Danton Richlin da Rocha Loures

Cirurgia cardíaca no idoso

BACKGROUND: Because of the increase in the life expectancy of the Brazilian population, elderly patients are being increasingly referred to cardiac surgery. MATERIAL AND METHODS: Seventy-five patients, 70 years of age or older, who underwent cardiac surgery in the HC-UFPR, between 1995 and 1999 were studied. The purpose of this study was to analyze early and long-term results. Ages from 70 to 88 years, with 34 females (46.7%) and 41 males (53.3%). Symptoms included angina (81.3%), dyspnea (42.6%) and syncope (16%). There was 57.3% of patients in NYHA class I, 17.3% in class II, 18.6% in class III and 6.6% in class IV. The main risk factors listed were high blood pressure (61.3%), smoke (48%), diabetes mellitus (28%) and 9.3% had already had cardiac operations. Surgical procedures included 50 coronary artery bypass grafts - CABG (66.6%), 9 aortic valve replacements (12%), 5 aortic operations (6.6%), 4 CABG + valve replacement (5.2%) and other procedures (7%). The main postoperative complications were cardiovascular - ventricular arrhythmias (22.6%), supraventricular arrhythmias (21.3%), low cardiac output (16%) - infections (16%) and pulmonary problems (9.3%). The median stay in the ICU was 5 days. RESULTS: Sixty-five (78.4%) survivors had complete follow-up. The mean follow-up time was 20.7 months and long-term survival was 92%. Only one of the late deaths was cardiac related. CONCLUSION: Although this subgroup is associated with chronic diseases compromising other organs, advances in cardiac surgery and intensive care have made possible an intervention with safety and low morbidity and mortality.

Plástica da valva mitral com emprego do anel de Gregori-Braile: análise de 66 pacientes

The complications of valvular prosthesis has led us to preserve the mitral valve. Objective: This paper analyses mitral reconstruction in 66 patients (pts.) where the ring of Gregori-Braile was used, in the period between October 1989 and October 1995. Casuistic and Methods: 45 (74.1%) were male and the mean age was 32.9 years. Rheumatic disease was present in 49 pts. and mitral insufficiency in 38 pts. (57.5%). The follow-up was 2.560 pts./mounth (mean 38.8 months) in 64 pts. (96.9%). The method used to evaluate the patients were as follows: clinical symptoms in FC (NYHAC), systolic mitral murmur and Doppler-echocardiographic study in the pre and post-operative period. The mitral techniques were: ring implantation, mobilization of leaflets and chordae tendinae and restriction of valve mobility. Shortening of the chordae was used in 44 pts. (66.6%). Associated procedures were: reduction of the LA (8 pts.), aortic valve replacement (3 pts.) and Cox procedure in 3 pts. One patient died (1.5%) in early PO from pulmonar thromboembolism. Results: The PO functional class improved. In the pre-op 41 pts. (62.1%) were in FC III and 23 pts. in FCIV (34.8%). In the PO, 53 pts (80.3%) were in FC I and 8 pts. (12.1%) in FC II. The mitral murmur was absent or + intensity in 92.4% in PO. The FC and murmur improved significantly (p < 0.001). The Doppler-echocardiographic study showed: mean left ventricular diastolic diameter was 5.96 cm in the pre-op and 5.33 cm in the PO (p < 0.001); mean LA dimension was 5.67 cm (pre-op) and 4.65 cm in the PO (p < 0.001); mean aortic diameter was 2.97 cm in the pre-op and 3.13 cm in PO (p < 0.01); the mean shortening was 35.38% in pre-op and 34.12% in PO (not significantly). The mean valve area was 1.7 cm2 in the pre-op period and 2.43 cm2 in PO (p < 0.003) and the mean gradient pressure in the pre-op and PO period was 11.10 mmHg and 5.58 mmHg (p < 0.003), respectively. In the late PO, 3 pts. died (4.5%). After 72 months, the survival was 95.5%, 96% free from reoperation and 98.4% free from thromboembolism. Conclusions: Mitral reconstruction is a safe procedure, the improvement in functional class was statistically significant, and the procedure should be done whenever possible to correct the mixed lesion and mitral insufficiency.

