Volume 22 - Número 1
EDITORIAL
BJCVS on track to Medline
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Is it possible to train an endovascular surgeon?
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Medicine and humanism
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
A 97-year-old patient in shock with acute aortic dissection - operate or not?
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
SPECIAL ARTICLE
Unusual presentation of idiophatic chronic constrictive pericarditis
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
A 55-year-old male patient presented in our service with progressive dyspnea and ascitis beginning 1 year and 8 months previously. He weighed 160 kg (normal weight 95 kg), with ascitis and orthopnea. On admission he presented normal echocardiograms. An electrocardiogram showed diffuse inverted T waves. An endomyocardial biopsy was not elucidative. A new echocardiogram confirmed a very thick pericardium. Surgical pericardial resection was indicated. The postoperative period was uneventful with complete remission of symptoms. The anatomopathological analysis was normal. The pericarditis was classified as idiopathic. This case is a warning for the need of much suspicion in patients with apparent causeless voluminous ascitis.
Keywords: Pericarditis, constrictive; Heart failure, congestive; Cardiomyopathy, restrictive; Echocardiography
ORIGINAL ARTICLE
Procedure-related mortality of endovascular abdominal aortic aneurysm repair using revised reporting standards
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: The aim of this study was to evaluate the definition of Procedure-related mortality after endovascular aneurysm repair (EVAR) as defined by the Committee for Standardized Reporting Practices in Vascular Surgery.
Methods: Data on patients with an AAA were taken from the EUROSTAR database. The patients underwent EVAR between June 1996 and February 2004 and were analyzed retrospectively. Explicit probability of cause of death was recorded. The time interval from operation, hospital discharge or second interventions till death was recorded.
Results: A total of 589 out of 5612 patients (10.5%) died after EVAR in total follow up and all causes of death were included. 141 (2.5%) patients died due to aneurysms reported after the EVAR procedure of which 28 (4.8%) were ruptures, 25 (4.2%) graft-infections and 88 (14.9%) patients who died within 30 days after the initial procedure (present definition, also known as short term clinical outcome). In addition 25 patients died after 30 days, but were then (at moment of death) still in the hospital, or were transferred to a nursing home for further re-evaluation, or needed second interventions. Taking into account the duration of hospitalization and mortality immediately after procedure-related second interventions, 49 delayed deaths might also be regarded as being EVAR procedure-related.
Conclusion: Delayed deaths are a considerable proportion of procedure-related deaths after EVAR within the revised time frame.
Keywords: Aortic aneurysm, abdominal, mortality; Aortic aneurysm, abdominal, surgery; Stents; Blood vessel prosthesis implantation, mortality
Comparative study between ischemic preconditioning and cerebrospinal fluid drainage as methods of spinal cord protection in dogs
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: This study compares the effects of immediate ischemic preconditioning based on somatosensory evoked potential (SSEP) monitoring with those of cerebrospinal fluid drainage in a model of descending thoracic aorta occlusion in dogs.
Method: Eighteen dogs were submitted to spinal cord ischemia induced by descending thoracic aortic cross-clamping for 60 minutes. The Control Group underwent only aortic cross-clamping (n=6). The Ischemic Preconditioning Group (IPC) underwent ischemic preconditioning (n=6) and the Drainage Group underwent cerebrospinal fluid drainage (n=6), immediately before aortic cross-clamping. An independent observer assessed neurological status according to the Tarlov score. The animals were sacrificed and spinal cord harvested for histopathologic study.
Results: Aortic pressure before and after the occluded segment was similar in the three groups. Seven days after the procedure, Tarlov scores were significantly higher only in the Drainage Group when compared to the Control Group (p<0.05). Lower SSEP recovery times were also observed with cerebrospinal fluid drainage during the final reperfusion period (p<0.01). In the histopathologic study, stain showed less significant neuronal necrosis in the thoracic and lumbar gray matter in animals submitted to both methods of spinal cord protection, with it being more pronounced in the Ischemic Preconditioning Group (p<0.001).
Conclusion: Cerebrospinal fluid drainage and immediate ischemic preconditioning seems to protect the spinal cord during descending thoracic aorta cross-clamping. Nevertheless, the obtained level of spinal cord protection seems to be more significant with cerebrospinal fluid drainage.
