Edmo Atique Gabriel

Lung perfusion during cardiac surgery with cardiopulmonary bypass: is it necessary?

Thirty-two pigs were randomized into group I (aortic cross clamping, antegrade cardioplegia, moderate hypothermia) and group II (normothermia, beating empty heart). Groups were subdivided into subgroups A, B and C, receiving no lung perfusion, perfusion with arterial blood and perfusion with venous blood. Swan-Ganz catheter was used to take mean pulmonary artery pressure which would be used as lung perfusion pressure. Cardiopulmonary bypass (CPB) was established through cannulating aorta and double venae cavae, mechanical ventilation was interrupted and lung perfusion was carried out for 30 min. Blood samples and pulmonary specimens were withdrawn pre- and postoperatively for gasometrical, histological and genic analyses. Postoperative comparison revealed that pulmonary vascular resistance was lower in IC than IA (P=0.01) and it was lower in IIC than IIA (P=0.005). Subgroup IIB had increasing venous oxygen tension (P=0.01) as well as arterial and venous oxygen saturation (P=0.01) compared to IIA. Arterial oxygen saturation was decreased in IIC vs. IIA (P=0.006). Histological differences were observed between subgroups A and B as well as A and C (P=0.003). Lung perfusion during CPB may improve pulmonary hemodynamic performance, optimize gas exchange and maintain cellular integrity.

Doença arterial obstrutiva periférica e índice tornozelo-braço em pacientes submetidos à angiografia coronariana

OBJECTIVE: To evaluate the prevalence of peripheral arterial disease (PAD) in patients with coronary arterial disease. To evaluate the relation between ankle-brachial index (ABI) and coronary arterial disease, and its correlation with cardiovascular risk factors. METHOD: ABI investigated with Doppler ultrasonic device. Clinical characteristics researched: age, gender, diabetes, hypertension, alcoholism, smoking and obesity. Population: 113 patients who had coronary angiography. First analyses: 2 groups - absence and presence of coronary arterial disease. Second analyses: 3 groups - Group 1 - absence of coronary lesion; Group 2 - stenosis 70%. Third analyses: 2 groups - absence and presence of PAD. RESULTS: 90.76% of patients with coronary arterial disease presented PAD. There were significant difference including age (p<0.001), hypertension (p<0.001). smoking (p<0.001), body mass index (BMI) (p<0.001), systolic blood pressure (SBP) (p<0.001), diastolic blood pressure (DBP) (p<0.001) and pulse pressure (PP) (p<0.001) and ABI (p<0.001) between patients with and without coronary lesion. There were significant difference including age (p<0.001), diabetes (p=0.030), hypertension (p<0.001), smoking (p<0.001), BMI (p<0.001), SBP (p<0.001), DBP (p<0.001) and PP (p<0.001) and ABI (p<0.001) between patients divided as severity of coronary arterial disease. There were significant difference including age (p<0.001), hypertension (p<0.001), smoking (p<0.001), BMI (p<0.001), SBP (p<0.001), DBP (p<0.001) and PP (p<0.001) between patients with and without PAD. By Logistic Regression Analysis, old obese patients with ABI<0.90 have a risk of coronary lesion of 98.93%. CONCLUSION: ITB<0.90 might be a marker of coronary arterial disease in patients at risk of cardiovascular diseases.

[Should biatrial heart transplantation still be performed?: A Meta-analysis].

The outcomes of total and bicaval heart transplantation techniques are better than those of the biatrial technique; however, the latter is still considered the gold-standard. The objective of this study was to determine whether the total and bicaval heart transplantation techniques are, in fact, better than the biatrial technique. A systematic review with meta-analysis was carried out. Studies were retrieved from Pubmed, Lilacs, Web of Science, Scirus, Scopus, Google Scholar, and Scielo databases, identified by sensitive strategy. Randomized, prospective, and retrospective controlled studies were selected for inclusion. Intra and postoperative parameters were assessed. A total of 11,602 studies were identified and 36 were included in our review. The number of atrial arrhythmias, tricuspid valve regurgitation, deaths, and embolic events, as well as bleeding volume; temporary and permanent pacemaker requirement; and length of stay in the intensive care unit are significantly lower for the total and bicaval techniques than for the biatrial technique. Also, hemodynamic variables such as pulmonary capillary pressure, mean pulmonary artery pressure, and right atrial pressure are lower in total and bicaval transplantation. In prognostic terms, total and bicaval orthotopic heart transplantations are better, than the biatrial transplantation. Therefore, indication of the biatrial technique for transplantation should be the exception, not the rule.