Efeitos da correção cirúrgica de estenose mitral sobre o ritmo cardíaco

Objetivo: Determinar a frequencia de reversao de fibrilacao atrial (FA) ao ritmo sinusal (SA) em pacientes com estenose mitral (EM) submetidos a tratamento cirurgico e identificar provaveis fatores favoraveis ou desfavoraveis a este evento. Casuistica e Metodos: Estudo de caso-controle, envolvendo 53 pacientes com EM, sem acometimento de outras valvas, submetidos a correcao cirurgica. A populacao estudada apresentou as seguintes caracteristicas: mulheres: 71,7%; idade media: 42,4 anos; classe funcional III: 67,9%; area mitral media: 0,92 cm2; atrio esquerdo medio: 56,0 mm; ritmo antes da operacao: SA: 51,0% e FA: 49,0%. Os pacientes foram divididos em dois grupos de acordo com o ritmo apresentado no periodo pos-operatorio tardio: grupo I, formado pelos pacientes que, apos a operacao, apresentavam ritmo SA e grupo II, constituido por aqueles que, no pos-operatorio, estavam em FA. Resultados: Dez (18,9%) pacientes (em relacao ao total; 38,5% em relacao aqueles com FA) apresentavam FA no periodo pre-operatorio e sofreram reversao para o ritmo SA no pos-operatorio e em 2 pacientes (3,8% em relacao ao total; 7,4% em relacao aqueles em ritmo SA) houve degeneracao do ritmo SA para FA. Houve diferenca estatisticamente significativa (p < 0,05) entre os dois grupos apenas em relacao a variavel idade (p = 0,0456). Conclusoes: A operacao de correcao de EM apresenta resultados insatisfatorios em relacao a reversao da FA para ritmo SA, sugerindo a necessidade de associacao de outro procedimento cirurgico para restaurar o ritmo normal. Varios estudos tentaram identificar os fatores predisponentes a permanencia e ao desenvolvimento de FA apos a operacao, porem foram obtidos resultados contraditorios. No presente estudo, a unica variavel que apresentou associacao com a FA foi a idade avancada.

Seguimento de 9 anos da bioprótese valvular cardíaca de pericárdio bovino IMC-Biomédica: estudo multicêntrico

A mitral pericardial bioprosthetic valve IMC-Biomedica was implanted in a consecutive series of 798 patients with mean age of 52 years, from December 1977 to November 1978. The 722 patients who survived operation were observed during a period of 9 years (mean 27036 months or 2253 years). Actuarial studies indicated an expected survived rate at 9 years of 66% for adult patients and 68% for younger patients. The probability of complications were the following: rupture 0.4; perivalvar leak 0.4%; thromboembolysm 2.7%; endocarditis 3.2%; calcification 4.4%. The actuarial freedom from calcification between 1977 to 1982 (Group I) was 94.0% to adults and 12.0% to younger patients. On the other hand, between 1982 to 1986 (Group II) the actuarial analysis of calcification showed that 99.0% adults and 92.0% younger patients were free from this complication. Hence we believe that our option for the pericardial bioprosthetic valve was appropriate because 96.0% patients were free of complications deaths with the valve; this means that in 9 years the bioprosthetic lethal potential was only 4.0%.

Bone Marrow Stem Cell Transplantation and Coronary Artery Bypass Grafting Surgery for Chronic Ischemic Myocardiopathy

We studied 12 consecutive patients with chronic ischemic myocardiopathy treated with bone marrow adult stem cell (ASC) transplantation and coronary artery bypass grafting (CABG). The aim of the study was to evaluate functional class (New York Heart Association), wall motion score index (WMSI), and ejection fraction by echocardiography and to evaluate myocardial perfusion by single-photon emission computed tomography (SPECT). Follow-up evaluations were performed at 3, 6, and 12 months. The results revealed functional class improvement until 12 months, a progressive increase in the ejection fraction of 15% to 20% in the first 6 months, and a progressive increase in the WMSI by 35% to 45% in 12 months. Evaluation of the WMSI in the stem cell and CABG areas separately revealed a similar improvement in the first 3 months and a better progression in the CABG area. SPECT images revealed perfusion improvements in ischemic areas and no difference in fibrous tissue areas. These preliminary results show the safety of the method and its reproducibility. When performed concomitantly with CABG, bone marrow ASC transplantation may improve functional class, ejection fraction, WMSI, and myocardial perfusion. This study will be completed with all patients followed up for 12 months and compared with a control group.