Keywords: Aorta, surgery; Spinal cord; Cerebrospinal fluid; Somatosensory evoked potentials; Dogs
Effects of myocardial protection in hypertrophic rabbit hearts: structural and ultra structural analysis
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To experimentally compare the structural and ultrastructural changes in isolated hypertrophied rabbits' hearts submitted to cardiac arrest protected using sanguineous and crystalloid cardioplegia solutions.
Method: The study comprised two experimental groups and one control group. In Experimental Group I, cardiac arrest was achieved by the continuous infusion of tepid sanguineous cardioplegia solution. In Experimental Group II, cardiac arrest was obtained by an intermittent infusion of a cold crystalloid cardioplegia solution. In the Control Group the hearts were submitted to normothermic anoxic arrest for 45 minutes. After the procedures, eight samples of the left ventricle lateral wall were collected and fixed in 10% formaldehyde and 2.5% glutaraldehyde for structural and ultrastructural analysis.
Results: The structural and ultrastructural results demonstrated that the hearts submitted to cardiac arrest protected by continuous tepid sanguineous cardioplegia, Group I, were better preserved and with less accentuated cellular alterations compared to those submitted to cardiac arrest protected using intermittent cold crystalloid cardioplegia and the Control Group.
Conclusion: Continuous tepid sanguineous cardioplegia was more efficient in the preservation of the structural and ultrastructural integrity of the myocardium when compared to intermittent cold crystalloid cardioplegia.
Keywords: Cardioplegic solutions, pharmacology; Hypertrophy; Cardiac surgical procedures
Preoperative risk factors for the development of acute renal failure in cardiac surgery
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To evaluate clinical risk factors for the development of Acute Renal Failure (ARF) in patients who undergo cardiac surgery.
Method: Over a period of 21 consecutive months, one hundred and fifty patients who underwent cardiac surgery were studied. There was a slight prevalence of men (57%) and the average age was 56 ± 14.8 years. Sixty-six percent presented with coronary artery disease as the main diagnosis and 34% valvular heart disease. The median preoperative serum creatinine was 1.1 mg/dL. ARF was defined as a 30% increase in serum creatinine above baseline. The protocol of clinical variables initiated 48 hours before the surgical procedure and finished 48 hours after it and included cardiological and non-cardiological variables and laboratory data.
Results: ARF was present in 34% of the cases. After multivariate analysis, being a man and the presence of peripheral vascular disease were identified as the preoperative factors.
Conclusion: The results obtained in this study identified some risk factors for the development of ARF in cardiac surgery, suggesting simple clinical procedures that may prevent renal dysfunction in these situations and, consequently, reduce the mortality rate. In the present study, the sample size has possibly impeded the identification of other significant risk factors.
Keywords: Renal insufficiency, acute; Cardiac surgical procedures; Postoperative complications
A novel adjustable pulmonary artery banding system for hypoplastic left heart syndrome
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: Hypoplastic left heart syndrome remains a challenge for worldwide surgeons. Initial palliation employing bilateral pulmonary artery banding along with ductal stent implantation and atrial septostomy has been proposed as an alternative approach. However, the surgically placed bands are fixed and may become inadequate after sternum closure or with somatic growth of the patient. We describe the first case in which a neonate with hypoplastic left heart syndrome was initially managed using a mini banding system that allows for fine percutaneous adjustments of pulmonary blood flow.
Method: Through a mid sternotomy, a 5 day-old neonate underwent bilateral pulmonary artery banding using this new system combined with placement of a main pulmonary artery to innominate artery shunt.
Results: The patient had an uneventful postoperative course. Three percutaneous adjustments of the banding system were necessary to keep the arterial oxygen saturation in the 75%-85% range. On the 48th day of life, she was submitted to stent placement (6 mm) within the atrial septum to treat a restrictive atrial septal defect. The Norwood operation and the bidirectional Glenn shunt were carried out on the 106th day of life. The bands were removed with no distortion of the pulmonary arteries.
Conclusions: The clinical use of this innovative pulmonary artery banding system was feasible, safe and effective. It allowed for customization of the pulmonary blood flow according to the underlying clinical needs, resulting in a more precise balance between the pulmonary and systemic circulations.
Keywords: Heart defects, congenital; Stents; Palliative care; Hypoplastic left heart syndrome; Pulmonary artery, surgery; Balloon dilatation
Peripheral arterial occlusive disease and ankle-brachial index in patients who had coronary angiography
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To evaluate the prevalence of peripheral arterial disease (PAD) in patients with coronary arterial disease. To evaluate the relation between ankle-brachial index (ABI) and coronary arterial disease, and its correlation with cardiovascular risk factors.
