Carlos Abreu Filho

Effectiveness of the Maze Procedure Using Cooled-Tip Radiofrequency Ablation in Patients With Permanent Atrial Fibrillation and Rheumatic Mitral Valve Disease

Background—Although the Cox-Maze III procedure is effective for treating permanent atrial fibrillation (AF), its high complexity limits its use. The Saline-Irrigated Cooled-tip Radiofrequency Ablation (SICTRA) System is an alternative source of energy used to ablate AF. The aim of this study was to evaluate the effectiveness of the SICTRA for the treatment of permanent AF in patients with rheumatic mitral valve (MV) disease. Methods and Results—Between February 2002 and April 2003, 70 patients with permanent AF and rheumatic MV disease were randomly assigned to undergo a modified Maze III procedure using SICTRA associated with MV surgery (group A) or MV surgery alone (group B). Groups A and B were similar in terms of baseline characteristics. The in-hospital mortality rate was 2.3% (1 death) in group A versus 0% (no deaths) in group B (P>0.99). The additional time required for the left-sided radiofrequency ablation in group A was 14.2±5.1 minutes and for right-sided ablation was 12.3±4.2 minutes. The mean postoperative follow-up periods were 13.8±3.4 and 11.5±7.3 months, respectively, in groups A and B. The overall mid-term survival rate was 95.1% in group A and 92.8% in group B (P>0.99). The cumulative rates of sinus rhythm were 79.4% in group A and 26.9% in group B (P=0.001). Doppler echocardiography documented biatrial transport function in 90.3% of group A patients in sinus rhythm. Conclusions—The SICTRA is effective for treating permanent AF associated with rheumatic MV disease.

Tratamento cirúrgico da coarctação do arco aórtico em adulto: avaliação clínica e angiográfica tardia da técnica extra-anatômica

OBJECTIVE: We analyzed late results of extra-anatomic aortic bypass technique with Dacron graft from the ascending aorta to the descending aorta for repair of aortic arch coarctation in adults. MATERIAL AND METHODS: From 1979 to 2000, a total of 15 adult patients, aged 18 years to 61 years (mean 30.8 ± 12.1 years) underwent extra-anatomic bypass graft for surgical repair of aortic arch coarctation. Operative exposure was median sternotomy with posterior pericardial approach in 13 (86.7%) patients and left thoracotomy in 2 (13.3%). Associated procedures were performed in 3 (20.0%) patient and there were 4 (26.7%) reoperations. The patients had clinical evaluation, echocardiographic and angiographic studies, the latter with magnetic resonance post-operative. Follow-up was 6.9 ± 6.7 years (range 30 days to 21 years). RESULTS: There was neither early or late mortality nor neurologic complications. There was no late complications with the Dacron graft neither reoperations. All patients were asymptomatic with patent Dacron graft confirmed by echocardiography. Five (33.3%) patients had mild hypertension. The magnetic resonance was done in 11 (73.3%) patients and the Dacron graft were long-term patent in all. CONCLUSIONS: The extra-anatomic bypass aortic technique with Dacron graft from the ascending aorta to the descending aorta for repair of aortic arch coarctation in adults is a safe operation with low morbidity and mortality. The good long-term results proved to be safe and less invasive technique to repair the aortic arch coarctation or recoarctation in adults.

Tratamento cirúrgico da rotura de parede livre do ventrículo esquerdo após infarto agudo do miocárdio

MATERIAL AND METHODS: Between January 1983 and May 1999, 12.405 patients were treated by the surgical team of the Heart Institute (InCor) with the diagnosis of acute myocardial infarction (AMI). From these patients, 127 (1.02%) had left ventricular free wall rupture as an ischemic complication of the myocardial infarction. The cardiac rupture was acute in 98 patients (77.1%) and sub-acute in 29 (22.9%). RESULTS: Twenty-four patients were operated on, 5 on acute rupture with 80% of hospital mortality and 19 on sub-acute rupture with 15.8% of hospital mortality. The post-operative overall survival including both groups was 70.8%. CONCLUSION: The conclusion was drawn that left ventricular free wall rupture is a severe complication of acute myocardial infarction that needs an immediate action. In acute ruptures, most patients develop hemodynamic deterioration without enough time to try to proceed any surgical correction. The sub-acute cases can be detected and monitored through periodic ecocardiographic exams after the AMI. In these cases the early surgical intervention, many times without using extra-corporeal circulation, has been increasing the chances of survival of the majority of these patients.