Avaliação microscópica e ultra-estrutural do endotélio de veia safena preparada pela técnica "no touch"

Objective: Saphenous vein grafts (SV) used in coronary artery bypass grafting have a limited life and vein occlusion may be the final adverse effect. Efforts to develop new techniques to harvest the saphenous vein may improve the viability of the graft. Methods: Twenty patients were randomly divided into two groups with the objective of evaluating the vascular endothelium. The No Touch (NT) technique consists in

Primeiro escore de risco inflamatório das endopróteses de aorta

OBJETIVO: Propor um escore de risco inflamatorio para tratamento endovascular dos aneurismas da aorta. METODOS: Vinte e cinco pacientes foram seguidos do periodo pre-operatorio ate 3o mes de pos-operatorio (1 hora, 6 horas, 24 horas, 48 horas, 7 dias, 1 mes, 2 meses e 3 meses). Variaveis inflamatorias avaliadas foram proteina C reativa, velocidade de hemossedimentacao, interleucinas (IL-6, IL8), fator de necrose tumoral alfa, L-selectina, molecula de adesao intercelular (ICAM-1), transfusao de hemaceas, volume de cristaloide, volume de contraste, material da protese, numero de proteses, contagem total de leucocitos e linfocitos. O teste de Spearman apontou as variaveis candidatas ao maior risco inflamatorio, segundo P < 20%. A regressao logistica apontou variaveis selecionaveis para escore final segundo P < 10%. A analise da curva ROC revelou valores de corte para variaveis selecionadas pela regressao logistica. RESULTADOS: Variaveis apresentadas pelo teste de Spearman foram: volume de cristaloide (P = 0,04), material da protese (P = 0,04), volume de contraste (P=0,02), IL-8 preoperatoria (P= 0,10), ICAM-1 1 mes (P=0,03) e L-selectina 1 mes (P = 0,06). A regressao logistica revelou que os valores do volume de cristaloide e IL-8 pre-operatoria sao primordiais para constituicao do escore de risco inflamatorio para tratamento endovascular dos aneurismas da aorta. O escore de risco seria dividido em tres categorias (leve, moderado e grave), com base em intervalos numericos das duas variaveis selecionadas e as categorias seriam correlacionadas com achados clinicos CONCLUSA: Volume de cristaloide e IL-8 pre-operatoria sao variaveis que poderiam contribuir para categorizar risco inflamatorio e, desse modo, ter um papel prognostico no tratamento endovascular dos aneurismas da aorta.

On-pump coronary artery bypass graft surgery: biochemical, hormonal and cellular features

OBJECTIVE The authors sought to assess biochemical, hormonal and cellular repercussions from use of cardiopulmonary bypass (CPB) in coronary artery bypass graft (CABG) surgery. METHODS Eighteen patients underwent on-pump CABG surgery. Mean time of CPB was 80.3 minutes. Hormonal, biochemical and cellular measurements were taken in some time points - preoperatively, immediately after coming off CPB, 24 and 48 hours postoperatively. Friedman and Wilcoxon tests were applied based on significance level of 5%. RESULTS There was activation and significant elevation of total leukocytes and neutrophils count over CPB, remaining this way up to 48 hours postoperatively. Total platelets count, in turn, was marked by relevant reduction immediately after coming off CPB as well as in two postoperative time points. Serum levels of total proteins and albumin, immediately after coming off CPB and also in two postoperative time points, were significantly decreased comparing with preoperative status. There was remarkable reduction of total T3, free T3 and total T4 particularly up to first 24 hours postoperatively. CONCLUSION In on-pump CABG surgery, inflammatory effects encompass activation of total leukocytes, neutrophils and platelets, reduction of serum level of total proteins and albumin and decreased thyroid hormones levels, especially within first postoperative 24 hours.

Perfusão da artéria pulmonar não melhora os índices de fator natriurético cerebral (BNP) em estudo experimental em suínos

OBJECTIVE Assess if the main pulmonary artery controlled perfusion over cardiopulmonary bypass (CPB) modifies BNP levels expressed by the ventricular myocardium. METHODS Experimental research involving 32 pigs, divided into two groups according to CPB strategy--group I (cardioplegia) and group II (beating heart). Both groups were allocated into three subgroups according to lung perfusion strategy--subgroup A (control: no lung perfusion), subgroup B (lung perfusion with arterial blood) and subgroup C (lung perfusion with venous blood). In subgroups B and C, lung was perfused for 30 minutes, using preoperative mean pulmonary artery pressure (MPAP) as perfusion pressure, which was monitored through manometer. MPAP and pulmonary vascular resistance (PVR) were measured after coming off CPB using Swan-Ganz catheter. At preoperative time and 30 minutes after lung perfusion, specimens were taken from the right ventricular myocardium aiming to assess brain natriuretic peptide (BNP) and histologic pattern. Immunohistochemical and hematoxylin-eosin techniques were used to determine, respectively, BNP expression and inflammatory myocardial lesions. RESULTS In animals submitted to controlled lung perfusion, there was a postoperative reduction of MPAP (P = 0.03) and PVR (P = 0.005).There was no differences among subgroups within the group, I (P = 0.228) and subgroups within group II (P = 0.325) as to postoperative BNP expression. There were no differences among subgroups with and without lung perfusion as to postoperative inflammatory lesions (P > 0.05). CONCLUSION Main pulmonary artery controlled perfusion for 30 minutes did not yield substantial modifications in BNP expression and histologic pattern of the right ventricular myocardium.

