Carlos Alberto Teles

Coronary artery bypass grafting without cardiopulmonary bypass

BACKGROUND Coronary artery bypass grafting without cardiopulmonary bypass is now an accepted technique of myocardial revascularization. We herein report our total experience with this procedure. METHODS In a consecutive series of 8,751 patients operated on in our institution for coronary artery disease from 1981 to 1994, 1,274 patients received coronary artery bypass grafting without cardiopulmonary bypass. RESULTS Results indicate that the operation can be performed with an acceptable mortality (2.5%), and that all types of arterial conduits can be used. Most commonly the left anterior descending and right coronary arteries were bypassed. The incidence of arrhythmias and of pulmonary and neurologic complications were significantly lower in this group of patients compared with patients receiving coronary artery bypass grafting with cardiopulmonary bypass. Most importantly, there was decreased cost when the procedure was used because no extracorporeal circulation, cardioplegia sets, or other cannulas were used. CONCLUSIONS We conclude that the continuing use of coronary artery bypass grafting without cardiopulmonary bypass is justified and that, with proper selection of patients, the procedure is safe and cost-effective.

Transplante cardíaco e infecção

Objective: To evaluate the incidence of infection, the etiological agents, to present the clinical aspects and the surgical morbi-mortality in patients who underwent cardiac transplant at Federal University of Sao Paulo. Material and Methods: From November 1966 to June 1998, a total of 97 patients were operated by the UNIFESP Cardiovascular Surgery team and survived longer than 1 week after the transplantation and were studied retrospectively as far as infections. The age of the patients ranged from 3 to 63 years (average 44.4 ± 13 years). Most of the patients had dilated myocardiopathy (46), or Chagas (24) or ischemis (23). The follow up ranged from 0.33 to 119 months (36 ± 30.7 months) Results: Of the 97 patients, 16 (16.4%) had infection as the main cause of death, followed by rejection in 10 (10.3%). The causes of infection were: bacterial sepsis in 6 patients, pneumonia in 6, intra-abdominal infection in 2, toxoplasmosis in 1 and cytomegalovirus infection in 1. There were 142 infection episodes, bacterial 76 (52.5%), viral 34 (28.8%), fungi 20 (17.5%) and protozoa 12 (12.4%). There were 8 episodes of the reactivation were treated successfully with alopurinol. Conclusions: Our data showed the predominance of bacterial infections as the cause of most mortality. In transplanted patients suffering from Chagas´disease, the reactivation of the disease may be adequately controlled by means of alopurinol. Such data serve as orientation in our community for our programs of transplants, since they show particular aspects of our enviroment.

Transesophageal echocardiography and transcranial doppler monitoring in coronary surgery without cardiopulmonary bypass: preliminary results.

Transesophageal Echocardiography and Transcranial Doppler Monitoring in Coronary Surgery without Cardiopulmonary Bypass: Preliminary Results Suzana M.F. Malheirosa, Ayrton R. Massaro e, Antonio C. Carvalho b, Valdir A. Moises b, Aurélia Mussib, Darwin Federico d, Carlos A. Telesc, Enio Buffoloc, Alberto A. Gabbaia Departments of aNeurology, bCardiology, cCardiovascular Surgery and dAnesthesiology, Universidade Federal de São Paulo, and eDepartment of Neurology, Universidade de São Paulo, Brazil

Transplante cardíaco ortotópico: experiência na Universidade Federal de São Paulo