Method: ABI investigated with Doppler ultrasonic device. Clinical characteristics researched: age, gender, diabetes, hypertension, alcoholism, smoking and obesity. Population: 113 patients who had coronary angiography. First analyses: 2 groups - absence and presence of coronary arterial disease. Second analyses: 3 groups - Group 1 - absence of coronary lesion; Group 2 - stenosis <70%; and Group 3 - stenosis ³70%. Third analyses: 2 groups - absence and presence of PAD.
Results: 90.76% of patients with coronary arterial disease presented PAD. There were significant difference including age (p<0.001), hypertension (p<0.001). smoking (p<0.001), body mass index (BMI) (p<0.001), systolic blood pressure (SBP) (p<0.001), diastolic blood pressure (DBP) (p<0.001) and pulse pressure (PP) (p<0.001) and ABI (p<0.001) between patients with and without coronary lesion. There were significant difference including age (p<0.001), diabetes (p=0.030), hypertension (p<0.001), smoking (p<0.001), BMI (p<0.001), SBP (p<0.001), DBP (p<0.001) and PP (p<0.001) and ABI (p<0.001) between patients divided as severity of coronary arterial disease. There were significant difference including age (p<0.001), hypertension (p<0.001), smoking (p<0.001), BMI (p<0.001), SBP (p<0.001), DBP (p<0.001) and PP (p<0.001) between patients with and without PAD. By Logistic Regression Analysis, old obese patients with ABI<0.90 have a risk of coronary lesion of 98.93%.
Conclusion: ITB<0.90 might be a marker of coronary arterial disease in patients at risk of cardiovascular diseases.
Keywords: Ankle, blood supply; Brachial artery; Atherosclerosis; Peripheral vascular diseases; Risk factors
Immediate results of right internal thoracic artery and radial artery as the second arterial graft in myocardial revascularization
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: We sought to compare early clinical outcomes in patients receiving a right internal thoracic artery or a radial artery as the second arterial graft in myocardial revascularization.
Methods: We retrospectively studied 58 consecutive patients who underwent coronary artery bypass surgery and received both a left internal thoracic artery graft and either a right internal thoracic artery (n=20) or a radial artery graft (n=38), between January 2004 and March 2006. Hospital mortality, pleural drainage, operative time and postoperative complications were analyzed.
Results: There were no significant preoperative differences between groups. There was only one (1.7%) in-hospital death which occurred in the Radial Group. Operative times was significantly higher in the Right Internal Thoracic Group (p-value = 0.0018), but were not associated with increased Intensive Care Unit stays, mechanical ventilation or other postoperative complications. We were able to perform significantly more distal anastomosis using the radial artery than the right internal thoracic artery (1.57 versus 1.05: p-value =0.003).
Conclusion: In our group of patients, the use of a right internal thoracic artery as a second arterial graft was associated with a prolonged operative time, but had no interference with the immediate clinical outcomes.
Keywords: Myocardial revascularization; Mammary arteries; Radial artery; Evaluation of results of therapeutic interventions
Mitral valve replacement with chordae tendineae preservation, traction and fixation in end-stage dilated cardiomyopathy
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: This study aimed at evaluating results of mitral valve replacement using a new technique of complete chordae tendineae adjustment for left ventricular remodeling.
Methods: Twenty end-stage idiopathic dilated cardiomyopathy patients with severe functional mitral valve regurgitation underwent mitral valve replacement. Seventeen (85%) were in functional class IV. Both anterior and posterior leaflets of the mitral valve were divided to obtain 4 pillars of chordae tendineae. These were displaced with traction toward the left atrium and anchored between the mitral annulus and a valvular prosthesis. To evaluate the left ventricular remodeling, Doppler echocardiography was performed. For statistical analysis, variance analysis and the Friedman's test were employed.
Results: Two (10%) early deaths occurred. Kaplan-Meyer showed survival at one year post-operative was 85%, 2 years it was 44%, at 3 years 44%, at 4 years 44% and at 5 years it was 44%. In the 48- and 54-month follow-ups, the McNemar test showed improvement in the functional class (p<0.001). In the third month of follow-up, variance analysis showed improvement in the ejection fraction (p=0.008) and reductions of the end diastolic diameter (p=0.038), end systolic diameter (p=0.008), end systolic volume (p=0.029) and end diastolic volume (p=0.009). No statistical differences were noted in the systolic volume. Comparing pre-operative and third- and six-month follow-ups, the Friedman test showed no statistical differences for all studied variables. Variance analyses between pre, three-month and final evaluations showed no significant differences.