Avaliação da agregação plaquetária e dosagem do fibrinogênio em pacientes com doenças cardiovasculares e sua correlação com o uso de aspirina e fatores de risco coronariano

OBJECTIVE: To evaluate aspirin resistance in patients with cardiovascular diseases and to compare the amount of serum fibrinogen in patients taking aspirin with those who do not. To correlate the platelet aggregation and serum fibrinogen to cardiovascular risk parameters. METHODS: Eighty-two patients were divided into two groups: Group 1 - 41 patients who took 100mg aspirin daily and Group 2 - 41 patients who did not utilized platelet antiaggregates. Epidemiological data were collected including age, gender and information on smoking and alcohol intake and serum fibrinogen and platelet aggregation were mesured. RESULTS: In the groups analyzed, advanced age (p=0.011), smoking (p=0.009) and alcoholism (p=0.007) were directly associated to the serum fibrinogenen level. There were no correlations between smoking, alcoholism, serum fibrinogen and platelet aggregation values (p>0.05). In Group 1, 29% of the patients presented with aspirin resistance. Of these, smokers (p=0.029) and the alcoholics (p=0.033) had higher serum fibrinogen levels. CONCLUSION: Aspirin resistance was present in a high number of patients. Moreover, advanced age, smoking and alcoholism had a direct influence on the serum fibrinogen levels.

Revascularização miocárdica com circulação extracorpórea: aspectos bioquímicos, hormonais e celulares

OBJECTIVE The authors sought to assess biochemical, hormonal and cellular repercussions from use of cardiopulmonary bypass (CPB) in coronary artery bypass graft (CABG) surgery. METHODS Eighteen patients underwent on-pump CABG surgery. Mean time of CPB was 80.3 minutes. Hormonal, biochemical and cellular measurements were taken in some time points - preoperatively, immediately after coming off CPB, 24 and 48 hours postoperatively. Friedman and Wilcoxon tests were applied based on significance level of 5%. RESULTS There was activation and significant elevation of total leukocytes and neutrophils count over CPB, remaining this way up to 48 hours postoperatively. Total platelets count, in turn, was marked by relevant reduction immediately after coming off CPB as well as in two postoperative time points. Serum levels of total proteins and albumin, immediately after coming off CPB and also in two postoperative time points, were significantly decreased comparing with preoperative status. There was remarkable reduction of total T3, free T3 and total T4 particularly up to first 24 hours postoperatively. CONCLUSION In on-pump CABG surgery, inflammatory effects encompass activation of total leukocytes, neutrophils and platelets, reduction of serum level of total proteins and albumin and decreased thyroid hormones levels, especially within first postoperative 24 hours.

Tratamento da persistência de canal arterial em recém-nascidos prematuros: análise clínica e cirúrgica

BACKGROUND: The surgical treatment of patency ductus arteriosus is indicated when the clinical intervention fails. However, this treatment may have some complications. OBJECTIVE: To analyze clinical and surgical aspects involved on the treatment of patency ductus arteriosus in premature newborn. METHODS: Twenty two premature newborns, submitted to surgical treatment for patency ductus arteriosus from January, 2000 to June, 2006, were evaluated. There were 77,3% female patients, the mean birth weight was 952,5g and the mean gestational age was 27 weeks. The use of vasoactive drugs, indometacin, echocardiograph parameters and complications, in the pre and postoperative periods were evaluated. RESULTS: In this casuistic 59,1% patients needed intratracheal intubation at birth, 77,3% needed surfactants, 59,1% used vasoactive drugs preoperative. The mean doses of indometacin were 3,43, with dose range 0,1 to 0,25 mg/Kg/day. The mean caliber of arterial duct patent was 1,96 mm. The surgical procedure was carried out through extrapleural approach in 59.1% of the patients, the mean time of postoperative intubation was 30,9 days, and 50% of the patients used vasoactive drugs postoperative. There were 18,1% postoperative complications (postoperative non-fatal complications). CONCLUSION: More than the half of the patients needed intratracheal intubation at birth, surfactant use and vasoactive drugs in the preoperative period. There was greater prevalence of the extrapleural approach during the surgery. In the postoperative period, there was less demand of vasoactive use and there was not deaths related to the surgical procedure.