Foram realizados no periodo de novembro de 1986 a abril de 1997, 92 transplantes ortotopicos, com receptores na faixa etaria de 3 a 63 anos (media de 44,9 anos). Os diagnosticos pre-operatorios foram de miocardiopatia dilatada em 42 (44,6%) pacientes, isquemica em 23 (25,0%), chagasica em 21 (22,8%), valvar em 3 (3,2%) e outras miocardiopatias em 3 (3,2%) pacientes. A tecnica operatoria empregada (Lower e Shumway, em 1960) foi satisfatoria e sem complicacoes. O tempo de isquemia - mais longo nos transplantes com captacao a distância - foi sempre inferior a quatro horas. As complicacoes relacionadas ao uso cronico de imunossupressores foram, principalmente, hipertensao arterial (84,6%), hiperuricemia (75,4%) e dislipidemia (63,0%). Quanto as infeccoes, houve predominio das virais, com 42 (45,6%) casos, seguidas das bacterianas, com 35 (38,0%) casos, e das por protozoarios, com 15 (16,3%) casos. Dentre as infeccoes bacterianas, sete foram do sitio cirurgico, com boa evolucao. Das infeccoes por protozoarios, sete (46,6%) forma por reativacao do Trypanosoma cruzi. A mortalidade geral nos primeiros 30 dias do pos-operatorio foi de 17,3% e teve, como principais causas: infeccao, complicacoes neurologicas e rejeicao. Apos esses 30 dias e ate o primeiro ano, houve 10 (10,3%) obitos, com predominio de rejeicao e infeccao como causas. Apos o primeiro ano de pos-operatorio, houve 13 (14,0%) falecimentos, por causas diversas, como: morte subita, infeccao, rejeicao, alem de outras. A curva actuarial mostrou no 1o, 2o, 3o, 4o, 5o e 6o anos uma sobrevivencia de receptores de 71,6%, 66,6%, 60,5%, 54,4%, 54,4%, 54,4%, respectivamente. Nao houve perda de seguimento de paciente, e os sobreviventes ate a conclusao do trabalho encontravam-se bem, todos em classe funcional I da NYHA. Os autores concluem que e possivel a realizacao de transplante cardiaco em nossa comunidade com sobrevivencia e taxa de complicacoes pos-operatorias aceitaveis, porem diferentes das estatisticas internacionais.

Miocardiopatia terminal com insuficiência mitral secundária: tratamento com implante de prótese e remodelamento interno do ventrículo esquerdo

OBJECTIVE: To present a new surgical approach that consists of the implantation of a mitral prosthesis smaller than the annulus with traction of the papillary muscles to reduce the sphericalness of the left ventricle. METHODS: Between December 1995 and September 2005, 116 heart disease patients were operated, all of whom were at end-stage despite of full medication. The patients were analysed according to clinical criteria, echocardiographic findings and morphology of the left ventricle. RESULTS: Hospital mortality was 16.3% (19/116) and mid-term follow-up (38 ± 16 months) showed evidence of improvement in the clinical status and some echocardiographic parameters, in particular reduction of the sphericalness of the left ventricle. CONCLUSION: This technique, despite of the high mortality rate, offers a promising therapeutic alternative for the treatment of patients in refractory heart failure with cardiomyopathy associated to moderate or severe secondary mitral regurgitation.

Revascularização do miocárdio sem circulação extracorpórea: resultados da experiência de 18 anos de sua utilização

Introduction: Myocardial revascularization without cardiopulmonary bypass is today an increasing alternative of revascularization although the limits of applicability are still to be defined. The authors review a series of cases and discuss its indications based upon their results. Patients and Methods: There were analyzed 2495 patients who underwent direct myocardial revascularization without extracorporeal circulation in the period from October 1981 to September 1999, from a total of 10656 patients, submitted to coronary bypass surgery during this period (23.4%). The age varied from 32 to 90 years (medium = 59) with most males (67%). Chronic coronary insufficiency was the most common surgical indication (70.8%) and the majority of the patients received 2 grafts (51.5%). Results: The global mortality rate (30 days) was 1.9% (48/ 2495) and only 45% of these patients needed blood transfusion. The global applicability of this technique was around 23%, however in the last 3 years the applicability was 32.8%, 35.1% and 42.2%. Conclusions: Myocardial revascularization without extracorporeal circulation is a safe tactical alternative for coronary insufficiency and has increased in the last years. This treatment is indicated in this subgroup of lower mortality and small incidence of postoperative complications. In the next years the use of this technique will increase with the use of stabilizers, special manipulation and functional revascularization.

Revascularização do miocárdio sem circulação extracorpória: análise dos resultados em 15 anos de experiência

Myocardial revascularization without cardiopulmonary bypass is now a subject of increasing interest. The purpose of this paper is to present the results obtained during 15 years of experience. From September 1981 till March 1996,1549 patients we operated on without the use of cardiopulmonary bypass with an applicability of this alternative around 18% of the total revascularized patients in this period. The ages varied from 28 to 86 years (medium 57) with 1126 males and 423 females. The number of grafts varied from 1 to 5 (medium 1.7 grafts/patient). The technique did not constitute special limitation to use arterial grafts. The thoracic internal arteries were used 1140 times. In 1515 patients the revascularization was achieved through medsternotomy and in 34 through a minor left anterior thoracotomy. The mortality rate was 2.4% (38/1549) the main primary cause of death, low cardiac output in patients operated under acute ischemia after failed angioplasty or evolving mycardial infarction. In 8 patients the revascularization was performed under intraaortic balloon pump. The results of this 15 years experience permit the conclusion that myocardial revascularization without extracorporeal circulation is an excelent alternative of surgical treatment of coronary artery disease for a subset of patients with lower mortality and morbidity being specially indicated in high risk patients.