Conclusion: This technique of mitral valve replacement improved the left ventricle ejection fraction and decreased the end diastolic and systolic diameters and the end systolic diastolic volumes up to the third month of follow-up. From then on the variables stabilized.
Keywords: Mitral valve, surgery; Heart failure, congestive; Cardiomyopathy, dilated; Heart valve prosthesis
Effects of gamma irradiation on mechanical behavior and calcification of glutaraldehyde-fixed bovine pericardium
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To evaluate the effect of gamma irradiation on glutaraldehyde-fixed bovine pericardium.
Method: Glutaraldehyde-fixed bovine pericardium was exposed to gamma radiation (doses from 0 to 10000 Gy). Six samples from each of nine groups were evaluated by optic microscopy, and shrinking and mechanical tests and the denaturation temperature was determined. Additionally, they were subcutaneously implanted in rats and after four months they were explanted and Ca2+ levels measured by atomic absorption spectroscopy.
Results: The Ca2+ levels were (in µg/mg): control (0 Gy) - 194.45; 50 Gy - 154.64; 100 Gy - 169.37; 200 Gy - 163.64; 500 Gy - 199.89; 1000 Gy - 184.02; 2000 Gy - 198.95; 5000 Gy - 227.95; 10000 Gy - 362.62. Gamma irradiation caused a significant effect on the biomechanical properties of the tissue.
Conclusion: Exposure to gamma irradiation did not reduce Ca2+ levels and caused a significant reduction in the tensile strength of glutaraldehyde-fixed bovine pericardium.
Keywords: Glutaral; Calcinosis; Gamma rays; Pericardium, radiation effects
Hemodinamic behavior of arterial anastomosis using fibrin sealant. Experimental study in swine
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objectives: To evaluate the flow, tear pressure, the need of reinforcement stitches in sutured arteries reinforced or not using fibrin sealant after a cross-section.
Method: Tissucol® fibrin sealant was used. The femoral and carotid arteries of seventeen swine from the same breed (weighing from 15 to 20 kg) were cross-sectioned after heparinization and subjected to anastomoses using a single continuous plane of prolene 7-0. We worked with 68 artery samples, 34 in the Treatment Group and 34 in the Control Group. For each animal, one carotid and one femoral artery randomly received fibrin sealant with the contralateral side being used as a control. The need and the number of reinforcement stitches were recorded. Ten minutes after protamine infusion, the animals were sacrificed and the arteries were catheterized. The arteries were measured and placed on a flow meter. The arteries were then subjected to air infusion at increasingly higher pressures (stepwise increases of 25 mmHg), the grafts were dipped in saline solution, the first air leakage was observed and the tear pressure recorded.
Results: The external diameters and thickness of the arteries were similar in both the Treatment and Control Group. There was no significant difference between the groups regarding the tear pressure (p=0.329), flow rate (p=0.943) and the number of samples with a tear pressure above 200 mmHg. However, the sealant reduced the number of reinforcement stitches necessary (p=0.029).
Conclusion: Fibrin sealant reduces the need of additional stitches.
Keywords: Fibrin tissue adhesive; Anastomosis, surgical, methods; Hemostasis
REVIEW ARTICLE
Mechanical forces and human saphenous veins: coronary artery bypass graft implications
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Vascular endothelial cells are exposed to a variety of in vivo mechanical forces, specifically, shear stress for the blood flow, tensile stress from the compliance of the vessel wall and the hydrostatic pressure from containment of blood within inside the vasculature. Many authors studied hemodynamic, functional and morphological human saphenous veins alterations caused by these different forces with conflictant results. This review text was motivated with the specific aim of analyze literature data and some experimental data carried out in our laboratory. The adopted review subjects were: 1) Endothelial responses and gene regulation to shear stress; 2) Effects of the hydrostatic pressure in the endothelial cell morphology, gene expression of the endothelial cellular surface and proliferation of endothelial cells; 3) Effects of the traction on the human saphenous vein endothelium.
