosclerotic and pre-atherosclerotic lesions. Among the risk factors considered, only age was correlated with microscopic lesions. The arteries measured, on average, 19.22 cm in males and 17.45 cm in females. Theirs diameters were 1.87 mm for men and 1.72 for women.
Conclusions: No atherosclerotic obstructions were found in the radial arteries of those cadavers. Age is a risk factor for microscopic atherosclerotic lesions.
Keywords: Radial artery; Arteriosclerosis; Cardiac surgical procedures
Predictors of major neurologic dysfunction after coronary bypass surgery
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: The aim of this study was to evaluate the incidence and to identify possible predictors of major postoperative neurologic dysfunction (defined as stroke) and to evaluate early clinical outcome in a non-selected cohort.
Method: A total of 1760 consecutive patients who underwent isolated CABG in the San Lucas Hospital -PUCRS, between January 1997 and February 2004, were enrolled. Demographic and laboratory data, informations regarding the procedure and perioperative endpoints were collected prospectively using a standard protocol of data register of the cardiac postoperative unit of our hospital. We considered statistically significant those variables with a p value no greater than 0.05 with a confidence interval of 95%.
Results: In this study, 52 (3%) patients presented with major neurologic dysfunction. On the univariable analysis advanced age, higher prevalence of obstructive pulmonary disease, previous cerebrovascular disease, higher mean value of fibrinogen, occurrence of shock or severe hypotension, presence of supraventricular tachycardia (atrial fibrillation or flutter), occurrence of the systemic inflammatory syndrome and prolonged mechanical ventilation were associated with stroke. On the multivariable analysis previous history of cerebrovascular disease and obstructive pulmonary disease presented as independent predictors for the occurrence of major neurologic dysfunction. Prolonged mechanical ventilation was also independently associated with the endpoint. Furthermore, the occurrence of stroke raised significantly the duration of hospital stay and in-hospital mortality.
Conclusion: Neurological dysfunction is still a significant cause of morbidity after CABG.
Keywords: Cerebrovascular acccident; Cerebrovascular disorders; Cardiac surgical procedures, adverse effects; Myocardial revascularization
Anti-calcifying treatment of glutaraldehyde fixed bovine pericardium: comparisons and evaluation of possible synergic effects
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: To evaluate a possible synergic effect of the most promising anti-calcifying agents investigated in literature by sequential treatment.
Method: Glutaraldehyde-fixed bovine pericardium was treated by: heating to 50ºC, 80% ether, 0.125% chitosan, heparin, NaBH4 and 4% formaldehyde. Samples were evaluated by optic microscopy, shrinking and mechanical tests and implanted subcutaneously in rats. Four months later the samples were explanted and Ca2+ levels measured by atomic absorption spectroscopy.
Results: Ca2+ levels were (in mg/mg): control - 194.45; heating at 50ºC - 6.87; ether - 3.69; chitosan - 68.89; heparin - 6.81; formaldehyde - 107.34; sequential treatment - 0.17. The mechanical characteristics changed according to the treatments employed.
Conclusion: Sequential treatment was effective to inhibit calcification and the tissue showed an adequate mechanical structure for the manufacture of bioprosthesis.
Keywords: Bioprosthesis; Glutaral; Calcinosis
The importance of preventive measures in the prophylaxis of infections in patients submitted to heart transplant during the first thirty potsoperative days
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: To describe the rate of infections presented by patients submitted to heart transplant during the first thirty days after surgery, in respect to the topography and etiological agent and to compare the rate of infection during the immediately postoperative period with the preventive measures adopted by infection control.
Methods: A retrospective study was made of a population consisting of 125 patients submitted to heart transplant from June 1984 to January 2004. Data were collected by analyzing the patients' records following a specific investigative sequence. The ages of the patients ranged from 9 days to 71 years old, with a median of 47 years. There was a predominance of men (75.2%).
Results: During the first thirty postoperative days, 32.8% of the patients presented with infections. There were predominantly bacterial infections (32%), followed by fungal infections (5.6%) and those caused by viruses (4%). No difference was observed in the rate of infection comparing two situations: (1) in nursing care of patients using protective isolation (29.9%); and (2) without protective isolation (36.2%) ( p = 0.835).
