Edemar Pereira

Aprotinin in children undergoing correction of congenital heart defects: A double-blind pilot study

Thirty children undergoing surgical repair for congenital heart defects were randomly selected for a double-blind study on the anti-hemorrhagic and blood-saving properties of aprotinin. The treatment group comprised 14 patients who received aprotinin 7 mg/kg of body weight until the end of perfusion. The placebo group (n = 16) received an infusion of the corresponding volumes of saline. Patients treated with aprotinin bled less during the operation (12.6 ml/kg versus 18.1 ml/kg, p = 0.25) and in the first 24 postoperative hours (chest drainage 12.1 ml/kg versus 17.7 ml/kg, p = 0.07). Hemoglobin loss into chest drainage was reduced in the treated group by half (0.66 versus 1.21 gm in 24 hours, p = 0.07). Fewer blood donors were needed during hospitalization by patients receiving aprotinin (1.07 versus 2.75 donors per patient, p = 0.04). Postoperative transfusion was unnecessary in 64.2% of patients receiving aprotinin compared with only 25% of the placebo group (p = 0.03). Aprotinin increased diuresis significantly during perfusion (4.3 ml/kg versus 1.0 ml/kg, p = 0.005). Other parameters are evaluated, and considerations are made regarding adequacy of the dosage regimen. The drug seems to be safe and easy to handle in children.

Modificações no perfil do paciente submetido à operação de revascularização do miocárdio

INTRODUCTION: The improvement in care and management of ischemic heart disease and the dissemination of percutaneous coronary intervention (PCI) changed the indications for coronary artery bypass grafting (CABG), regarding procedures for patientswith multivessel disease in bad clinical conditions. OBJECTIVE: To compare surgical and clinical profiles between two groups of CABG patients at a 10 year interval observing the influence on hospital mortality rates. METHOD: Retrospective Cohort study, including 307 CABG patients operated on in 1991to 1992 (n=153) and 2001 to 2002 (n=154). Demographic characteristics, heart disease severity, comorbidities and pre-operative events were evaluated and compared between the groups. RESULTS: Patients operated in 2001 and 2002 were older, more severely ill (in a worse NYHA classand had higher prevalence of heart failure, and multi-vessel involvement) and with more co-morbidities. Patients operated in 1991 and 1992 had more urgent procedures. The observed surgical mortality rates were similar (3.3% and 1.9%, respectively). CONCLUSION: Patients submitted to CABG currently are older and in worse clinical conditions than those operated 10 years ago, but hospital mortality has not altered significantly.

Morbimortalidade em octogenários submetidos à cirurgia de revascularização miocárdica

FUNDAMENTO: O progressivo aumento da longevidade da populacao tem levado cada vez mais pacientes octogenarios a necessitarem de cirurgia de revascularizacao miocardica (CRM), sendo necessario conhecer os riscos e beneficios desse procedimento nessa faixa etaria. OBJETIVO: Descrever a morbimortalidade hospitalar de pacientes com idade igual ou superior a 80 anos submetidos a CRM e identificar variaveis que se constituem em seus preditores. METODOS: Foram estudados 140 casos consecutivos entre janeiro de 2002 e dezembro de 2007. Os pacientes possuiam em media 82,5 ± 2,2 anos (80-89), e 55,7% eram do sexo masculino. Na amostra, 72,9% tinham hipertensao arterial, 26,4% diabete, 65,7% lesao grave em tres ou mais vasos e 28,6% em tronco da coronaria esquerda. Cirurgia associada esteve presente em 35,7% dos pacientes, sendo a valvar aortica em 26,4% e a mitral em 5,6%. RESULTADOS: A mortalidade foi de 14,3% (CRM isolada 10,0% x 22,0% associada; p = 0,091) e a morbidade de 37,9% (CRM isolada 34,4% x 44,0% associada; p = 0,35). Complicacoes mais frequentes: baixo debito cardiaco (27,9%), disfuncao renal (10,0%) e suporte ventilatorio prolongado (9,6%). Na analise bivariada, os maiores preditores de mortalidade foram sepse (RR 10,2 IC 95%: 6,10-17,7), CRM previa (RR 8,06 IC 95%: 5,16-12,6), baixo debito cardiaco pos-operatorio (RR 7,77 IC 95%: 3,03-19,9) e disfuncao renal pos-operatoria (RR 7,36 IC 95%: 3,71-14,6). Quanto a morbidade, foram preditores tempo de circulacao extracorporea >120 min. (RR: 2,34 IC 95%: 1,62-3,38) e de isquemia > 90 min. (RR: 2,29 IC 95%: 1,56-3,37). CONCLUSAO: A CRM em octogenarios esta relacionada a uma morbimortalidade maior do que nos pacientes mais jovens, o que, entretanto, nao impede a intervencao se houver indicacao pela condicao clinica.