Termo-coronário-angiografia: padronização do método e primeiras aplicações clínicas no Brasil

The authors report the experience with the methodological implantation of thermo-coronary-angiography in the Division of Cardiovascular Surgery of the Hospital de Clinicas, Federal University of Parana, and the Hospital Universitario Evangelico de Curitiba. It is a totally noninvasive technique that allows the real time assessment of the coronary blood flow with no interruption on the surgical procedure. Using TCA, it was possible to analyze the heart before and after the bypass graft completion, which allowed the visualization and recording of the ischemic area in the myocardial wall, the assessment of the graft patency, including stenoses, and the status of myocardial perfusion by preestablished collateral branches. Therefore, TCA is helpful in order to improve the results of the coronary artery bypass graft surgery, providing a higher treatment quality to the patient with coronary artery disease. Due to its great number of advantages, this infrared imaging method has an enormous likelihood to become a crucial tool to perform a safe myocardial revascularization. Further more, a permanent TCA system established in the operating room would extend all its benefits to other cardiac surgical procedures.

Emprego do anel de Gregori na posição invertida para o tratamento da insuficiência tricúspide: experiência inicial

Purpose: To analyse the technique and results for correction of functional tricuspid insufficiency with Gregoris ring in the inverted position. Material and Methods: Between July 1991 and November 1997, 11 patients were operated on and the mean age was 37 years. The assessment of the patients was made by clinical symptoms (NYHA-FC) classification and echocardiography study. The ring was implanted in tricuspid position and the retilineal part of the ring was sutured with interruped stitches in the annulus of the anterior leaflet. The reason behind this technique was to reduce the natural ring that is dilated in that region. Eight patients was in functional class (FC) III or IV (72.7%) in the pre-operative period and atrial fibrilation (AF) was presented in 6 patients (54.5%). The mean right ventricular diameter was 34 mm (normal value is up to 26mm). Results: There was no early or late mortality. The associated procedures were: mitral valve replacement in 5 patients; closure of ASD in 2; aortic valve replacement plus mitral valve repair in 1; isolated mitral valve repair in 1; ressection of bilateral endomyocardial fibrosis (EMF) in 1 and myocardial revascularization in 1. Follow-up was possible in 10 patients (91%). Nine patients (89%) were in FC I or II. The patient in FC III presented residual mitral valve insufficiency post-correction of EMF. Three patients were in AF and 7 in sinus rythm and none in total A-V block. None of the patients were reoperated. The mean right ventricular diameter was 24.6 mm (p < 0.001). Conclusions: 1) The technique is safe and reproducible; 2) clinical improvement was evident; 3) reduction of the right ventricular cavity was statistically significant; 4) considering the excellent results of this technique, it can be employed, routinely.

Tratamento cirúrgico dos aneurismas de ventrículo esquerdo e isquemia coronária

Desde os primeiros relatos sobre aneurismectomia do ventriculo esquerdo, varios aspectos foram estabelecidos. Existem controversias relacionadas a tecnica ideal de reconstrucao ventricular, seus efeitos na morfolofia, funcao ventricular, estado sintomatico pos-operatorio e sobrevida a longo prazo. Este estudo visa levantar a casuistica do Servico, observando as principais indicacoes e tratamento cirurgico, o estado sintomatico pre e pos-operatorio e a sobrevida imediata e tardia dos pacientes. Foram avaliados 12 portadores de aneurisma do ventriculo esquerdo, 9 masculinos, idade media de 60 anos, cujas principais indicacoes cirurgicas foram angina (58%) e angina + insuficiencia cardiaca (42%). O cateterismo cardiaco demonstrou acinesia/discinesia segmentar em 92% dos pacientes, aneurisma apical ou ântero-apical em 83% e doenca coronaria obstrutiva em 100%, acometendo 3 ou mais vasos em 75%; a arteria interventricular anterior foi mais comprometida (29%). A fracao de ejecao variou de 32% a 66% e o encurtamento percentual de 15% a 36%. Todos foram submetidos a revascularizacao do miocardio, 9 sofreram aneurismectomia do ventriculo esquerdo, 7 com sutura linear e 2 com reconstrucao geometrica. O tempo medio de circulacao extracorporea e clampeamento aortico foi 96 e 50 minutos para sutura linear e 180 e 86 para reconstrucao geometrica. As principais intercorrencias pos-operatorias foram sindrome de baixo debito cardiaco e fibrilacao atrial (16%). A mortalidade hospitalar foi de 16%. Os pacientes encontram-se com seguimento medio de 15 meses, sobrevida geral de 75%; estao livres de angina 89%, aqueles operados por ICC estao em classe II. Esses fatores melhorando a qualidade de vida justificam a aneurismectomia.

