Felipe Homem Valle

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.

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.

Direct intramyocardial transthoracic transplantation of bone marrow mononuclear cells for non-ischemic dilated cardiomyopathy: INTRACELL, a prospective randomized controlled trial

Objective We tested the hypothesis that direct intramyocardial injection of bone marrow mononuclear cells in patients with non-ischemic dilated cardiomyopathy can improve left ventricular function and physical capacity. Methods Thirty non-ischemic dilated cardiomyopathy patients with left ventricular ejection fraction <35% were randomized at a 1:2 ratio into two groups, control and treated. The bone marrow mononuclear cells group received 1.06±108 bone marrow mononuclear cells through mini-thoracotomy. There was no intervention in the control group. Assessment was carried out through clinical evaluations as well as a 6-min walk test, nuclear magnectic resonance imaging and echocardiogram. Results The bone marrow mononuclear cells group showed a trend toward left ventricular ejection fraction improvement, with magnectic resonance imaging - at 3 months, showing an increase from 27.80±6.86% to 30.13±9.06% (P=0.08) and returning to baseline at 9 months (28.78%, P=0.77). Magnectic resonance imaging showed no changes in left ventricular ejection fraction during follow-up of the control group (28.00±4.32%, 27.42±7.41%, and 29.57±4.50%). Echocardiogram showed left ventricular ejection fraction improved in the bone marrow mononuclear cells group at 3 months, 25.09±3.98 to 30.94±9.16 (P=0.01), and one year, 30.07±7.25% (P=0.001). The control group showed no change (26.1±4.4 vs 26.5±4.7 and 30.2±7.39%, P=0.25 and 0.10, respectively). Bone marrow mononuclear cells group showed improvement in New York Heart Association functional class, from 3.40±0.50 to 2.41±0.79 (P=0.002); patients in the control group showed no change (3.37±0.51 to 2.71±0.95; P=0.17). Six-minute walk test improved in the bone marrow mononuclear cells group (348.00±93.51m at baseline to 370.41±91.56m at 12 months, P=0.66) and there was a non-significant decline in the control group (361.25±90.78m to 330.00±123.42m after 12 months, P=0.66). Group comparisons were non-significant. Conclusion The trend of intragroup functional and subjective improvement was not confirmed when compared to the control group. Direct intramyocardial application of bone marrow mononuclear cells in non-ischemic dilated cardiomyopathy was not associated with significant changes in left ventricular function. Differences observed within the bone marrow mononuclear cells group could be due to placebo effect or low statistical power.

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.

Long-term survival of octogenarian patients submitted to isolated coronary artery bypass graft surgery

INTRODUCTION An increasing number of octogenarian patients is undergoing coronary artery bypass graft surgery (CABG). The short-term results of this procedure have been broadly studied, but there are few national reports on long-term outcomes. OBJECTIVES To describe hospital mortality and long-term survival of patients aged > 80 years undergoing isolated CABG. METHODS Retrospective cohort study with 142 consecutive patients aged > 80 years undergoing isolated CABG in the period between January/1996 and December/2007 in a Brazilian reference center. Mean age (± SD) was 82.3 ± 2.1 years, and 56.3% were male. The prevalence of hypertension was 73.2%, of previous myocardial infarction 30.3%, of diabetes 26.8%, and of renal dysfunction (creatinine ³ 2.0 mg/ml) was 4.9%. The median follow-up was 4.0 years, with a loss of 11.6% of patients. Survival analysis was performed by the Kaplan-Meier method. RESULTS Overall hospital mortality was 14.8% (95% CI: 8.8 to 20.8), with a reduction of this rate during the study period (1996-1999: 25.9%, 2000-2003: 15.8%, and 2004-2007: 8.6%). Mean survival was 6.5 years (95% CI: 5.5 to 7.5), and the survival rate at 1, 3 and 5 years was 79.4, 73.4 and 65.2%, respectively. CONCLUSION Results are in agreement with international reports. Mean survival was 6.5 years and the survival rate at 5 years was 65.2%.

Results of aortic valve surgery in patients over 75 years old, at 4.5 years of follow-up

BACKGROUND The increased longevity elevated the frequency of elderly requiring surgery, among them the correction of aortic stenosis. OBJECTIVES To evaluate medium-term mortality, need for reoperation for valve replacement and valve complications [systemic thromboembolism (STE) and prosthetic endocarditis (PE)] in patients over 75 years old who had undergone surgery for aortic stenosis. METHODS Retrospective study of 230 patients from 2002 to 2007. Mean age was 83.4 years and 53% were male. The prevalence of hypertension was 73.2%, atrial fibrillation 17.9% and previous cardiac surgery 14.4%. Another cardiac procedure was associated in 39.1%. RESULTS In a mean follow-up of 4.51 years the overall survival of the population studied was 57.4%. Death in the immediate postoperative period occurred in 13.9% (9.4% in the isolated aortic stenosis surgery group vs. 20.9% when another procedure was associated). Deaths in the medium term occurred in 28.7% of the patients (25.0% vs. 34.4%), with 34 of these because of cardiovascular causes. There were 6 cases of PE, 8 cases of STE and 6 reoperations. The predictors of mortality were ischemia time >90 min (OR 1.99 95% CI 1.06-3.74), ejection fraction <60% (OR 1.76 95% CI 1.10-2.81) and prior stroke (OR 2.43 95% CI 1.18-5.30). CONCLUSION Although the immediate surgical risk of the elderly is high, survival rates for surgical treatment of patients over 75 years old are acceptable and allow this intervention. The prognosis is worse especially because of the association with coronary artery disease.

