Volume 22 - Número 4
EDITORIAL
RBCCV/BJCVS is on PubMed/Medline!
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Cardiovascular Surgery Outcomes - Oportunity to rediscuss medical and cardiological care in the Brazilian Public Health System
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Different procedures and therapeutic indications
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
ORIGINAL ARTICLE
Tricuspid valve repair using the proportion between segments of normal tricuspid annulus as a parameter for annuloplasty
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To determine the proportion between the segments of the normal human tricuspid valve (TV) annulus and its use as a parameter for ring annuloplasty "in vitro" and "in vivo". Methods: Digital images of the tricuspid ring of 30 human cadaveric hearts, without fixation and without tricuspid regurgitation (TR), were analyzed and the proportion between the antero-posterior and septal segments was determined. This proportion was used for TV annuloplasty with bovine pericardium (BP) flexible rings on 15 hearts from adult cadavers with TR and ring dilatation. The same proportion and technique were used for TV repair on 11 patients with functional TR. Preoperatively, seven patients had severe and four moderate TR; five patients were class IV and six class III (NYHA). Results: The mean ratio between the antero-posterior and septal segments was 2.43±0.212 in the 30 hearts without TR. The mean size of the BP flexible ring used for "in vitro" surgical procedure was 71.5±5.2 mm, median 70 mm, and there was no TR after that in all 15 hearts. The mean size of the orthesis used on the patients was 73.4±6.5 mm, median 72 mm. There was 1 hospital death. Six months after surgery, 7 patients had no TR and 3 had mild TR; 6 patients were in NYHA class I, 3 in class II and 1 in class III. Conclusion: The use of the ratio 2.43:1 between the anterior-posterior and septal segments as a parameter in tricuspid valve annuloplasty with a bovine pericardium flexible ring leads to satisfactory results.
Keywords: Heart, anatomy & histology; Tricuspid valve; Heart valve diseases; Cardiac surgical procedures
Late pulmonary tomography assessment in premature infants with bronchopulmonary dysplasia submitted to patent ductus artLate pulmonary tomography assessment in premature infants with bronchopulmonary dysplasia submitted to patent ductus arteriosus managem
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To assess through high-resolution computed tomography the pulmonary parenchyma of children prematurely born with both very low birth weight and patent ductus arteriosus submitted to medical or surgical treatment that developed bronchopulmonary dysplasia. Methods: Between December 2006 and January 2007, 14 children prematurely born with a weight less than 1500g with bronchopulmonary dysplasia (BPD) and patent ductus arteriosus (PDA) were submitted to high-resolution computed tomography (HRCT). All of them underwent surgical closure of the canal divided into two groups: A - medical (n=6) and B - surgical (n=8). The pool of patients comprised 9 baby boys and 5 girls who were 36.5±4.3 month-old. The HRCT were analyzed by two independent observers and quantified in each patient. The statistical analyses were assessed using the Mann-Whitney test, and p<0.05 was considered statistically significant. Results: Three patients presented normal tomographies, being two of A group and one of B. In A, the most frequent finding was multifocal ground-glass opacity. In B, multifocal ground-glass opacity, atelectasis, and low attenuation areas with relatively decreased number and caliber of vessels were prevalent (62.5%). There was a statistically significant difference between both groups, with B having higher averages in the intubation times, use of oxygen, and admission. However, as to the number of injuries found on HRCT there was no statistically significant difference (p=0.0787). Conclusion: The lately use of HRCT have shown no significant difference between both medical and surgical treatment aiming at to occlude the PDA in pulmonary parenchyma injuries of premature with PDA that developed bronchopulmonary dysplasia.
