Adilson Scorzoni Filho

Risk factors for acute renal failure after heart surgery

OBJECTIVE The aim of the present study was to identify risk factors for acute renal failure in patients with normal levels of serum creatinine who had undergone coronary artery bypass graft (CABG) surgery and/or valve surgery. METHODS Data from a cohort of 769 patients were assessed using bivariate analyses and binary logistic regression modeling. RESULTS Three hundred eighty one patients underwent CABG, 339 valve surgery and 49 had undergone both simultaneously. Forty six percent of the patients were female and the mean age was 57 +/- 14 years (13 to 89 years). Seventy eight (10%) patients presented renal dysfunction postoperatively, of these 23% needed hemodialysis (2.4% of all patients). The mortality for the whole cohort was 10%. The overall mortality for patients experiencing postoperative renal dysfunction was 40% (versus 7%, P < 0.001), 29% for those who did not need dialysis and 67% for those who needed dialysis (P = 0.004). The independent risk factors found were: age (P < 0.000, OR: 1.056), congestive heart failure (P = 0.091, OR: 2.238), COPD (P = 0.003, OR: 4.111), endocarditis (P = 0.001, OR: 12.140), myocardial infarction < 30 days (P = 0.015, OR: 4.205), valve surgery (P = 0.016, OR: 2.137), cardiopulmonary bypass time > 120 min (P = 0.001, OR: 7.040), peripheral arterial vascular disease (P = 0.107, 2.296). CONCLUSION Renal dysfunction was the most frequent postoperative organ dysfunction in patients undergone CABG and/or valve surgery and age, congestive heart failure, COPD, endocarditis, myocardial infarction < 30 days, valve surgery, cardiopulmonary bypass time >120 min, and peripheral arterial vascular disease were the risk factors independently associated with acute renal failure (ARF).

Retrograde autologous priming in cardiopulmonary bypass in adult patients: effects on blood transfusion and hemodilution

Introduction: Retrograde autologous priming (RAP) is a cardiopulmonary bypass (CPB) method, at low cost. Previous studies have shown that this method reduces hemodilution and blood transfusions needs through increased intraoperative hematocrit. Objective: To evaluate RAP method, in r elation to standard CPB (crystalloid priming), in adult patients. Methods: Sixty-two patients were randomly allocated to two groups: 1) Group RAP (n = 27) of patients operated using the RAP and; 2) Control group of patients operated using CPB standard crystalloid method (n = 35). The RAP was performed by draining crystalloid prime from the arterial and venous lines, before CPB, into a collect recycling bag. The main parameters analyzed were: 1) CPB hemodynamic data; 2) Hematocrit and hemoglobin values; 3) The need for blood transfusions. Results: It was observed statistically significant fewer transfusions during surgery and reduced CPB hemodilution using RAP. The CPB hemodynamic values were similar , observing a tendency to use lower CPB flows in the RAP group patients. Conclusion: This investigation was designed to be a small-scale pilot study to evaluate the ef fects of RAP, which were demonstrated concerning the CPB hemodilution and blood transfusions.INTRODUCTION Retrograde autologous priming (RAP) is a cardiopulmonary bypass (CPB) method, at low cost. Previous studies have shown that this method reduces hemodilution and blood transfusions needs through increased intra-operative hematocrit. OBJECTIVE To evaluate RAP method, in relation to standard CPB (crystalloid priming), in adult patients. METHODS Sixty-two patients were randomly allocated to two groups: 1) Group RAP (n = 27) of patients operated using the RAP and; 2) Control group of patients operated using CPB standard crystalloid method (n = 35). The RAP was performed by draining crystalloid prime from the arterial and venous lines, before CPB, into a collect recycling bag. The main parameters analyzed were: 1) CPB hemodynamic data; 2) Hematocrit and hemoglobin values; 3) The need for blood transfusions. RESULTS It was observed statistically significant fewer transfusions during surgery and reduced CPB hemodilution using RAP. The CPB hemodynamic values were similar, observing a tendency to use lower CPB flows in the RAP group patients. CONCLUSION This investigation was designed to be a small-scale pilot study to evaluate the effects of RAP, which were demonstrated concerning the CPB hemodilution and blood transfusions.

