Alexandre Motta de Menezes

Pulmonary Valve Replacement After Operative Repair of Tetralogy of Fallot: Meta-Analysis and Meta-Regression of 3,118 Patients From 48 Studies

Because the real benefit of pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot who develop pulmonary insufficiency remains unclear, it is necessary to analyze the evidence published around the world. We performed a systematic review of studies that reported data about the effect of PVR in patients with repaired tetralogy of Fallot that developed pulmonary insufficiency, until December 2012. The variables chosen to represent the benefit were both right ventricular (RV) and left ventricular measures, QRS duration, and functional class. The principal summary measures were difference in means with 95% confidence interval and p values (considered statistically significant when p < 0.05). The differences in means were combined across studies with the weighted DerSimonian-Laird random effects model. Meta-analysis, sensitivity analysis, and meta-regression were completed with the software Comprehensive Meta-Analysis (version 2, Biostat, Inc., Englewood, New Jersey). Forty-eight studies involving 3,118 patients met the eligibility criteria. The pooled 30-day mortality was 0.87% (47 studies; 27 of 3,100 patients); the pooled 5-year mortality was 2.2% (24 studies; 49 of 2,231 patients); the pooled 5-year re-PVR was 4.9% (15 studies; 88 of 1,798 patients). The results of this meta-analysis demonstrate that after PVR: 1) the RV experiences improvement of its volumes and function; 2) the left ventricle experiences improvement of its function; 3) QRS duration decreases; 4) symptoms improve; 5) pre-operative RV geometry modulates the effect of PVR; and 6) there is important heterogeneity of the effects among the studies, and few publication biases. In conclusion, PVR seems to be a positive approach in the analyzed scenario.

Revascularização miocárdica em pacientes octogenários: estudo retrospectivo e comparativo entre pacientes operados com e sem circulação extracorpórea

OBJECTIVE: The purpose of the present study is to compare and analyze the benefits of this operation with and without cardiopulmonary bypass in octogenarian patients. METHOD: Retrospective data of the patients aged eighty years or more from December 1995 to December 2003 were analyzed. During this period 73 patients were submitted to coronary artery bypass grafting (CABG), 26 (35.6%) on-pump and 47 (64.4%) off-pump. A comparison was made of the demographic data, preoperative risks, concurrent morbid conditions, types of angina, postoperative complications and surgical outcomes between the on-pump and off-pump groups. The Student t-test was used to compare the groups and the level of significance was set at p-value < 0.05. RESULTS: Both groups showed a high preoperative risk, although the off-pump group presented less surgical mortality (11.5% vs 2.1%, p < 0.05). No strokes were observed in the patients operated on off-pump (11.5% vs 0.0%, p < 0.005). Atrial fibrillation (AF) in the immediate postoperative period was present less often in the off-pump group (30.8% vs 12.8%, p < 0.005). The postoperative mechanical ventilation time and the presence of respiratory failure were less in the off-pump group (p < 0.005). The presence of acute renal insufficiency (ARI) was 19.2% in the on-pump group and 0% in the off-pump group (p < 0.05). There was less need for transfusion of blood or blood derivatives in the off-pump group (69.2% vs 31.9%, p < 0.005). The mean sojourn in the intensive care unit (ICU) was shorter in the off-pump group (p < 0.05). The percentage of patients with no postoperative complications was higher in the off-pump group than in the on-pump group (89.4% vs 61.5%, p <0.001). CONCLUSIONS: The present study suggests that patients aged eighty years and over benefit when submitted to off-pump CABG and that this procedure is associated with low rates of postoperative complications such as stroke, AF, ARI and respiratory insufficiency, and with less time in the ICU, a shorter hospital sojourn, less use of blood derivatives and lower mortality. In octogenarian patients off-pump CABG surgery is a safe and effective technique, and may be the operation of choice when correctly indicated.

Tratamento da fibrilação atrial com ablação por ultrassom, durante correção cirúrgica de doença valvar cardíaca

Objective: This study aims to evaluate the surgical treatment of atrial fibrillation with ultrasound ablation concomitant to mitral surgery in PROCAPE’s patients with permanent atrial fibrillation. Methods: From March 2008 through January 2009 a prospective study was performed at the Pernambuco Cardiology Emergency Facility on 44 consecutive patients with a permanent atrial fibrillation and concomitant cardiac valvular surgery indication, from March 2008 through January 2009 at Pernambuco Cardiology Emergency Facility Twenty two patients underwent right atrium epicardial ultrasonic ablation and left atrium endocardial ultrasonic ablation performed concomitant with the valve procedure. The other 22 patients, the concurrent controls were submitted to valve procedure without ultrasonic ablation. Patients with serious diseases such as coronary and others were excluded of the research. Results: It was observed 90% restoration to sinus rhythm immediately after surgery in patients submitted to treatment of atrial fibrillation with ultrasound ablation simultaneous a mitral surgery. The evolution in late post operation showed that the maintenance of sinus rhythm drops although it was still 27% higher in the group which received ablation compared with the control group. 86.40% of the patients who received ablation had improved in functional class; they also have fewer complications than patients in the control group. Conclusion: The results showed that the patients who received treatment for atrial fibrillation simultaneously with valvar surgery had advantages related to the control group.

Aspectos técnicos na esqueletização da artéria torácica interna com bisturi ultra-sônico

Resumo Objetivo: Descrever a tecnica e avaliar os resultados imediatos da utilizacao do bisturi ultra-sonico nas esqueletizacoes da arteria toracica interna, na cirurgia de revascularizacao do miocardio. Metodo: Foram operados com essa tecnica 188 pacientes submetidos a cirurgia de revascularizacao do miocardio, no periodo de janeiro de 2000 a outubro de 2006. Setenta e um (37,8%) pacientes eram do sexo feminino. A idade variou de 28 a 81 anos. A tecnica utilizada na dissecacao consistiu em expor toda arteria toracica interna, abrindo-se a fascia endotoracica com tesoura o mais proximo possivel da adventicia da arteria. Com o bisturi ultra-sonico e feita a seccao dos ramos colaterais e sua respectiva hemostasia, dispensando-se o uso de “clips” metalicos na arteria toracica interna. Resultados: As arterias toracicas internas esqueletizadas

Ventricular–arterial and aortic mechanical valve dehiscence evaluated by advanced post-processing techniques in multislice computed tomography

Figure 1: (A) Volume rendering reconstruction (VRr) showing the pseudoaneurysm (pAn). (B) VRr shows ventricular–arterial and prosthetic valve dehiscence. Muscular tissue (in red) fixed in aortic prosthesis. (C–F) Image sequence. 180 rotation from inside aorta showing the pAn involving the entire anterior half of the aortic annulus. A: anterior; AA: ascending aorta; AL: anterior left; ARI: anterior right inferior; LA: left atrium; LS: left superior; LV: left ventricle; LVOT: left ventricular outflow tract; P: posterior; PLS: posterior left superior; RI: right inferior.

Experiência clínica inicial na desmineralização química da valva aórtica: potencial aplicação como procedimento minimamente invasivo

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 cm 2 , with a mean of 1.1 cm 2 . The following comorbidities 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.