Keywords: Tomography; Patent ductus arteriosus; Bronchopulmonary dysplasia
Hemodynamic disorders related to beating heart surgery using cardiac stabilizers: experimental study
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To study in swine the hemodynamic changes secondary to the use of stabilizers for off-pump coronary artery bypass graft surgeries by means of both a suction device "Octopus" and a compression device (Speroni). Methods: Ten swine underwent median sternotomy. Monitoring of ECG, continuous cardiac output, mean arterial pressure, mean pulmonary artery pressure, mean right and left atrial pressures, and right and left ventricular diastolic pressure were performed. Stroke volume and systemic vascular resistance were calculated. Both stabilizers were studied placed on three vessels: anterior interventricular branch, posterior interventricular branch, and the left marginal artery of the circumflex branch. Each animal was randomly designed to application regarding the type of stabilizer and the target artery. The measurements were carried out 5 minutes before and after the stabilizer application. Results: In the anterior interventricular branch changes have occurred only with the compression device, thus reducing cardiac output, stroke volume, and mean arterial pressure, but increasing the systemic vascular resistance. In the posterior interventricular branch changes have occurred with the compression device (Speroni), reducing cardiac output and stroke volume, but increasing the heart rate. With the suction device (octopus) there was an increase of both heart rate and systemic vascular resistance, but a decrease in stroke volume. In the left marginal artery of the circumflex branch there was a decrease of cardiac output, stroke volume, and mean arterial pressure with both stabilizers. Also, there was a decrease in the mean pulmonary artery pressure and an increase in the mean right atrial pressure with the compression device (Speroni). Conclusion: Both stabilizers have caused hemodynamic changes. The compression device (Speroni) is more associated with changes than the suction device (Octous).
Keywords: Myocardial revascularization, methods; Heart, physiopathology; Hemodynamics; Intraoperative period; Animal models
Neuroprotective effects of diltiazem in rabbits with occluded aorta
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: In the present study, we aimed to determine the protective effect of the perfusion of the distal aorta with diltiazem and ringer lactate solution on the spinal cord. Methods: Twenty-seven New Zealand rabbits were used in which spinal cord ischemia was provided by occlusion of the aorta for thirty minutes. Experimental animals were divided into four groups: group A (n=4), the sham operation group; group B (n=8) in which intraaortic balloon occlusion alone was applied; group C (n=7), ringer lactate group in which ringer lactate was perfused into distal aorta at a rate of 40 ml/kg, hr, following intraaortic balloon occlusion; group D (n=8) diltiazem group in which diltiazem 40 mg/kg, hr, in Ringer lactate was perfused into distal aorta following intraaortic balloon occlusion. Motor function of hind limbs was evaluated by Tarlov's scoring system. After observation, spinal cords were removed for histopathological evaluation. Results: The degree of histopathological injury was well correlated with neurological function. The most severe histopathological injury and neurological dysfunction occurred in group B, followed by group C, D and A respectively. No injury or neurological dysfunction occurred in the sham group. Conclusions: The protective effect of diltiazem on both histopathological injury and neurological function was significant in comparison with control groups.
Keywords: Reperfusion; Aorta; Animal models
Is the RACHS-1 (Risk adjustment in congenital heart surgery) a useful tool in our scenario?
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: The aim of this study was to evaluate the applicability of the RACHS-1 (Risk Adjustment in Congenital Heart Surgery) as a predictor of surgical mortality in a pediatric population of a public hospital of the Northeast of Brazil. Methods: From June 2001 through June 2004, 145 patients undergone surgical treatment of CHD in our institution of whom 62% were female, and the mean age was 5.1 years. The RACHS-1 was used to classify the surgical procedures into categories of risk 1 to 6, and logistic regression analysis was used to identify the risk factors related to surgical death. Results: Age, type of CHD, pulmonary flow, surgical procedure, pump time and cross clamp time were identified as a risk factor for postoperative mortality (p<0.001). There was a linear correlation between the categories of the RACHS-1 and the mortality rate; however, the observed mortality was greater than the predicted figures by that scoring system. Conclusion: Although the RACHS-1 is easily applicable, it can not be applicable in our scenario because it takes into account only the surgical procedure as a categorized variable, not considering others factors presented in our scenario that could interfere in the final surgical result.
Keywords: Heart defects, congenital, surgery; Mortality; Risk adjustment
Characterization of the patients' caregivers on the waiting list for heart transplant at UNIFESP
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objectives: To identify and describe the main caregiver of the patients on the heart transplant waiting list; to compare relevant information provided by patients and caregivers, and to classify the caregivers according to their dedication and efficiency in assisting the patient by correlating them to sociodemographic data. Methods: Descriptive study performed from October 2004 to October 2005 at UNIFESP outpatient clinics. The study sample consisted of 21 patients and their caregivers. Data were collected through a structured interview. Results: The main caregiver was a family member (95%), usually the spouse. There were 13 women (81%) and three men (19%). Patient age ranged from 24 to 65 years (mean 44.3). Patients were married (56%); catholic (43.8%); 29% have finished elementary school; 24% have finished high school; 14% have higher education; 68.8% have a regular job; and 81.4% had their own income. All caregivers lived in the same house as the patient. Once a score was established, the caregivers were classified as: "good" - 8 (50%); "regular" - 7 (43.7%); and "bad" 1 - (6.3%). The scores were correlated with education, professional activity, and income without any significant statistical correlation. Conclusion: It is important to determine the instruments to recognize and describe the caregivers. The caregiver is usually a family member (spouse), female, mean age of 44.3 years; has his/her own income and, most of the time, he/she is classified as "good" or "regular", and no correlation was found with education, professional activity and income. Further studies with a larger sample should establish the relationship between the caregiver's role and the heart transplant outcomes.