Tratamento cirúrgico da fibrilação atrial

INTRODUCTIONAtrial fibrillation (AF) is a sustained tachyarrhythmiacommonly seen in the clinical practice. It can present withhigh morbid-mortality rates due to hemodynamicinvolvement, the cardiomyopathy originating from thetachycardia and to the occurrence of thromboembolicphenomena [1].The association between AF and structural heartdiseases is common among patients with mitral valve diseaseindicated for surgery, with from 40% to 60% of the casespresenting with AF during the surgery [2].It is fundamental that the electrophysiological bases ofthis arrhythmia are well understood to comprehend itssymptoms and to establish the correct treatment. James Cox[3] proposed a new classification of the symptoms of thedisease. The classification is based on the constancy ofarrhythmia or not. Thus, AF can appear in two principal

Transplante cardíaco com anastomose bicaval e anuloplastia tricúspide profilática no enxerto

OBJECTIVE This study aims to evaluate the effects of prophylactic heart donor tricuspid annuloplasty in patients after heart transplantation with bicaval anastomosis. METHODS From 2002 to 2005, 20 patients undergoing heart transplantation with bicaval anastomosis and with a survival rate over 6 months were deliberately selected. Patients were divided into two groups: Group I - 10 patients who underwent prophylactic heart donor tricuspid annuloplasty by the De Vega technique; and Group II - 10 patients did not undergo annuloplasty. In both groups, presurgical clinical characteristics were the same. The tricuspid regurgitation degree was evaluated by transthoracic Doppler echocardiography and it was qualified from 0 to 3 (0=absent, 1=mild, 2=moderated, 3=severe). Myocardial performance was evaluated by ventricular ejection fraction and invasive hemodynamic study performed during routine endomyocardial biopsies. RESULTS Mean clinical follow-up was 14.6+/-4.3 (6 and 16) months. There was only one death in group II. It was not related to annuloplasty. Mean degree of tricuspid regurgitation in Group I was 0.4+/-0.6 and in Group II was 1.6+/-0.8 (p < 0.05). There was a statistically significant difference between both groups in right atrium pressure, which was higher in Group II. CONCLUSIONS In view of the limitations of the study, the prophylactic tricuspid annuloplasty in heart donor reduced the degree of valvar regurgitation in the medium term after heart transplantation with bicaval anastomosis, in spite of not interfering with the allograft hemodynamic performance in the period under consideration.

Análise direcional do fluxo sangüíneo miocárdico após revascularização transmiocárdica com laser de CO2: estudo através da ressonância magnética com imagens de gradiente ultra-rápido

OBJECTIVE: The aim of this work is to analyze the myocardial flow direction of patients submitted to transmyocardial laser revascularization (TMLR), using the first - pass magnetic resonance imaging (MRI). METHODS: Ten patients submitted to TMLR with CO2 laser (potency of 800 W) were studied with magnetic resonance imaging (MRI) of fast gradient ¾ eco- EPI hybrid sequence used in a 1.5 TGE CV/i scanner (Sigma CVMR - General Eletric ¾ Milwaukee-USA) to evaluate myocardial perfusion. Bolus of Gadolinium ¾ DTPA (0.1mmol/Kg) was injected by a peripherical intra-venous line at 5 ml/sec at rest and during peak stress of dypiridamole. The distribution of the contrast through the myocardial regions was analyzed. RESULTS: After a mean follow-up of 14.7 months, 6 (60%) patients showed significant myocardial ischemia at least in one of the left ventricular walls. The blood flow was inverted, from subendocardium to subepicardium, just in 1 (10%) patient. CONCLUSIONS: First-pass MRI is an efficient method to show the direction of the myocardial blood flow. In one of the studied patients, the inverted myocardial blood flow (from the endocardium to the epicardium), suggested the patency of the channels created by TMLR.

Rotura cardíaca após infarto agudo do miocárdio (IAM): uma complicação passível de correção cirúrgica?