Conclusion: Bacterial infections predominated followed by fungal and viral infections. The protective isolation initially used in post-heart transplant patients proved unnecessary as a measure to prevent or reduce rates of infection, confirming data obtained mainly in North American studies. These data are useful to guide protocols as they take specificities of our environment into account.
Keywords: Heart transplantation, nursing; Infection control
Chemical demineralization of the aortic valve: a potential application and preliminary clinical experience
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: To discuss the use of new technology in the chemical demineralization of the aortic valve in coronary artery bypass surgery, together with its hemodynamic changes and to report events related to the technique.
Method: Five patients with mild to moderate aortic stenosis submitted to myocardial revascularization underwent chemical treatment of the aortic valve. The patients' ages ranged from 65 to 81 years, with a mean of 73 years. All were men. One patient had the involvement of a single artery and four multiple arteries (four vessels). The gradient ranged from 13 to 49 mmHg, with a mean of 25 mmHg. The size of the aortic orifice ranged from 0.8 to 1.3 cm2, with a mean of 1.1 cm2. The following antecedents were observed: arterial hypertension, hypercholesterolemia, diabetes mellitus and smoking.
Results: The aorta clamping time ranged from 94 to 126 minutes, with a mean of 107 minutes and the bypass time was from 134 to 171 minutes, with a mean of 152 minutes. The time of surgery was from 13 to 33 minutes with a mean of 28 minutes. No deaths were recorded. The only postoperative complication noted was a total AV block in three patients. No events were observed that might impair the integrity of the aortic valve or cause aortic insufficiency following treatment. Likewise, no neurologic, systemic, metabolic or hematologic events were seen. The postoperative transvalvular gradient identified by echocardiography showed an improvement in the systolic gradient and in the mean gradient.
Conclusions: The treatment proved to be effective and safe, causing no lesions of the valve or any systemic event. The changes in the conduction system appear to be related to the equipment and its system of releasing the lavage solution. The use of this technology may, in the future, be an important adjuvant in aorta valve replacement using percutaneous techniques.
Keywords: Aortic valve, surgery; Aortic valve stenosis; Decalcification technique; Calcinosis; Demineralization
Histopathological reaction of the abdominal aorta wall to non-drug eluting stents
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: To evaluate the histopathological reaction of the abdominal aorta wall in pigs' renal arteries to the presence of non-drug eluting stainless steel stents.
Methods: The abdominal aorta of ten pigs (6 months old and weighing 86.6 kg on average) was histopathologically studied 100 days after the implant to a stainless steel stents in the abdominal aorta, with one segment of the stent inplanted in the renal artery. Self-expanding non-drug eluting stents were released by laparotomy. The histological slices were made at the transition from the normal aorta and the aorta containing the stent; the aorta portion containing the stent; the portion with the ostia of renal arteries; periaortic lymph nodes and renal parenchyma. The samples were stained by hematoxylin and eosin technique.
Results: Macroscopic findings showed periaortic lymphadenopathy, thickened aortic wall, patency of lumbar and renal arteries and normal renal anatomical structure. Microscopic analyses near the stents revealed thickening of vessel wall, secondary to the intima fibrosis, and media layer affected by interstitial fibrosis. Micrometric measurements of aorta wall with the stent, compared to the aortic portion without it, presented a 75.90% increasein the total thickness of the wall by thickening of the intima layer secondary to fibroblast proliferation, collagen deposits with lymphocitary inflammatory infiltrate and foreign body-type granulomas.
Conclusion: The non-drug eluting stainless steel stent in pigs' aortas produced a significant inflammatory reaction with fibrosis in the media and intima layers evidenced by histopathological analyses; their presence did not interfere in the patency of the abdominal aorta or the renal and lumbar arteries.