Influências temporais nas características e fatores de risco de pacientes submetidos a revascularização miocárdica

OBJECTIVE To compare the clinical and surgical profile between two groups of patients submitted to Myocardial Revascularization (MCR) surgery at the Instituto de Cardiologia of Rio Grande do Sul with a ten year interval, to observe its influence upon MCR hospital mortality and to verify the predictability of this result using the risk score. METHODS A retrospective cohort study involving 307 patients who underwent MCR surgery within a six month period during 1991/92 (INITIAL group, n=153) or 2001/02 (CURRENT group, n=154). Demographic characteristics, heart disease, comorbidities and surgical events were analyzed to compare the groups and to define the hospital mortality risk score (based on the Cleveland Clinic method). RESULTS The CURRENT group was older, had more severe heart condition (functional class, incidence of heart failure and number of vessels with severe lesions) and a greater prevalence of comorbidities. The INITIAL group had a higher prevalence of nonelective surgery. Both groups had similar mean risk scores (2.8 +/- 3.1 for INITIAL and 2.2 +/- 2.5 for CURRENT) and hospital mortality rates (3.3% and 1.9% respectively). These figures are comparable to those for reported by Cleveland Clinic (for a risk score of 3 the predicted mortality range between 2.0 %; using a confidence level of 95% the predicted mortality is between 0 and 4.3%; and actual mortality confirmed by the study was 3.4%). CONCLUSION Patients currently submitted to MCR are older and in worse clinical condition (heart and systemic) than those operated on ten years ago; however, the risk scores and hospital mortality rates were slightly higher in the INITIAL group. The higher number of nonelective surgical interventions could have contributed to this. A risk score can be used to identify patients that require a higher level of care and to predict surgical outcomes.

Fatores de risco e morbimortalidade associados à fibrilação atrial no pós-operatório de cirurgia cardíaca

OBJETIVO: Determinar a incidencia de fibrilacao atrial no pos-operatorio de cirurgia cardiaca, seu impacto sobre a morbimortalidade e o tempo de internacao hospitalar e analisar os fatores de risco presentes no pre, trans e pos-operatorio. METODO: Estudo de coorte contemporâneo com 158 pacientes adultos submetidos a cirurgia cardiaca, sendo excluidos aqueles com fibrilacao atrial no pre-operatorio. Os pacientes foram avaliados por monitorizacao cardiaca continua e eletrocardiogramas diarios e a fibrilacao atrial considerada como qualquer episodio de ritmo irregular, com presenca de ondas f de morfologia e amplitude variaveis. RESULTADOS: A incidencia de fibrilacao atrial foi de 28,5%, sendo 21,6% para os pacientes revascularizados e 44,3% para os submetidos a correcao valvar. Fatores independentemente associados a fibrilacao atrial foram insuficiencia cardiaca esquerda no pre-operatorio (p=0,05; RC=2,2), balanco hidrico total (p=0,01; RC=1,0), tempo de cirurgia (p=0,03; RC=1,01) e outros fatores associados: idade > 70 anos, doenca valvar aortica, agitacao psicomotora, tempo de permanencia de drenos, congestao pulmonar e insuficiencia respiratoria no pos-operatorio. O uso de betabloqueadores (p=0,01; RC=0,3) foi um fator de protecao. Fibrilacao atrial pos-operatoria associou-se a aumento do tempo de internacao hospitalar (16,9 ± 12,3 dias vs 9,2 ± 4,0 dias, p<0,001) e a maior incidencia de acidente vascular cerebral ou obito pos-operatorio, (p=0,02). CONCLUSAO: A incidencia de fibrilacao atrial no pos-operatorio de cirurgia cardiaca foi elevada e ocasionou significativo aumento de morbimortalidade e tempo de internacao hospitalar. Entre os fatores de risco independentes destaca-se o balanco hidrico excessivo e, como fator protetor, uso de betabloqueadores.

Morbimortalidade em pacientes acima de 75 anos submetidos à cirurgia por estenose valvar aórtica