Keywords: Endothelium; Saphenous vein; Nitric oxide; Myocardial revascularization
Aspirin resistance and atherothrombosis
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
EXPERIENCE THE OF SERVICE
OPCAB in patients on hemodialysis
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To analyze the hospital outcomes of patients, with chronic renal insufficiency in the hemodialysis, submitted to OPCAB.
Method: Fifty-one patients with chronic renal insufficiency were submitted to OPCAB. Hemodialysis was performed on the day before and the day after the operation. Myocardial revascularization was performed using LIMA's suture and suction stabilization.
Results: Fifty-one patients, with an averageof 61.28±11.09 years, were analyzed. Thirty patients (58.8%) were female. The predominant functional class was IV in 21 (41.1%) of the patients. The left ventricle ejection fraction was dire in 21 (41.1%) patients. The mean EUROSCORE of this series was 7.65±3.83 and the mean number of distal anastomosis was 3.1±0.78 per patient. The average time of mechanical ventilation was 3.78±4.35 hours and the mean ICU stay was 41.9±13.8 hours, while the average hospitalization was 6.5±1.31 days. In respect to complications, nine (17.6%) of the patients developed atrial fibrilation, and one (1.9%) patient presented with a case of ischemic stroke but had a good recovery during hospitalization. There were no deaths in this series.
Conclusion: Chronic renal patients submitted to hemodialysis were always a high risk population for myocardial revascularization. In this series, the absence of extracorporeal circulation appeared to be safe and efficient in this special subgroup of patients. The operations were performed with low indices of complications, absence of deaths and relatively low stays in the ICU and in hospital.
Keywords: Myocardial revascularization; Renal insufficiency, chronic; Renal dialysis
Left mini-thoracotomy off-pump coronary revascularization
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objectives: Stent restenosis is a common complication in angioplasty. Studies have shown better outcomes when the left internal thoracic artery (LITA) is anastomosed to the left anterior descending artery (LAD). Patient selection, operative technique and results for off-pump left mini-thoracotomy (LME) coronary surgery, as a pilot study, are presented.
Methods: Eighteen patients (three women) with a mean age of 56.6 ± 9.2 were operated on through a 9-14 cm LME to perform off-pump LITA to LAD anastomoses (14 patients) or diagonalis (DI) and LAD sequential anastomoses (4 men). The grafts were skeletonized during dissection and anastomoses were performed using 7-0 polypropylene running sutures. An access device (CardioThoracic Systems®) allowed approach and coronary stabilization.
Results: There were no deaths, conversion to sternotomy, transfusions or high enzyme levels. All patients were released from hospital on the 3rd to 5th postoperative days and returned to their day-to-day activities within 30 days. One woman was readmitted for angina, presented with graft occlusion, and a stent was implanted and one man was readmitted for wound infection. Future angiography was performed on six patients and showed patent grafts.
Conclusion: The operation was performed with low morbid-mortality, short hospital stays and without transfusions. Appropriate instruments and the ability of the surgeon to use his left hand, made this operation technically easy. Randomized studies may prove if there are sufficient clinical and economic benefits over the long term to make this surgery the first choice.
Keywords: Myocardial revascularization, methods; Surgical procedures, minimally invasive; Mammary arteries; Thorax, surgery
CASE REPORT
Cerebral hyperperfusion syndrome occurring three weeks after carotid endarterectomy
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Cerebral hyperperfusion syndrome is a recognized complication of carotid endarterectomy. Various studies have documented an incidence of 0.3 to 1.2%. It occurs in the setting of sudden reperfusion of a chronically hypoperfused hemisphere. We present here a case of a 48-year-old lady who developed cerebral hyperperfusion syndrome three weeks after undergoing a carotid endarterectomy for high-grade carotid artery stenosis.
Keywords: Carotid endarterectomy, complications; Cerebrovascular accident; Cerebrovascular disorders, etiology
Spontaneous coronary dissection: case report
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
The purpose of the paper is to demonstrate the case of a 62-year-old man, with spontaneous coronary dissection of the left circumflex artery, treated surgically by myocardial revascularization. The successfully accomplished surgery demonstrates, in this case, to be the only possible way of a cure.
Keywords: Coronary vessels; Coronary circulation; Coronary arteriosclerosis; Myocardial revascularization
CLINICAL-SURGICAL CORRELATION
Juxtaposition of atrial appendix at left side on great arteries transposition
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Left atrial isomerism in the defect of partial atrioventricular septum
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025