Post-transplant Lymphoproliferative Disease Presenting as a Mass in the Left Ventricle in a Heart Transplant Recipient at Long-term Follow-up

Neoplasms are among the most common solid-organ transplant complications, occurring in 11.7% of all transplant recipients and in 6% to 15% of heart transplant recipients, according to early studies. The skin and lips are the most common sites for neoplasms, but they also appear in the setting of post-transplant lymphoproliferative disease. Post-transplant lymphoproliferative disease (PTLD) is one of the most serious complications of long-term immunosuppression after transplantation. Herein we report the case of a 53-year-old man who underwent orthotopic heart transplantation for Chagas cardiomyopathy and had developed a mass in the left ventricle with symptomatic ventricle outflow obstruction. The patient was initially treated with anti-coagulation but his condition worsened and he was given emergency surgery to remove the mass. The patient recovered well and histologic assessment revealed PTLD as the etiologic culprit. Lymphoproliferative disorders are the second most frequently identified malignant neoplasm after heart transplantation. B-cell tumors are the most common histologically and are associated with infection by Epstein-Barr virus in 80% to 90% of cases.

Síndrome vasoplégica: nova forma de síndrome pós perfusão

A maioria dos implantes valvulares cardiacos realizados no Brasil e representada pelas valvulas de pericardio bovino, seguidas por proteses porcinas. Na avaliacao de valvulas biologicas, deve-se considerar: desempenho hidrodinamico, resistencia a fadiga e processo de calcificacao. No presente estudo, foi avaliado o desempenho hidrodinamico de bioproteses de pericardio bovino (Biopro-PB-Braile Biomedica) comparativamente as valvulas porcinas (Biopro-PP-Braile Biomedica) atraves do gradiente medio transvalvular. Os testes hidrodinamicos foram realizados em proteses de diâmetros variando de 19 a 35 mm, submetidas ao Sistema Duplicador de Pulsos Shelhigh (Shelhigh Inc.). O volume de ejecao foi mantido constante em 90 ml, com frequencia de pulso de 60, 70,80, 90 e 100 ciclos por minuto, possibilitando fluxos entre 5 e 9 litros por minuto, equivalentes a fluxos continuos aproximados de 8 a 18 litros por minuto. Houve tendencia a diminuicao dos gradientes pressoricos a medida em que aumenta o diâmetro externo das proteses. O gradiente pressorico medio encontrado em proteses de pericardio bovino foi significativamente menor que o de proteses porcinas (p<0,01), para todos os diâmetros estudados. Em vista da grande variabilidade dos protocolos de testes encontrados na literatura, reforca-se a necessidade de testes padronizados para avaliacao hidrodinâmica de proteses valvulares, visando comparacao adequada entre os diferentes modelos existentes.A new form of postperfusion syndrome, termed vasoplegic syndrome and presenting in the postoperative period of heart surgery with cardiopulmonary bypass (CPB) is described. The patients exhibit hipotension, normal or elevated cardiac output, low systemic vascular resistance and decreased filling pressures. Physical examination revealed normal capillaryfilling atthe extremities, but oliguria and hipotension. These patients needed a high dosage of vasoconstrictor drugs (norepinephrine) for blood pressure control and even high dose of norepinephrine did not produce the classical situation of coo I extremities. Twelve patients who presented signals and symptoms of vasoplegic syndrome are shown. The characteristics of vasoplegic syndrome are similar to those observed in the septic shock. ln sepsis, the alterations are mediated by cytokines and TNF-a. The appearance of vasoplegic syndrome augments operative morbidity, with an increased risk to the patient. DESCRIPTORS: Extracorporeal circulation, postperfusion syndromes. Postperfusion syndromes, vasoplegic. Extracorporeal circulation, si de effects. REFERÊNCIAS BIBLIOGRÁFICAS 4 BUTLER, J.; ROCKER, G. M.; WESTABY, S. ALLARDYCE, D. B.; YOSHIDA, S. H.; ASHMORE, P. G. The importance of microembolism in the pathogenesis of organ disfunction caused by prolonged use of pump oxygenator. J. Thorac. Cardiovasc. Surg., 52: 706-712, 1996. 