Blood Cardioplegia with N-Acetylcysteine May Reduce Coronary Endothelial Activation and Myocardial Oxidative Stress

OBJECTIVES The aim of this prospective study was to compare the efficacy of intermittent antegrade blood cardioplegia with or without n-acetylcysteine (NAC) in reducing myocardial oxidative stress and coronary endothelial activation. METHODS Twenty patients undergoing elective isolated coronary artery bypass graft surgery were randomly assigned to receive intermittent antegrade blood cardioplegia (32 degrees C-34 degrees C) with (NAC group) or without (control group) 300 mg of NAC. For these 2 groups we compared clinical outcome, hemodynamic evolution, systemic plasmatic levels of troponin I, and plasma concentrations of malondialdehyde (MDA) and soluble vascular adhesion molecule 1 (sVCAM-1) from coronary sinus blood samples. RESULTS Patient demographic characteristics and operative and postoperative data findings in both groups were similar. There was no hospital mortality. Comparing the plasma levels of MDA 10 min after the aortic cross-clamping and of sVCAM-1 30 min after the aortic cross-clamping period with the levels obtained before the aortic clamping period, we observed increases of both markers, but the increase was significant only in the control group (P= .039 and P= .064 for MDA; P= .004 and P= .064 for sVCAM-1). In both groups there was a significant increase of the systemic serum levels of troponin I compared with the levels observed before cardiopulmonary bypass (P< .001), but the differences between the groups were not significant (P= .570). CONCLUSIONS Our investigation showed that NAC as an additive to blood cardioplegia in patients undergoing on-pump coronary artery bypass graft surgery may reduce oxidative stress and the resultant coronary endothelial activation.

Anomalous origin of the left coronary artery from the pulmonary artery in an adult with systemic collateral circulation to the left coronary artery

A case of anomalous origin of the left coronary artery from the pulmonary artery in an adult with collateral circulation between the left coronary artery and systemic extracardiac vessels is reported. After evaluating the surgical options, my colleagues and I conclude that ligation of the left coronary artery and a left internal thoracic artery graft to the left anterior descending coronary artery is the preferable option for treating such patients.

Isolated mitral and aortic valve replacement with the St. Jude Medical valve: a midterm follow-up

BACKGROUND In our country, the biological valvular prostheses predominate, considering the difficulties related to anticoagulation, even in young patients, in spite of the need for repeated operations due to the degeneration of the bioprostheses. OBJECTIVES To report our consecutive series of recipients of isolated St Jude Medical mechanical valve prosthesis in the mitral (MVR) or aortic (AVR) position. METHODS Data from patients operated between January 1995 and December 2003 were revised in order to determine patient survival and prosthesis-related events up to December 2006. RESULTS One hundred sixty eight patients had MVR and 117 had AVR. In the MVR cohort, the mean age was 45 years, 75% were 55 years old or younger, and 65% were females. In the ARV cohort, the mean age was 45 years, 66% were 55 years old or younger and 69% were males. Operative mortality for AVR and MVR was 7% and 7.5%, respectively. Freedom from late mortality was 81.8% at 10 years for MVR and 83% for AVR (p=0.752). Freedom from valve-related death at 10 years for the MVR cohort and AVR was 85.6% and 88.7%, respectively (p=0.698). In the MVR cohort, the freedom from reoperation was 97% and 99% in the AVR cohort (p=0.335). Freedom from thromboembolic events was 82% in the MVR cohort and 98% in the AVR cohort (p=0.049). Freedom from bleeding was 71% in the MVR cohort and 86% n the AVR cohort (0.579). Freedom from endocarditis was 98% in the MVR cohort and 99% in the AVR cohort (p=0.534). CONCLUSIONS This series of predominantly young adult patients undergoing isolated MVR and AVR with the St Jude Medical mechanical prosthesis confirms the good performance of this valve prosthesis in agreement with previous reports.FUNDAMENTO: Em nosso meio as proteses valvares biologicas predominam, considerando-se as dificuldades relacionadas a anticoagulacao, mesmo em pacientes jovens, a despeito da necessidade de repetidas operacoes devido a degeneracao das proteses biologicas. OBJETIVO: Apresentar a evolucao em medio prazo de pacientes submetidos a substituicao da valva mitral ou aortica por protese valvar mecânica St. Jude. METODOS: Foi analisada retrospectivamente a evolucao dos pacientes operados entre janeiro de 1995 e dezembro de 2003 e seguidos ate dezembro de 2006. RESULTADOS: Cento e sessenta e oito pacientes receberam protese valvar mitral e 117, aortica. A idade media de ambos os grupos foi de 45 anos. Entre os mitrais, 75% tinham ate 55 anos e 65% eram mulheres. Entre os aorticos, 66% tinham ate 55 anos e 69% eram homens. Considerando-se apenas mortes relacionadas as proteses valvares, a sobrevida foi de 85,6% para os mitrais e de 88,7% para os aorticos (p=0,698). Entre os mitrais, 97% estavam livres de reoperacao, e entre os aorticos 99% (p=0,335). Quanto aos eventos tromboembolicos, a porcentagem de pacientes livres foi de 82% entre os mitrais e de 98% entre os aorticos (p=0,049), e para os eventos hemorragicos foi de 71% e 86% respectivamente (0,579). Quanto a ocorrencia de endocardite, 98 % entre os mitrais e 99% entre os aorticos estavam livres ao final de 10 anos (p=0,534). CONCLUSAO: Nossa experiencia com proteses metalicas St. Jude em uma populacao predominantemente jovem confirma o bom desempenho desta protese, em acordo com outras experiencias publicadas.