PURPOSE: Analise the incidence of cardiac rupture within the patients received in our hospital with the diagnosis of AMI in a period of 10 years and try to identify cases when the cardiac rupture can be submitted to a successful approach. METHODS: 9162 patients were received by INCOR with the diagnosis of AMI in the period from January 1983 to december 1993. From these patients 1.05% had cardiac rupture as an ischaemic complication of the myocardium infarction. The average of age was 69.5 years and showing a predominance of white people (93.75%) and female sex (55.3%). Data from patients include clinical history, complementary investigations, drugs used in the treatment and surgical or anatomopathological findings. The cardiac ruptures were classified as acute and sub-acute, according to literature. RESULTS: We found 72 cases of acute myocardial rupture with a mortality rate of 98.6% and 24 cases of sub-acute myocardial rupture with 41.6% of deaths. Four patients were operated on acute rupture and 15 patients were operated on subacute rupture. The post surgery survival was 78.9%. The patients who had a successful thrombolitic therapy, 76.4% died while the others who received routine therapy, 86.1 % passed away. Once the thrombolitic therapy was given until an hour the mortality was 33.3%; from 3 to 6 hours it was 60% and after 6 hours it was 100%. When it turns to the lenght of time of the onset of the cardiac rupture after I AM treatment, it happend after 5 days just in 5.9% of the patients who received trombolitic agents but in 40.5% of the patients with the routine therapy. CONCLUSIONS: We recognized the importance and the necessity of a immediate action for the patient with cardiac rupture even in sub-acute cases when 30% of the patients with an echographic probability of having a progression of the transmural ischaemic area die. In acute ruptures the situation is dramatic and survical depends on logistic factors. In sub-acute conditions however, new sutureless techniques without using extra-corporeal circulation are now available and they will have a huge importance in the treatment of this extremely serious complication of AMI.

Dissecção da aorta após transplante cardíaco ortotópico: relato de 2 casos

From March 1985 to September 1999, 214 patients were submitted to cardiac transplantation in consequence of refractory cardiomyopathy to medical therapy. Two patients (0.9%) aged 33 and 49 years, had developed thoracic aortic dissection as fatal late complication after the orthotopic cardiac transplantation. In the first patient suffering from idiopathic cardiomyopathy this complication occurred in the 93rd month of evolution, while in the second, with ischemic cardiomyopathy, the occurrence was early, in the 11th month. Systemic arterial hypertension and a smoking history had been showed as factors of risk in both cases. The clinical manifestations of the dissection had occurred of acute form and catastrophic that had prevented any surgical management. Greater attention of this rare complication can affect its bad natural evolution.

Ação inibitória da Interleucina - 1ß sobre a proliferação de células musculares lisas cultivadas a partir de veias safenas humanas

Objective: The saphenous vein (SV) is an effective graft used in coronary artery bypass grafting, although, its patency can be affected by the development of atherosclerosis. We have developed an experimental study demonstrating the development of apoptosis in SV grafts cultivated under arterial hemodynamic conditions (AHC). The interleukin-1â expression was also elevated in these veins slices. The aim of this study is to evaluate the influence of interleukin-1â in the precocious proliferation of the cultures of primary smooth muscle cells (PSMC). Methods: PSMC of 6 different human SVs were cultivated in Dulbecco’s Modified Eagle Medium associated with bovine fetal serum. The control group was not treated with Interleukin-1â but treated groups were. Cellular proliferation (CP) was evaluated by measuring triple thymidine (3H), incorporated into the proliferated cells. Results: The treatment with Interleukin-1â decreases cellular proliferation. The control group presented 100 ± 4.5% of CP. In the treated groups the quantity of Interleukin1 administered and the respective levels of CP observed were: 0.1 ng/mL – 112 ± 0.7%; 1 ng/mL – 83 ± 4.7%; 10 ng/mL – 69.1 ± 3.8% and 100 ng/mL – 76.3 ± 10.9% (p < 0.01). Conclusion: We can conclude that the administration of increasing quantities of Interleukin-1â inhibits the proliferation of PSMC cultivated from human SVs. This suggests that the precocious process of apoptosis observed in the SV grafts exposed to AHC can be related to the action of this Interleukin.

Enxerto venoso intercoronariano na revascularização de artéria coronária comprometida por dissecção de aorta tipo I

A thirty nine-year-old patient presenting arterial hypertension was operated upon for type I acute aortic dissection. Due to important alterations in the ascendent aorta with involvement of the right coronary ostium, the surgical procedure included resection of the segment of aorta containing the intimal tear and replacement with a Dacron prosthesis, suspension of the aortic valve and ligadure of the right coronary ostium. Technical difficulties brought the necessity of a different approach for the myocardium revascularization. Instead of the traditional described procedures, an intercoronary venous graft was put between the anterior interventricular artery (branch of the left coronary artery) and the right coronary artery. The intercoronary graft presented a good flow since the begining, keeping a good myocardial contratility. Patient left the hospital in a good clinical condition, with preserved myocardial function. Intercoronary graft should be an efficient alternative for revascularization of a corohary artery involved by aortic dissections.