2 BELLOMO, R. The cytokine network in the critically iiI. Anaesth. Intens. Care, 20: 288-302, 1992. 3 BERNARDI , C. & TEDGUI , A. Cytokine network and 42 the vessel wall: insights into septic shock pathogenesis. Eur. Cytokine Netw., 3: 19-33, 1992. Inflammatory response to cardiopulmonary bypass. Ann. Thorac. Surg., 55: 552-559, 1993. 5 CHENOWETH, D. E.; COOPER, S. W. ; HUGLI, T. E.; STEWART, R.; BLACKSTONE, E. H.; KIRKLlN, J. W. Complement activation during cardiopulmonary bypass: evidence for generation of C3a and C5a anaphylatoxins. N. Engl. J. Med., 304: 497-503, 1981 . 6 DOWNING, S. W. & EDMUNDS Jr., L. H. Release of vasoactive substances during card iopulmonary bypass. Ann. Thorac. Surg., 54: 1236-1248, 1992. GOMES, W. J.; SILAS, M. G.; LOPES, M. G.; PALMA, J. H.; TELES, C. A.; BRANCO, J. N. R.; CARVALHO, A. C.; BUFFOLO, E. Síndrome vasoplégica nova forma de síndrome pós perfusão. Rev. Bras. Cir. Cardiovasc., 11 (1 ):39-43, 1996. 7 FINN, A.; NAIK, S.; KLEIN, N.; LEVINSKY, R. J.; STROBEL, S.; ELLlOTT, M. Interleukin-8 release and neutrophil degranulation after pediatric cardiopulmonary bypass. J. Thorac. Cardiovasc. Surg., 105: 234-241, 1993. 8 FONG, Y.; MOLDAWER, L. L.; SHIMS, G. T.; LOWRY, S. F. The biological characteristics of cytokines and their implication in surgical injury. Surg. Gynecol. Obstet., 170: 363-378, 1990. 9 GOMES, W. J.; CARVALHO, A. C.; PALMA, J. H.; GONÇALVES, 1.; BUFFOLO, E. Vasoplegic syndrome: a new dilemma. J. Thorac. Cardiovasc. Surg., 107: 942-943, 1994. 10 HENNEIN, H. A.; EBBA, H.; RODRIGUEZ, J. L.; MERRICK, S. H.; KEITH, F. M.; BRONSTEIN, M. H.; LEUNG, J. M.; MANGANO, D. T.; GREENFIELD, L. J.; RANKIN, J. C. Relationship of the proinflammatory cytokines to myocardial ischemia and dysfunction after uncomplicated coronary revascularization . J. Thorac. Cardiovasc. Surg., 108: 626-635, 1994. 11 JANSEN, N. J. G.; van OEVEREN, W.; GU, Y. J.; van VLlET, M. H.; EIJSMAN, L.; WILDEVUUR, C. R. H. Endotoxin release and tumor necrosis factor formation during cardiopulmonary bypass. Ann. Thorac. Surg., 54: 744-748, 1992. 12 KIRKLlN, J . K. The postperfusion syndrome: inflammation and the damaging effects of cardiopulmonary bypass. ln: TINKER, J. H. Cardiopulmonary bypass: current concepts and controversies. Philadelphia, W. B. Saunders, 1989, p.131-146. 13 KIRKLlN, J. K.; WESTABY, S~ BLACKSTONE, E. H.; KIRKLlN, J. W.; PACIFICO, A. D.; CHENOWETH, D. E. Complement and the damaging effects of cardiopulmonary bypass. J. Thorac. Cardiovasc. Surg., 86: 845-857, 1983. 14 LAMAS, S.; MICHEL,T.; BRENNER, B. M.; MARSDEN, P. A. Nitric oxidein endothelial cells: evidence for a pathway inducible by TNF-alpha. Am. J. Physiol., 261: C634-C641, 1991. 15 MANTOVANI, A & DEJANA, E. Cytokines as communication signals between leukocytes and endothelial cells. Immunol. Today, 10: 370-5,1989. 16 MORRISON, D. C. & RYAN, J. L. Endotoxins and disease mechanisms. Am. Rev. Med., 38: 417-432, 1987. 17 RIGATO Jr., O Avaliação dos níveis séricos de fator de necrose de tumor alfa (TNF-a) em pacientes com diagnóstico clínico de sepse. Relevância da doença de base e associação com evolução. São Paulo, 1993. [Tese. Mestrado. Escola Paulista de Medicina]. 18 ROCKE, D. A.; GRAFFIN, S. L. ; WELLS, M. T.; KOEN, Y.; BROCK-UTINE, J. G. Endotoxemia associated with cardiopulmonary bypass, J. Thorac. Cardiovasc. Surg., 93: 832-837, 1987. 19 STARNES Jr., H. F.; WARREN, R. S.; JEEVANANDAM, M. Tumor necrosis factor and the acute metabolic response to tissue injury in mano J. Clin. Invest., 82: 1321-1325, 1988. 20 WATARIDA, S.; MPRI, A.; ONOE, M.; TABATA, R.; SHIRAISHI, S.; SUGITA, T.; NOJIMA, T.; NAKAJIMA, Y.; MATSUNO, S. A clinical study on the effects of pulsatile cardiopulmonary bypass on the blood endotoxin leveis. J. Thorac. Cardiovasc. Surg., 108: 620-625, 1994. 