Keywords: Patient care; Family; Heart transplantation
Is the endovascular procedure an option for treatment of cronic type B aortic dissections?
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: Questions regarding the specific patient/disease that should be submitted to the endovascular procedure still remain unclear. The purpose of this report is to evaluate the endovascular treatment in chronic type B aortic dissections. Methods: Between 2003 and 2006, 11 patients with chronic type B aortic dissection were submitted to endovascular procedure through femoral artery. All of them were monitored with CT within 6 months, 1 year and afterwars anually. We prospectively evaluated false lumen patency and thoracic and abdominal aortic diameters in each time point. The data comparisons were made using Anova and chi-square tests with SPSS 13. Results: The endovascular stent-graft deployment was technically successful for all patients, with no hospital mortality. During the follow-up period the false lumen flows remained persistent in the thorax in 27.3% of the patients and in the abdomen in 81.8%. However, in all patients, in both segments, the aorta diameter was not significantly changed in size and shape. Conclusion: Despite the small number of studied patients, the endovascular procedure for chronic type B aortic dissections does not appear to be an option for the treatment of these patients.
Keywords: Aneurysm, dissecting, surgery; Aorta, surgery; Aorta, thoracic, surgery; Stents; Aortic aneurysm, surgery; Vascular surgical procedures
Mitral valve repair with “Double Teflon” technique: 10-year results
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: The purpose of this paper is to present the late clinical results of mitral valve repair with the "Double Teflon" technique. Methods: "Double Teflon" technique consists of a quadrangular resection of the posterior leaflet, annulus plication with "pledgetted" stitches over a Teflon patch, and leaflet suture. Between 1994 and 2003, 133 patients with degenerative mitral insufficiency due to ruptured or elongated chordae in the posterior leaflet underwent repair with this technique. The mean patient age was 60.4 years and 60.9% patients were male. According to clinical evaluation, 29.3% of the patients were in New York Heart Association functional class IV, 55.7% in class III and 15.0% in class II. Associated techniques of mitral valve repair were used in 15.2% of the patients; the most common was chordal shortening. Twenty six (19.5%) patients had associated procedures. Results: There was one (0.75%) operative death. In the late postoperative period, 95.5% of the surviving patients were in New York Heart Association functional class I. Linearized rates of thromboembolism, reoperation and death were 0.9%, 0.3% and 0.6% patient/year, respectively. The actuarial survival at 10 years was 94.7% ± 3.6%. Actuarial freedom from thromboembolism and reoperation were 97.3 ± 1.5% and 99.2 ±0.8%, respectively. There were no episodes of hemolysis or endocarditis. Conclusion: Mitral valve repair with "Double Teflon" technique presents low morbimorbidity and good clinical late evolution.
Keywords: Mitral valve insufficiency, surgery; Mitral valve, surgery; Heart valves, surgery; Myxomatosis, infectious
Ross Operation with decelularized pulmonary allografts: medium-term results
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To evaluate the medium-term results (4 years) of decelularized allografts during Ross Operation. Methods: From January 2003 to February 2007, 68 patients underwent Ross Operation with decelularized allografts. Forty eight were male and the mean age was 30.3±11.2 years. Decelularization was done with deoxicolic acid (DOA) in 35 cases and with sodium dodecylsulfate (SDS) in 33. For comparison of the gradients, 68 patients with cryopreserved allografts and matched for age were selected. All patients had a control echo before hospital discharge and annually thereafter. In addition, eight patients had MRI studies. In two patients, samples of the conduit wall were analyzed by histological analysis. Results: There was one (1.4%) early death. In the late follow-up, there were two reoperations for endocarditis and one late death. The early gradients varied between 4 - 29 mmHg (m= 10.3± 5.5mmHg) and exhibited an increase to 16.5±12.2 mmHg (min=4, max=45) at 24 months postoperatively. There were no significant differences when compared to the cryopreserved group. There was, however, a tendency towards lesser gradients in the SDS decelularized group after 12 months. Histological analysis revealed partial reendothelization and progressive repopulation of the tunica media with autogenous cells. There was no progressive pulmonary insufficiency. The MRI results showed a lesser tendency to shrinkage in the decelularized conduits. Conclusions: The use of decelularized allografts was safe and with good medium-term results up to 4 years. There was a tendency to lower late gradients in the SDS decelularized allografts after 12 months.