BACKGROUND The greater longevity observed today has caused an increase in the number of elderly who need surgery. Aortic stenosis is a common condition in this age group. OBJECTIVE To evaluate morbidity and mortality in people aged 75 years or older who have undergone valvuloplasty or valve replacement surgery for aortic stenosis alone or associated with other injuries. METHODS We studied 230 consecutive cases between Jan/2002-Dec/2007. Patients were 79.5 +/- 3.7 years (75 - 94), and 53.9% were men. In the sample, 68.7% had hypertension, 17.9% had atrial fibrillation, 15.9% were obese, and 14.4% had undergone previous heart surgery. At surgery, 87.4% underwent aortic stent placement, and 12.6% underwent aortic valvuloplasty. RESULTS The mortality rate was 13.9% (9.4% with isolated aortic stenosis versus 20.9% with an associated procedure, p = 0.023) and the morbidity rate was 30.0% (25.2% with aortic stenosis alone versus 37.4% with an associated procedure, p = 0.068). The most common complications were: low cardiac output (20.2%), renal dysfunction (9.7%), and prolonged ventilatory support (7.9%). In the bivariate analysis, the main predictors of mortality were low cardiac output (RR 10.1, 95% CI: 5.02-20.3), use of intra-aortic balloon (RR 6.6, 95% CI: 3.83-11.4), sepsis (RR 6.77, 95%: 1.66-9.48) and renal dysfunction after surgery (RR 6.21, 95%: 3.47-11.1). As for morbidity, the predictors were: pre-operative renal dysfunction (RR 2.22, 95%: 1.25-3.95), atrial fibrillation (RR 1.74, 95%: 1.16-2.61), and chronic obstructive pulmonary disease (COPD) (RR 1.93, 95%: 1.25-2.97). CONCLUSION Aortic valve surgery in the elderly is related to a slightly higher mortality rate than in younger patients, and its main risk factors were associated procedures, renal failure, atrial fibrillation, COPD, and sepsis.

Morbimortality in octogenarian patients submitted to coronary artery bypass graft surgery

FUNDAMENTO: O progressivo aumento da longevidade da populacao tem levado cada vez mais pacientes octogenarios a necessitarem de cirurgia de revascularizacao miocardica (CRM), sendo necessario conhecer os riscos e beneficios desse procedimento nessa faixa etaria. OBJETIVO: Descrever a morbimortalidade hospitalar de pacientes com idade igual ou superior a 80 anos submetidos a CRM e identificar variaveis que se constituem em seus preditores. METODOS: Foram estudados 140 casos consecutivos entre janeiro de 2002 e dezembro de 2007. Os pacientes possuiam em media 82,5 ± 2,2 anos (80-89), e 55,7% eram do sexo masculino. Na amostra, 72,9% tinham hipertensao arterial, 26,4% diabete, 65,7% lesao grave em tres ou mais vasos e 28,6% em tronco da coronaria esquerda. Cirurgia associada esteve presente em 35,7% dos pacientes, sendo a valvar aortica em 26,4% e a mitral em 5,6%. RESULTADOS: A mortalidade foi de 14,3% (CRM isolada 10,0% x 22,0% associada; p = 0,091) e a morbidade de 37,9% (CRM isolada 34,4% x 44,0% associada; p = 0,35). Complicacoes mais frequentes: baixo debito cardiaco (27,9%), disfuncao renal (10,0%) e suporte ventilatorio prolongado (9,6%). Na analise bivariada, os maiores preditores de mortalidade foram sepse (RR 10,2 IC 95%: 6,10-17,7), CRM previa (RR 8,06 IC 95%: 5,16-12,6), baixo debito cardiaco pos-operatorio (RR 7,77 IC 95%: 3,03-19,9) e disfuncao renal pos-operatoria (RR 7,36 IC 95%: 3,71-14,6). Quanto a morbidade, foram preditores tempo de circulacao extracorporea >120 min. (RR: 2,34 IC 95%: 1,62-3,38) e de isquemia > 90 min. (RR: 2,29 IC 95%: 1,56-3,37). CONCLUSAO: A CRM em octogenarios esta relacionada a uma morbimortalidade maior do que nos pacientes mais jovens, o que, entretanto, nao impede a intervencao se houver indicacao pela condicao clinica.

Fatores de risco hospitalar para implante de bioprótese valvar de pericárdio bovino

BACKGROUND Identification of preoperative heart valve surgery risk factors aim to improve surgical outcomes with the possibility to offset conditions related to increased morbidity and mortality. OBJECTIVE Intent of this study is to identify hospital risk factors in patients undergoing bovine pericardial bioprosthesis implantation. METHODS Retrospective study including 703 consecutive patients who underwent implantation of at least one St. Jude Medical-Biocor bovine pericardial bioprosthesis between September 1991 and December 2005 at the Rio Grande do Sul Cardiology Institute; 392 were aortic, 250 were mitral and 61 were mitroaortic. Characteristics analyzed were gender, age, body mass index, NYHA (New York Heart Association) functional class, ejection fraction, valve lesions, systemic hypertension, diabetes mellitus, kidney function, arrhythmias, prior heart surgery, coronary artery bypass graft, tricuspid valve surgery and elective, urgent or emergency surgery. Main outcome was in-hospital mortality. Relationship between risk factors and in-hospital mortality was analyzed using logistic regression. RESULTS Were 101 (14.3%) in-hospital deaths. Characteristics with significant relationship to increased mortality were female gender (p<0.001), age over 70 years (p=0.004), atrial fibrillation (p=0.006), diabetes mellitus (p=0.043), creatinine > 2.4 mg/dl (p=0.004), functional class IV (p<0.001), mitral valve lesion (p<0.001), previous heart surgery (p=0.005), tricuspid valve surgery (p<0.001) and emergency surgery (p<0.001). CONCLUSION Mortality rate observed is accepted by literature and is justifiable due to the high prevalence of risk factors, showing an increased significance level for female gender, age above 70, functional class IV, tricuspid valve repairs and emergency surgery. Offsetting these factors could contribute to reduced in-hospital mortality for valve surgery.