ELECTRICAL STORM IN CHAGAS HEART DISEASE PATIENTS WITH IMPLANTABLE CARDIOVERTER DEFIBRILLATOR – CLINICAL PREDICTORS, OUTCOME AND ARRHYTHMIC CHARACTERISTICS: A PROSPECTIVE REGISTRY FROM A UNIVERSITY HOSPITAL

Background: Electrical storm (ES) is a common problem in Chagas cardiomyopathy (CC) patients harboring an implantable cardioverter defibrillator (ICD), but data on clinical predictors and outcomes is limited. In this study of CC patients with an ICD for secondary prevention of sudden cardiac death

Methylene Blue to Treat Protamine-induced Anaphylaxis Reactions. An Experimental Study in Pigs

OBJECTIVE: To examine if methylene blue (MB) can counteract or prevent protamine (P) cardiovascular effects. METHODS: The protocol included five heparinized pig groups: Group Sham -without any drug; Group MB - MB 3 mg/kg infusion; Group P - protamine; Group P/MB - MB after protamine; Group MB/P - MB before protamine. Nitric oxide levels were obtained by the nitric oxide/ozone chemiluminescence method, performed using the Nitric Oxide Analizer 280i (Sievers, Boulder, CO, USA). Malondialdehyde plasma levels were estimated using the thiobarbiturate technique. RESULTS: 1) Groups Sham and MB presented unchanged parameters; 2) Group P - a) Intravenous protamine infusion caused mean arterial pressure decrease and recovery trend after 25-30 minutes, b) Cardiac output decreased and remained stable until the end of protamine injection, and c) Sustained systemic vascular resistance increased until the end of protamine injection; 3) Methylene blue infusion after protamine (Group P/MB) - a) Marked mean arterial pressure decreased after protamine, but recovery after methylene blue injection, b) Cardiac output decreased after protamine infusion, recovering after methylene blue infusion, and c) Sustained systemic vascular resistance increased after protamine infusion and methylene blue injections; 4) Methylene blue infusion before protamine (Group MB/P) - a) Mean arterial pressure decrease was less severe with rapid recovery, b) After methylene blue, there was a progressive cardiac output increase up to protamine injection, when cardiac output decreased, and c) Sustained systemic vascular resistance decreased after protamine, followed by immediate Sustained systemic vascular resistance increase; 5) Plasma nitrite/nitrate and malondialdehyde values did not differ among the experimental groups. CONCLUSION: Reviewing these experimental results and our clinical experience, we suggest methylene blue safely prevents and treats hemodynamic protamine complications, from the endothelium function point of view.