Keywords: Transplantation, homologous; Tissue engineering; Aortic valve; Heart valves
Approach of the pulmonary valve using right heart bypass and bicaval cannula: experimental study
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objective: To reproduce the surgery for correction of pulmonary valve anomalies using right heart bypass and a new bicaval cuffed venous cannula for minimal access surgery. Methods: Fifteen Large-White pigs were used for this study. The standard technique model was established with the first five pigs, the experiment was done with nine animals by sternotomy, and one was submitted to a minimally invasive procedure, but has been excluded of the sample. Bicaval drainage by a single cannula was obtained through the internal jugular vein. The cuffs were inflated to increase blood flow to the machine. The return was established by putting the arterial cannula into the pulmonary artery trunk. Pre-bypass parameters were measured and compared with the parameters during the right bypass: Median Arterial Tension (MAT); Heart Rate (HR); O2 Saturation (SAT O2); end-tidal CO2 measures (etCO2); Temperature (T). The statistical analysis was done comparing the pre-bypass and during bypass values. Results: Pre-bypass values: MAT: 90.8 mmHg; HR = 101.6 beat/min; O2 SAT = 93.8%; PetCO2 = 28.4 mmHg; T = 36.1ºC. During bypass the obtained values were: MAT: 88.1 mmHg; HR = 98.0 beat/min; O2 SAT = 93.1%; PetCO2 = 25.3 mmHg; T = 36.9ºC. Comparing the average values between the two abovementioned moments, no significant difference occurred in MAT, HR and O2 SAT; PetCO2 and T presented significant differences. Conclusions: The bicaval cuffed venous cannula showed efficient drainage of both venae cavae with appropriate hemodynamic parameters during right bypass allowing access to the pulmonary valve.
Keywords: Pulmonary valve; Pulmonary valve stenosis; Extracorporeal circulation, methods; Surgical procedures minimally invasive
REVIEW ARTICLE
Quality control in cardiovascular surgery: a new paradigm
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
The objective is to write a literature review of the relevant information related to quality control in cardiovascular surgery. The authors have studied several parameters to allow quality control in cardiovascular surgery: 1. Construction of a database as complete as possible to the similar ones of the Society of Thoracic Surgeons and the European Association for Cardio-thoracic Surgery; 2. To create a surgical risk model like the Euroscore; 3. To make an analysis of the different reasons for a poor surgical outcomes and try to correct them; 4. To study the human factor as an important element to the surgical outcome and discuss methods to avoid erros in an action similar to the ones used in aviation. Enabling a tight control of quality in cardiovascular surgery it is possible to obtain a major improvement in surgical outcomes.
Keywords: Quality control; Cardiac surgical procedures; Database
Peculiarities of ischemic heart disease treatment in the elderly
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Considering that the world's population average age is increasing and the proportions of those over the age of 80, the fastest growing population worldwide, new approaches to health care and treatment will be necessary. Due to the development of new drugs and by means of transluminal coronary angioplasty or coronary artery bypass graft, many elderly patients had their lives prolonged and their quality of life improved. We carried out a bibliography review to search for evidence to support the best treatment choice according to the clinical manifestation of the patient.
Keywords: Myocardial revascularization; Angioplasty, transluminal, percutaneous coronary; Aged
EXPERIENCE THE OF SERVICE
Risk factors for the development of acute renal failure following on-pump coronary artery bypass grafting
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Objectives: To evaluate incidence, mortality, and risk factors related to the development of acute renal failure (ARF) after on-pump coronary artery bypass grafting (CABG), between January 2002 and November 2004. Methods: Seventy four patients who underwent on-pump CABG were analyzed retrospectively and distributed into two groups according to the development of ARF. Bivariate and multivariate analyses were performed to analyze. P £ 0.05 was considered statistically significant. Results: During the period analyzed, 18 patients (24.32%) developed acute renal failure (ARF); 1 patient (1.35%), who required dialysis, died. Associated risk factors identified in-between the development of ARF was: the postoperative use of inotropic or vasoconstrictor drugs (p=0.048) and body mass index greater than 25 (p=0.004). The CPB time did not determine the ARF increase (p=0.0668). Conclusion: The CPB time was not associated with an increased of ARF following on-pump CABG.
