Eduardo Keller Saadi

Oxygenation and static compliance is improved immediately after early manual hyperinflation following myocardial revascularisation: a randomised controlled trial

QUESTION Are oxygenation and static compliance improved immediately after manual hyperinflation following myocardial revascularisation? Does this lead to earlier extubation and shorter hospital stay? Does it reduce postoperative pulmonary complications? DESIGN Randomised controlled trial with concealed allocation, blinded assessment and intention-to-treat analysis. PARTICIPANTS Fifty-five patients who underwent myocardial revascularisation. INTERVENTION After an hour in recovery, the experimental group received manual hyperinflation with positive end expiratory pressure followed by suction while the control group received suction only. OUTCOME MEASURES Oxygenation (PaO(2) in mmHg) and static lung compliance (in ml/cmH(2)O) were measured immediately after suction. Time to extubation (in minutes) and length of hospital stay (in days) were collected and postoperative pulmonary complications were confirmed by X-ray. RESULTS PaO(2) was 11.7 mmHg (95% CI 9.4 to 14.0) greater in the experimental group while static compliance was 8.5 ml/cmH(2)0 (95% CI 6.4 to 10.6) greater than in the control group. The experimental group was extubated 76 minutes (95% CI 24 to 128) earlier than the control group but did not have a shorter length of stay (mean difference 0.5 days, 95% CI -0.2 to 1.2). The relative risk of postoperative pulmonary complications was no greater (RR 0.57, 95% Cl 0.20 to 1.60) in the experimental group than in the control group. CONCLUSION The group that received early manual hyperinflation had markedly better oxygenation and static compliance as well as shorter mechanical ventilation times than the control group. The length of hospital stay and incidence of postoperative pulmonary complications were similar in the two groups.

Thoracic endovascular aortic repair – a Brazilian experience in 255 patients over a period of 112 months

The aim of this study is to analyze the immediate and late evolution for death and reintervention in a thoracic endovascular aortic repair (TEVAR) group, over a follow-up period of 112 months. Retrospective data of 255 patients, from 1998 to 2007, were obtained. The most prevalent diseases were thoracic aortic aneurysms (89), thoracic and abdominal aneurysms (85) and thoracic aortic dissections (61). The mean age was 63.2 years and 67.1% were male. Three hundred and three endoprostheses were used. Causes of morbidity, in the immediate postoperative period, were hyperthermia (45.9%), endoleaks (9.8% - being 7.1% type I), vascular complications (5.2%), renal insufficiency (3.1%) and neurological complications (3.1%). There were two (0.8%) hospital deaths and 17 (6.7%) late deaths. Time of follow-up was up to 112 months (mean of 60 months). The Kaplan-Meier curve analysis showed an increase of reintervention, compared with death, after a follow-up period of 42 months. Freedom from death at 36, 60 and 112 months was 96%, 89.1%, 85.1% and for reintervention, for the same periods was 93.6%, 82.7%, 57.2%, respectively. This study showed low incidence of prostheses related morbidity and immediate mortality. After a period of 42 months there was an increase on the percentual tax of reintervention.

The axillary artery – a new approach for endovascular treatment of thoracic aortic diseases

Endovascular procedures are increasing in number for the treatment of thoracic aortic diseases (TAD). Retrograde approach through the femoral artery is the preferred vascular access. Despite the improvements in the devices, femoral artery complications still occurs and some times this access is not possible because of the small size of the vessels, obstruction, calcification, dissection or extreme tortuosity. An axillary approach could be an alternative. We present a series of five patients and describe the technique we used in the axillary artery approach to treat TAD. There were two ascending aortas and three descending aortic aneurysms treated. The left axillary artery was used in three patients and the right in two. There were no local or neurological complications. In this preliminary approach, both axillary arteries were a good alternative access for endovascular graft insertion to treat aortic diseases when femoral access was not possible or was suboptimal.

Tratamento endovascular dos aneurismas de aorta abdominal: experiência inicial e resultados a curto e médio prazo

Objective: The purpose of this study is to present the short and medium-term results of the endovascular treatment of abdominal aortic aneurysms (AAAs). This is an initial experience of a multidisciplinary team. Method: Between July 2003 and October 2005, 42 patients (25 of whom suffered from AAAs) were treated with endovascular therapy for aortic diseases. The mean patient age was 74 ± 10.2 years with 92% men. The endovascular procedures were performed by a multidisciplinary team in the Hospital de Clinicas de Porto Alegre and Hospital Luterano (ULBRA). In twenty-four of the AAA patients, bifurcated grafts were used and only one had a straight graft. In all patients the procedure was carried out by femoral artery dissection in a catheterization laboratory. There was no need to convert to open repair. Results: There were no operative or postoperative deaths. The survival rate free from re-interventions is 96% after two years and three months. One (4%) patient needed a new endovascular procedure for a type I endoleak one year after, and three extensions were used successfully. Two other patients needed femoro-femoral bypasses, one at the same time as the endovascular procedure and the other one 24 hours later because of lower limb ischemia. Conclusion: The endovascular treatment of AAAs represents a new less invasive alternative to conventional surgery, especially for high risk patients. Further prospective and randomized studies to evaluate the long term outcomes are needed. Excellent results in the short and medium-terms can be obtained by multidisciplinary teams in our country.