21 WEST ABY, S. Organ disfunction after cardiopulmonary bypass: a sistemic inflammatory reaction initiated by the extracorporeal circuito Int. Care Med., 13: 8995,1987. 22 YOUNG, L. S. Endotoxins and mediators: an introduction. ln: STURK, A. Bacterial endotoxins: citokine mediators and new therapies for sepsis. New York, Wiley-Liss, 1991, p. 1-7.A new form of postperfusion syndrome, termed vasoplegic syndrome and presenting in the postoperative period of heart surgery with cardiopulmonary bypass (CPB) is described. The patients exhibit hipotension, normal or elevated cardiac output, low systemic vascular resistance and decreased filling pressures. Physical examination revealed normal capillary filling atthe extremities, but oliguria and hipotension. These patients needed a high dosage of vasoconstrictor drugs (norepinephrine) for blood pressure control and even high dose of norepinephrine did not produce the classical situation of cool extremities. Twelve patients who presented signals and symptoms of vasoplegic syndrome are shown. The characteristics of vasoplegic syndrome are similar to those observed in the septic shock. In sepsis, the alterations are mediated by cytokines and TNF-α. The appearance of vasoplegic syndrome augments operative morbidity, with an increased risk to the patient.Most of the cardiac valve implantations in Brazil are represented by bovine pericardial valves, followed by the porcine prostheses. In the evaluation of biological valves, the following should be taken into consideration: hydrodynamic performance resistance to fatigue and calcification process. In this study, the hydrodynamic performance of bovine pericardial bioprostheses (Biopro-BP-Braile Biomedica) was evaluated comparatively to porcine valves (Biopro-PP-Braile Biomedica), through the transvalvular medium gradient. The hydrodynamic tests were made on prostheses varying from 19 to 35 mm in diameter, which underwent the pulse duplicator system Shelhigh (Shelligh Inc.). The ejection volume was constantly kept at 90 ml. The pulse frequencies varied between 60 and 100 cycles per minute, allowing flows between 5 and 9 liters per minute, equivalent to approximate continuos flows of 8 to 18 liters per minute. There was tendency to decrease the gradients, in proportion to increase of the bioprostheses external diameters. The medium pressure gradient found in the bovine pericardial prostheses was significantly smaller than that in the porcine prostheses (p<0.01), for all diameters studied. Respecting the large variability of protocols of tests in the literature for hydrodynamic evaluation of valve prostheses, the necessity of standard tests becomes stronger, seeking adequate comparison among the several valves.

Coronary artery bypass using only computed tomography as pre-operative angiogram.

La cirugia de revascularizacion del miocardio (CRM) es un procedimiento bien establecido con indicaciones actuales precisas. El advenimiento y la divulgacion de esta tecnica fueron posibles despues de la introduccion del angiograma coronario. Aunque muchos metodos de evaluacion hayan evolucionados en los ultimos anos, ninguno ha conseguido sustituir al angiograma coronario invasivo como examen preoperatorio. La tomografia computada (TC) surgio como una alternativa al angiograma coronario invasivo. El presente informe describe dos casos de CRM realizadas usando solo la TC como tecnica de evaluacion anatomica de las arterias coronarias preoperatoria.Coronary artery bypass graft (CABG) is a well established procedure with current precise indications. The advent and spread of this technique was possible after the introduction of the coronary angiogram. Although many evaluation methods have been developed in the past years, to date, none have been able to replace the invasive coronary angiogram as a pre-operative exam. Computed tomography angiography (CTA) has emerged as an alternative to invasive coronary angiogram. In this report we describe two CABG cases that were performed using only this technique as a pre-operative anatomic coronary arteries evaluation.