Keywords: Myocardial revascularization; Renal insufficiency, acute; Extracorporeal Circulation
CASE REPORT
Vídeo-assisted minimally invasive mitral valve replacement
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
The use of minimally invasive technics in cardiac surgery has become widely discussed, aiming improvements not only in the aesthetics aspects but also better functional results. In this report, we present a case of a patient with severe mitral stenosis that underwent succesful video-assisted minimally invasive mitral valve replacement.
Keywords: Mitral valve, surgery; Minimally invasive surgical procedures, methods; Video assisted thoracic surgery
New surgical strategy for acute type A aortic dissection: hybrid procedure
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
The new surgical strategy to treat patients with acute type A aortic dissection, the hybrid procedure with an uncovered aortic stent, allows surgeons to treat the aortic arch and the proximal descending aorta, besides the ascending segment, without extension of cerebral or systemic ischemia.
Keywords: Aneurysm, dissecting, surgery; Aorta, surgery; Stents
Heart valve replacement during pregnancy
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
We describe a woman with gestational age of 20 weeks, who was submitted to a complex procedure. She underwent replacement of the biological mitral and aortic valve, both by biological prosthesis, valvuloplasty of the tricuspid valve, as well as thrombectomy of the left atrium. Extracorporeal circulation (ECC) was used during 105 minutes. The patient was discharged from hospital in good health conditions and the newborn remained in the Neonatal Intensive Care Unit (NICU) in a stable state. This is a complex procedure with a high maternal and fetal mortality. Therefore, this is an important case regarding valve abnormalities treatment during pregnancy.
Keywords: Cardiac surgical procedures; Pregnancy; Heart valve prosthesis; Mitral valve, surgery; Aortic valve, surgery
Aortic coarctation in the adult: regarding a case and extra-anatomic bypass approaches
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
The authors describe the operative technique approach and its post-operative course used in an adult patient with coarctation of aorta, in which it was not possible to perform the traditional correction with an end-to-end anastomosis with graft interposition. During the surgery it was necessary to make an extra-anatomic bypass: ascending-descending aorta with an enlarged left posterior-lateral thoracotomy approach. The authors also make a short review of several possible approaches used for extra-anatomic bypass as well as its advantages and drawbacks.
Keywords: Heart defects, congenital; Aortic coarctation, surgery; Aorta, surgery
Myocardial revascularization in anomalous origin of the right coronary artery: case report
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
A 21-year-old man with angina-like chest pain and syncope related to ischemic ECG changes due to an anomalous origin of the right coronary artery. The patient was submitted to surgical correction with myocardial revascularization with internal thoracic artery. A literature review of this rare congenital heart disease is presented.
Keywords: Coronary vessel anomalies; Sinus of Valsalva; Coronary disease
PRIOR NOTICE
Pre and post-pulmonary thromboendarterectomies campnographic variables
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
In these case report, the results of late dead space fraction (fDlate), end-tidal alveolar dead space fraction (AVDSf), arterial-alveolar gradient CO2 [P(a-et)CO2], and slope phase 3 of spirogram of two patients who underwent thromboendarterectomy for pulmonary embolism (PE) are shown. PE was diagnosed by pulmonary scintigraphy, helical tomography, and pulmonary angiography. The calculation of fDlate, AVDSf and P(a-et)CO2 was based on volumetric capnography associated with arterial blood gas analysis. The pre-operative fDlate of the first patient was 0.16 (cutoff 0.12) and AVDSf was 0.30 (cutoff 0.15). However, the fDlate of the second patient was false-negative (0.01) but, the AVDSf was positive (0.28). Postoperative fDlate of the first patient was -0.04 and AVDSf was 0.16; for the second patient, the values were 0.07 and 0.28, respectively. The association of these capnographic variables with image exams reinforces the importance of this noninvasive diagnosis method.
Keywords: Pulmonary embolism; Pulmonary gas exchange; Capnography
CLINICAL-SURGICAL CORRELATION
Partial anomalous pulmonary venous connection into the right atrium with absence of interatrial communication
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
Interatrial communication and hypothyroidism in patient with Down Syndrome
Braz J Cardiovasc Surg 22;
Publish in: 8/2/2025
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