Gastrointestinal bleeding due to angiodysplasia in a patient with severe aortic stenosis: Heyde's syndrome

ABSTRACT There is a frequent association between aortic valve stenosis and gastrointestinal bleeding, also known as Heyde’s syndrome. The pathophysiologic basis for this syndrome seems to be an acquired von Willebrand factor deficiency, leading to bleeding of angiodysplastic arteriovenous malformations. Treatment options include the location and cauterization of bleeding points, which is associated to high recurrence rates. Valve replacement appears to offer the best hope of long-term resolution of bleeding, and should be considered in most cases. We report a 79 year-old patient with aortic stenosis and gastrointestinal bleeding due to duodenal angiodysplasia treated by transcatheter aortic valve implantation.

Two HEmostasis Methods After TransradIal Catheterization: THEMATIC - protocol for a randomized clinical trial.

OBJECTIVE Randomized clinical trial protocol to evaluate the incidence of radial artery occlusion with two different arterial compression devices after transradial procedures. METHODS Barbeaus test will be performed in adults scheduled to undergo transradial interventional procedures. Those with A, B, or C plethysmographic patterns will be selected. At the end of the procedure, patients will be randomly assigned (1:1) to receive patent haemostasis with TR Band™ device or conventional haemostasis with an elastic adhesive bandage. The primary outcome is the incidence of radial artery occlusion. Secondary outcomes are Barbeaus test curve change, additional time to achieve haemostasis, incidence of bleeding at the puncture site, pain severity, development of arteriovenous fistula, radial pseudo aneurysm, any access-site complication requiring vascular surgery intervention and costs between the two devices. DISCUSSION The results of this trial should provide valuable additional information on the best approach for haemostasis after transradial percutaneous cardiovascular interventions.

An Overview of Care Changes in the Last 6 Year in Primary PCI in ST-Elevation Myocardial Infarction in a Tertiary University Brazilian Hospital

Mailing Address: Guilherme Pinheiro Machado Rua Domingos Crescencio, 545. Postal Code: Santana, Porto Alegre, RS Brazil. E-mail: gpmachado89@gmail.com, guimachado@hcpa.edu.br An Overview of Care Changes in the Last 6 Year in Primary PCI in ST-Elevation Myocardial Infarction in a Tertiary University Brazilian Hospital Guilherme Pinheiro Machado,1,2 Fernando Pivatto Junior,2 Rodrigo Wainstein,2 Gustavo Neves de Araujo,2 Christian Kunde Carpes,1,2 Mateus Correa Lech,1,2 Felipe Homem Valle,2 Luiz Carlos Corsetti Bergoli,2 Sandro Cadaval Gonçalves,2 Marco Vugman Wainstein1,2 Faculdade de Medicina, Universidade Federal do Rio Grande do Sul,1 RS Brazil Serviço de Cardiologia, Hospital de Clínicas de Porto Alegre,2 RS Brazil

On- vs. off-hours admission of patients with ST-elevation acute myocardial infarction undergoing percutaneous coronary interventions: data from a tertiary university Brazilian hospital

Introduction: Early reperfusion therapy is crucial in patients with ST-elevation myocardial infarction (STEMI). Off-hours hospital presentation may increase the time from pain to coronary reperfusion, and it may be responsible for increased cardiovascular outcomes. The aim of this study was to compare the effect of different times of presentation (on- and off-hours) on early mortality and major cardiovascular outcomes in patients with STEMI who underwent primary percutaneous coronary intervention (PCI). Methods: We have included consecutive patients with STEMI who underwent primary PCI between April 2011 and November 2016 in a tertiary university hospital in southern Brazil. Patients were divided into on- and off-hours admission. In-hospital and 30-day outcomes were evaluated. Results: A total of 301 patients (57.4%) were admitted during off-hours, and 223 (42.5%) during on-hours. Baseline characteristics were well balanced between the two groups. Median door-to-balloon time was higher in the off-hours group than in the on-hours group: 75 min (IQR 60-95) vs. 60 min (IQR 50-73.7) respectively (p < 0.001). In-hospital mortality was similar between groups (odds ratio [OR] = 0.56; 95% confidence interval [95%CI] 0.31-1.03; p = 0.06) and at 30-day follow-up (OR = 0.2; 95%CI 0.02-1.72 p = 0.14). In the matched cohort, no difference was found in the rates of in-hospital mortality (OR = 2.0; 95%CI 0.75-5.32; p = 0.16) and 30-day MACE (OR= 0.9; 95%CI 0.49-1.66; p = 0.75). Conclusions: In our center with PCI available 24/7 – without in-house staff – we did not observe any difference in patient characteristics, management, and outcomes, although a significant longer door-to-balloon time was found in patients treated during night shifts. Our results are consistent with those of other trials. Keywords: Myocardial infarction; percutaneous coronary intervention; system delay