Substituição valvar isolada com próteses metálicas St. Jude Medical em posição aórtica ou mitral: seguimento de médio prazo

BACKGROUND In our country, the biological valvular prostheses predominate, considering the difficulties related to anticoagulation, even in young patients, in spite of the need for repeated operations due to the degeneration of the bioprostheses. OBJECTIVES To report our consecutive series of recipients of isolated St Jude Medical mechanical valve prosthesis in the mitral (MVR) or aortic (AVR) position. METHODS Data from patients operated between January 1995 and December 2003 were revised in order to determine patient survival and prosthesis-related events up to December 2006. RESULTS One hundred sixty eight patients had MVR and 117 had AVR. In the MVR cohort, the mean age was 45 years, 75% were 55 years old or younger, and 65% were females. In the ARV cohort, the mean age was 45 years, 66% were 55 years old or younger and 69% were males. Operative mortality for AVR and MVR was 7% and 7.5%, respectively. Freedom from late mortality was 81.8% at 10 years for MVR and 83% for AVR (p=0.752). Freedom from valve-related death at 10 years for the MVR cohort and AVR was 85.6% and 88.7%, respectively (p=0.698). In the MVR cohort, the freedom from reoperation was 97% and 99% in the AVR cohort (p=0.335). Freedom from thromboembolic events was 82% in the MVR cohort and 98% in the AVR cohort (p=0.049). Freedom from bleeding was 71% in the MVR cohort and 86% n the AVR cohort (0.579). Freedom from endocarditis was 98% in the MVR cohort and 99% in the AVR cohort (p=0.534). CONCLUSIONS This series of predominantly young adult patients undergoing isolated MVR and AVR with the St Jude Medical mechanical prosthesis confirms the good performance of this valve prosthesis in agreement with previous reports.FUNDAMENTO: Em nosso meio as proteses valvares biologicas predominam, considerando-se as dificuldades relacionadas a anticoagulacao, mesmo em pacientes jovens, a despeito da necessidade de repetidas operacoes devido a degeneracao das proteses biologicas. OBJETIVO: Apresentar a evolucao em medio prazo de pacientes submetidos a substituicao da valva mitral ou aortica por protese valvar mecânica St. Jude. METODOS: Foi analisada retrospectivamente a evolucao dos pacientes operados entre janeiro de 1995 e dezembro de 2003 e seguidos ate dezembro de 2006. RESULTADOS: Cento e sessenta e oito pacientes receberam protese valvar mitral e 117, aortica. A idade media de ambos os grupos foi de 45 anos. Entre os mitrais, 75% tinham ate 55 anos e 65% eram mulheres. Entre os aorticos, 66% tinham ate 55 anos e 69% eram homens. Considerando-se apenas mortes relacionadas as proteses valvares, a sobrevida foi de 85,6% para os mitrais e de 88,7% para os aorticos (p=0,698). Entre os mitrais, 97% estavam livres de reoperacao, e entre os aorticos 99% (p=0,335). Quanto aos eventos tromboembolicos, a porcentagem de pacientes livres foi de 82% entre os mitrais e de 98% entre os aorticos (p=0,049), e para os eventos hemorragicos foi de 71% e 86% respectivamente (0,579). Quanto a ocorrencia de endocardite, 98 % entre os mitrais e 99% entre os aorticos estavam livres ao final de 10 anos (p=0,534). CONCLUSAO: Nossa experiencia com proteses metalicas St. Jude em uma populacao predominantemente jovem confirma o bom desempenho desta protese, em acordo com outras experiencias publicadas.

Sustitución valvular aislada con prótesis metálicas St. Jude Medical en posición aórtica o mitral: seguimiento de medio plazo