Optimização da perviabilidade do enxerto venoso na revascularização miocárdica: compreensão da fisiopatologia, novas drogas e avanços técnicos

Background: This study analyzes the experience of 3116 cases of coronary artery by-pass grafting revascularization of our group and define the percentage of early and late patency of the venous grafts. We also look this issue under the new concepts of endothelial reaction, influence of various drugs and improvement of surgical techniques. Material and Methods: From September 1971 until August 1998, 3116 cases of myocardial revascularization with cardiopulmonary by-pass were operated in our service. The surgical procedures were analyzed separately regarding the type of grafts used in each case; exclusively venous grafts, exclusively arterial grafts and venous and combined arterial grafts . We also made the analysis in three different periods, 1971-80, 1981-90 and 1991-98. The incidence of reoperation was analyzed trying to identify the patency of the different types of grafts and their results. Results: The age of the patients varied from 22 to 85, with a mean of 52.4 years, male sex was predominant with 68.4%. The mortality varied from 1.7% for vein grafts revascularization to 15.8% when associated complex procedures were done. Of the 3116 patients, 255 were reoperated, being 3.8% with isolated internal thoracic artery and 8.1 % isolated vein graft. Conclusions: a) The immediate result of vein grafts patency was dependent upon the surgical handling during vein harvesting and preparations, care during anastomosis and quality of coronary arteries. b) The late results in the 5th and 10th year were influenced by the spectrum of the arteriosclerosis. c) Patients with vein grafts represent the majority of reoperations when compared with those who received arterial grafts. d) There is a possibility of increasing vein grafts patency by a better handling of the graft, use of drugs such as calcium blockers, papaverin, aprotinin, nitrates and the prophylaxis of arteriosclerosis.

Inversão total da circulação do pulmão esquerdo: análise morfo-funcional

Desenvolvemos um modelo experimental de inversao total da circulacao do pulmao esquerdo. Com este modelo, buscamos demonstrar a possibilidade da inversao total do fluxo sanguineo pulmonar, mantendo normais as suas caracteristicas funcionais e histologicas. Foram operados 8 caes onde a circulacao do pulmao esquerdo foi totalmente invertida. O sangue do tronco pulmonar foi direcionado para as veias pulmonares e o retorno sanguineo da arteria pulmonar para o atrio esquerdo. Os caes foram reoperados apos 15 dias, para nova analise. Para monitorizacao do fluxo atraves do sistema invertido foi realizado no 9o PO um ecocardiograma com Dopplerfluxometria a cores. Para a analise funcional do pulmao utilizamos amostras gasometricas do sangue do pulmao esquerdo e da aorta. Para a analise morfologica comparamos o padrao histologico pre com o pos inversao. Foram comparados os resultados gasometricos das amostras da aorta e da arteria pulmonar na primeira operacao e na reoperacao. Todos os resultados gasometricos puderam ser comparaveis, mostrando nao haver diferenca entre a oxigenacao do sangue do pulmao esquerdo e da aorta. A analise ecocardiografica foi um metodo eficaz na avaliacao do fluxo pelo enxerto. A histologia pode mostrar que o pulmao com a circulacao invertida nao apresenta alteracoes de sua estrutura histologica. Com a inversao total da circulacao do pulmao esquerdo, a funcao de troca gasosa e a estrutura morfologica permaneceram inalteradas.