Endovascular repair of an abdominal aortic aneurysm in patient with horseshoe kidney: a case report

Horseshoe kidney is a rare congenital anomaly that may cause various technical problems during conventional repairs of abdominal aortic aneurysms. We report the case of a 68-year-old woman with a horseshoe kidney, symptomatic abdominal aortic aneurysm and mild renal failure. The patient underwent endovascular repair using a bifurcated endoprosthesis. The postoperative was uneventful. We describe the diagnosis and the endovascular technique and literature review.

Diretrizes para o tratamento cirúrgico das doenças da aorta da Sociedade Brasileira de Cirurgia Cardiovascular - Atualização 2009

DESCRICAO DO METODO DE COLETA DEEVIDENCIASO documento original de 2007 [1] foi contruido a partirde reunioes periodicas para elaboracao do texto cominclusao das citacoes bibliograficas, por uma comissao demembros titulares designados pela Diretoria da SociedadeBrasileira de Cirurgia Cardiovascular. A partir de um textobasico referencial, os participantes, divididos em gruposde trabalho, agregaram contribuicoes, correcoes, erecomendacoes aprovadas em consenso, que permitiram aedicao do texto preliminar. Em diferentes momentos foramrealizadas as buscas de referencias cruzadas e artigosrelacionados mais relevantes, como metanalises, revisoessistematicas, e estudos multicentricos classicos. Procurou-se indicar trabalhos relevantes de autores brasileiros,particularmente os gerados pela Revista Brasileira deCirurgia Cardiovascular e pelos Arquivos Brasileiros deCardiologia, orgaos de divulgacao oficial da Cardiologiabrasileira.Na presente atualizacao, os editores procuraram revisarsistematicamente as publicacoes mais relevantes, nos

Multiple recurrences of cardiac myxomas with acute tumoral pulmonary embolism

We report the case of a 42-year-old female with a second recurrence of cardiac myxoma. Her first diagnosis was at the age of 24 years, when cardiac tumors were withdrawn from her right ventricle and left atrium. Her first recurrence was at the age of 36 years, when tumors were removed from the left and right atria, and the right ventricle. Six years later, the patient was admitted to the Hospital das Clínicas de Porto Alegre complaining of sudden dyspnea, dry cough, and pain in the right hypochondrium, which bore no relation to breathing. The transesophageal echocardiography showed a small tumor in the interatrial septum, close to the superior vena cava, and 2 larger tumors in the right ventricle, 1 close to the outflow tract and the other almost completely obstructing the right branch of the pulmonary artery. The patient was referred to surgery, in which myxomas were removed from the right atrium and ventricle with extension to the right pulmonary artery. The postoperative period was uneventful.

Enxertos arteriais na cirurgia de revascularização do miocárdio: papel da artéria radial

Because of the low patency rate of saphenous vein grafts, the use of arterial grafts for myocardial revascularization has been increased. The revascularization of the left anterior descending coronary (LAD) with the left internal thoracic artery (ITA) is the gold standard in almost all centers in the last 15 years. There are also evidences that one additional arterial graft decrease short and long-term (10 years) morbi-mortality. Radial artery is an excellent choice for the second arterial graft because of good midterm patency (84-92% vs 70-80% of saphenous vein in 5 years). Spasm, a potential problem in arterial grafts, occurs in 5 to 10% of radial grafts. Nitroglicerin and nitrates are the most effective drugs in its control and calcium antagonists did not show any clinical benefit. The Allen test alone has been effective to assess patency of collateral blood flow and palmar arch continuity. It seems reasonable, therefore, to suggest association of another arterial graft with left ITA in attempting to improve the results of CABG and that this other graft be the radial artery.

Implante percutâneo de valva aórtica: mito ou realidade?

Aortic valve replacement with mechanical or biological prosthesis with extracorporeal circulation is the goldstandard for the treatment of calcific aortic stenosis. Although the results are excellent with the conventional approach some elderly patients, with multiple high-risk comorbid conditions, reoperations and severe left ventricular dysfunction have high surgical risk. During the last years percutaneous techniques have been developed. The present study aim to analyse the literature, since the experimental development untill clinical application of this novel treatment in patients with high surgical risk aortic stenosis. Percutaneous implantation of aortic valve prosthesis is beeing done in some centers and the cardiovascular surgeon that treats valve disease should be involved in this development.Aortic valve replacement with mechanical or biological prosthesis with extracorporeal circulation is the gold-standard for the treatment of calcific aortic stenosis. Although the results are excellent with the conventional approach some elderly patients, with multiple high-risk comorbid conditions, reoperations and severe left ventricular dysfunction have high surgical risk. During the last years percutaneous techniques have been developed. The present study aim to analyse the literature, since the experimental development until clinical application of this novel treatment in patients with high surgical risk aortic stenosis. Percutaneous implantation of aortic valve prosthesis is being done in some centers and the cardiovascular surgeon that treats valve disease should be involved in this development.

Endovascular repair of ascending aorta and coronary stent implantation

Endovascular treatment of ascending aorta pseudoaneurysms with coronary stents implantation at the same procedure was feasible, although longer followup is necessary.