BACKGROUND In our country, the biological valvular prostheses predominate, considering the difficulties related to anticoagulation, even in young patients, in spite of the need for repeated operations due to the degeneration of the bioprostheses. OBJECTIVES To report our consecutive series of recipients of isolated St Jude Medical mechanical valve prosthesis in the mitral (MVR) or aortic (AVR) position. METHODS Data from patients operated between January 1995 and December 2003 were revised in order to determine patient survival and prosthesis-related events up to December 2006. RESULTS One hundred sixty eight patients had MVR and 117 had AVR. In the MVR cohort, the mean age was 45 years, 75% were 55 years old or younger, and 65% were females. In the ARV cohort, the mean age was 45 years, 66% were 55 years old or younger and 69% were males. Operative mortality for AVR and MVR was 7% and 7.5%, respectively. Freedom from late mortality was 81.8% at 10 years for MVR and 83% for AVR (p=0.752). Freedom from valve-related death at 10 years for the MVR cohort and AVR was 85.6% and 88.7%, respectively (p=0.698). In the MVR cohort, the freedom from reoperation was 97% and 99% in the AVR cohort (p=0.335). Freedom from thromboembolic events was 82% in the MVR cohort and 98% in the AVR cohort (p=0.049). Freedom from bleeding was 71% in the MVR cohort and 86% n the AVR cohort (0.579). Freedom from endocarditis was 98% in the MVR cohort and 99% in the AVR cohort (p=0.534). CONCLUSIONS This series of predominantly young adult patients undergoing isolated MVR and AVR with the St Jude Medical mechanical prosthesis confirms the good performance of this valve prosthesis in agreement with previous reports.FUNDAMENTO: Em nosso meio as proteses valvares biologicas predominam, considerando-se as dificuldades relacionadas a anticoagulacao, mesmo em pacientes jovens, a despeito da necessidade de repetidas operacoes devido a degeneracao das proteses biologicas. OBJETIVO: Apresentar a evolucao em medio prazo de pacientes submetidos a substituicao da valva mitral ou aortica por protese valvar mecânica St. Jude. METODOS: Foi analisada retrospectivamente a evolucao dos pacientes operados entre janeiro de 1995 e dezembro de 2003 e seguidos ate dezembro de 2006. RESULTADOS: Cento e sessenta e oito pacientes receberam protese valvar mitral e 117, aortica. A idade media de ambos os grupos foi de 45 anos. Entre os mitrais, 75% tinham ate 55 anos e 65% eram mulheres. Entre os aorticos, 66% tinham ate 55 anos e 69% eram homens. Considerando-se apenas mortes relacionadas as proteses valvares, a sobrevida foi de 85,6% para os mitrais e de 88,7% para os aorticos (p=0,698). Entre os mitrais, 97% estavam livres de reoperacao, e entre os aorticos 99% (p=0,335). Quanto aos eventos tromboembolicos, a porcentagem de pacientes livres foi de 82% entre os mitrais e de 98% entre os aorticos (p=0,049), e para os eventos hemorragicos foi de 71% e 86% respectivamente (0,579). Quanto a ocorrencia de endocardite, 98 % entre os mitrais e 99% entre os aorticos estavam livres ao final de 10 anos (p=0,534). CONCLUSAO: Nossa experiencia com proteses metalicas St. Jude em uma populacao predominantemente jovem confirma o bom desempenho desta protese, em acordo com outras experiencias publicadas.

A new experimental model of chemical ablation of the Intrinsic Cardiac Nervous System reduces heart contractility and causes a type of dilated cardiopathy in rats

OBJECTIVE: The function of Intrinsic Cardiac Nervous System is largely unknown, as is its role in heart disease. In the digestive system, a topic aplication of Benzalkonium chloride (BC) leads to intrinsic denervation of the viscera. Thus, our aim was to obtain an experimental model of cardiac intrinsic denervation by the application of BC. METHOD: Thirty male Wistar rats received intrapericardic injection of CB 0.3% (CB animals) and thirty similar animals received saline (C animals). After 15 days the animals were divided in three groups, with 10 CB-treated and 10 saline-treated animals each. Group I was submitted to radiological and morphologic studies. The cardiac shadow area (CSA) and cardiothoracic index were calculated in roentgenograms with a semi-automatic image analysis system (MINI-MOP). The day after the animals were weighted and sacrificed with heart, liver and lung collected for histopathologic analysis. The animals of group II were submitted to a hemodynamic study. Measurements of blood pressure, heart rate and cardiac output were performed using the Cardiomax II termodilution system and a Termistor sensor. With the animals of the group III, the integrity of extrinsic parassympatic cardiac innervartion was examined by measuring heart rate response to electrical stimulation of the right vagus. Electrical activity was assessed by ECG. RESULTS: CB animals presented increases in cardiothoracic index, CSA, body and liver weight. In these animals the histopathologic analysis showed passive chronic congestion and reduction of the number of atrial neurons. In the hemodynamic study, total peripheral resistance and heart rate were similar in both groups, but blood pressure and cardiac index were reduced in the CB group. The vagal stimulation and ECG were similar in both groups. CONCLUSION: The Intrinsic Cardiac Nervous System denervation caused dilated cardiopathy in rats with left and right heart failure. The etiology of some dilated cardiopathies in human is largely unknown. Thisunpublished experimental model should provide future studies with the objective of elucidating the relationship between neuronal injures and heart disease.