Late outcome of unsupported annuloplasty for rheumatic mitral regurgitation

OBJECTIVES The aim of this study was to evaluate medium- and long-term (range 4 months to 17 years) clinical results in a series of patients treated surgically by unsupported mitral annuloplasty. BACKGROUND Mitral valve regurgitation has usually been treated by valve replacement or ring annuloplasty. A few series have reported plastic repair procedures without annular support or remodeling. Furthermore, in rheumatic lesions the results have been inferior to those in degenerative mitral insufficiency, and the majority of previous reports have provided information on short- or medium-term follow-up. METHODS One hundred fifty-four patients were operated on (55 male [36%] and 99 female [64%]). The mean age +/- SD was 36 +/- 16 years (range 5 to 73). Associated lesions comprised 47 aortic and 21 tricuspid valve lesions and 2 atrial septal defects. Patients with concomitant mitral stenosis were not included. Preoperative functional class was I or II in 19% and III or IV in 81%. The cardiothoracic ratio was 0.61 +/- 0.10. All patients underwent an unsupported mitral annuloplasty procedure in which the mural portion of the annulus was reduced by applying two buttressed mattress sutures at the commissures without compromising the width of the septal leaflet. When necessary, additional chordal procedures were performed. No patients received ring or posterior annular support. RESULTS The early mortality rate was 1.9% (three patients; one of the three died of myocardial failure and two of pulmonary thromboembolism). The late mortality rate was 5.8% (nine patients; three of the nine died of myocardial failure, one each of septicemia, pulmonary thromboembolism and sudden arrhythmic death and three of unknown causes). Twenty-eight patients (18.2%) were reoperated on because of mitral valve dysfunction and 2 (1.3%) because of prosthetic aortic valve dysfunction. A residual late systolic murmur was present in 48% of patients. Late complications were systemic thromboembolism in 5.8% (one third with an aortic valve prosthesis), infective endocarditis in 1.3% and pulmonary thromboembolism in 0.6%. Postoperative functional class was I or II in 84% and III or IV in 16%. Cardiothoracic ratio was 0.58 +/- 0.10. Actuarial probability of late survival was 79.5 +/- 5.3% at 10 years and 71.0 +/- 7.4% at 14 years. Event-free survival was 67.9 +/- 8.9% at 10 years and 56.1 +/- 11.7% at 14 years. CONCLUSIONS Rheumatic mitral regurgitation can be effectively treated by annuloplasty without prosthetic annular support, with late results comparable to those obtained with more complicated procedures. This observation is particularly important for treatment of children and young adult patients.

Use of intra-aortic balloon pump in cardiac surgery: analysis of 80 consecutive cases

BACKGROUND About 10% to 15% of patients undergoing cardiac surgery may develop low cardiac output syndrome in the perioperative period; of this total, 2% require mechanical support for adequate hemodynamic control. OBJECTIVE To describe the mortality rates of patients who required the use of IABP in the perioperative or postoperative period of cardiac surgery, identifying preoperative variables associated with a worse outcome, as well as to describe the postoperative complications and medium-term survival. METHODS Retrospective cohort study including 80 consecutive cases between January/2009 and September/ 2011. The patients had on average 62.9 ± 11.3 years and 58.8% were male; 81.3% were hypertensive, 50.0% had prior myocardial infarction and 38.8% has NYHA III/IV heart failure. The mainsurgery performed was isolated coronary artery bypass grafting (37.5%). RESULTS Hospital mortality was 53.8% (IC 95%: 42.7-64.9), and cross-clamp time > 90 minutes was an independent predictor of mortality in multivariate analysis (OR 1.52 CI 95%: 1.04-2.22). 71.3% of patients (CI 95%: 61.2-81.4) had at least one additional complication in the perioperative period, with lower limb ischemia observed in 5.0% patients. One-year survival was 43.6%, with a plateau in survival rates after a sharp initial drop, related to hospital mortality. CONCLUSION Patients who require IABP comprise a group of very high risk for morbidity and mortality. IABP use, however, enables the recovery of many patients from an evolution that would invariably be fatal, and patients discharged from hospital have a good medium-term survival.