Keywords: Aorta, abdominal, surgery; Stents; Foreign-body reaction
REVIEW ARTICLE
Bronchiectasis and clearence physiotherapy: emphasis in postural drainage and percussion
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Bronchiectasis consists of abnormal, permanent and irreversible dilation of bronchi and bronchia, with recurrent infections, inflammation, hypersecretion and reduction of mucus clearance. It predominantly affects women of between 28 and 48 years old and more frequently affects the inferior lobes. Clinical manifestations are chronic cough, fever and voluminous expectoration, with a fetid odor. The etiology is unspecific and is considered the final stage of diverse pathological processes. It can be classified in cylindrical, varicose and cystic, and also in respect to located and whether it affects multiple segments. Postural drainage and chest clapping are commonly used clearence however, there are few published comparative population studies or reviews of techniques. In this context, this study aimed at evaluating the efficaciouness of postural drainage and chest clapping on bronchus clearence in bronchiectasis patients and to compare the effects and associations of these techniques with others reported in the literature. Recent research reported that postural drainage and chest clapping are effective therapies to mobilize pulmonary secretions as they increase the velocity of mucus transportion, improving pulmonary function and gas exchange. This requires the assistance of a professional, which can make the necessary daily treatment difficult. For this reason physiotherapists have been choosing techniques that give more independence to patients.
Keywords: Respiratory tract diseases; Bronchiectasis, rehabilitation; Drainage, postural; Posture; Physical Therapy Techniques
EXPERIENCE THE OF SERVICE
Endovascular treatment of abdominal aortic aneurysms: initial experience and short and mid-term results
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Objective: The purpose of this study is to present the short and mid-term results of the endovascular treatment of abdominal aortic aneurysms (AAA). This is an initial experience of a multidisciplinary team.
Method: Between July 2003 and October 2005, 42 patients (25 of whom suffered from AAAs) were treated with endovascular therapy for aortic diseases. The mean patient age was 74 ±10.2 years with 92% men. The endovascular precedures were performed by a multidisciplinary team in the Hospital de Clínicas de Porto Alegre and Hospital Luterano (ULBRA). In twenty-four of the AAA patients, bifurcated grafts were used and only one had a straight graft. In all patients the procedure was carried out by femoral artery dissection in a catheterization laboratory. There was no need to convert to open repair.
Results: There were no operative or postoperative deaths. The survival rate free from reintervention is 96% after two years and three months. One (4%) patient needed a new endovascular procedure for type I endoleak one year after, and three extensions were used successfully. Two other patients needed femoro-femoral bypasses, one at the same time as the endovascular procedure and the other one 24 hours later because of lower limb ischemia.
Conclusion: The endovascular treatment of AAAs represents a new less invasive alternative to conventional surgery, especially for high risk patients. Further prospective and randomized studies to evaluate the long term outcomes are needed. Excellent results in short and mid-terms can be obtained by a multidisciplinary teams in our country.
Keywords: Aortic aneurysm; Prostheses and implants; Stents
CASE REPORT
Right atrial myxoma prolapsing into the right ventricle
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
We report on a rare case of a 67-year-old woman with a right atrial myxoma prolapsing into the right ventricle in the diastolic phase. These tumors comprise approximately 18% of all cardiac myxomas, which occur in 0.0017% of collected autopsy series.
Keywords: Myxoma; Heart neoplasms; Heart atria
Chlamydia psittaci as a cause of mitral valve endocarditis: presentation of a rare case
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
The authors report a clinical case of bird breeder who evolved with fever, myalgia, weight lost and negative blood cultures. On three occasions he was treated with different antibiotics, without improvement. He became progressively worse and after four months a diagnosis of endocarditis was made. An echocardiogram showed mitral valve dysfunction with vegetation that had not been seen previously. A blood test proved positive for Chlamydia psittaci (indirect immunofluorescence). In surgery the mitral valve was seen to have severe lesions with anterior cuspid rupture and large areas with vegetation. After surgery, he presented with a clinical improvement and was discharged on the thirteenth post-operative day on specific antibiotic therapy. Although rare, Chlamydia psittaci must be considered in cases of endocarditis with negative blood cultures, when there is a possibility of contact with birds.
Keywords: Endocarditis; Mitral valve, sugery; Chlamydia; Ornithosis
CLINICAL-SURGICAL CORRELATION
Breastfeeding baby with fungal endocarditis at the right ventricle outflow tract - Case 3/2006
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
Pulmonary artery aneurysm post pulmonary valve stenosis - Case 4/2006
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
LETTERS FROM THE PRESIDENT
Letter of the president
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025
LETTERS TO THE EDITOR
Medicine based on evidence
Braz J Cardiovasc Surg 21;
Publish in: 8/2/2025