Fernando Antibas Atik

Minimally invasive versus conventional mitral valve surgery: A propensity-matched comparison

OBJECTIVE Less invasive approaches to mitral valve surgery are increasingly used for improved cosmesis; however, few studies have investigated their effect on outcome. We sought to compare these minimally invasive approaches fairly with conventional full sternotomy by using propensity-matching methods. METHODS From January 1995 to January 2004, 2124 patients underwent isolated mitral valve surgery through a minimally invasive approach, and 1047 underwent isolated mitral valve surgery through a conventional sternotomy. Because there were important differences in patient characteristics, a propensity score based on 42 factors was used to obtain 590 well-matched patient pairs (56% of cases). RESULTS In-hospital mortality was similar for propensity-matched patients: 0.17% (1/590) for those undergoing minimally invasive surgery and 0.85% (5/590) for those undergoing conventional surgery (P = .2). Occurrences of stroke (P = .8), renal failure (P > .9), myocardial infarction (P = .7), and infection (P = .8) were also similar. However, 24-hour mediastinal drainage was less after minimally invasive surgery (median, 250 vs 350 mL; P < .0001), and fewer patients received transfusions (30% vs 37%, P = .01). More patients undergoing minimally invasive surgery were extubated in the operating room (18% vs 5.7%, P < .0001), and postoperative forced expiratory volume in 1 second was higher. Early after operation, pain scores were lower (P < .0001) after minimally invasive surgery. CONCLUSION Within that portion of the spectrum of mitral valve surgery in which propensity matching was possible, minimally invasive mitral valve surgery had cosmetic, blood product use, respiratory, and pain advantages over conventional surgery, and no apparent detriments. Mortality and morbidity for robotic and percutaneous procedures should be compared with these minimally invasive outcomes.

Monitorização hemodinâmica em cirurgia cardíaca pediátrica

A cirurgia cardiaca pediatrica e considerada uma dassubespecialidades mais complexas dentro da medicina. Oconhecimento acumulado nas ultimas decadas pelo enten-dimento da fisiopatologia das diversas cardiopatias conge-nitas, aliado aos progressos tecnologicos incorporados apratica medica, tem permitido a correcao cirurgica de grandeparte das anomalias cardiacas, com reducao significativados indices de morbidade e mortalidade. Contribuem para tala melhoria na protecao miocardica e cerebral, na tecnica ci-rurgica, no cuidado peri-operatorio e nas tecnicas de circu-lacao extracorporea. Muitas das cardiopatias congenitasconsideradas inoperaveis no passado, como a hipoplasiado coracao esquerdo, sao tratadas cirurgicamente no perio-do neonatal, com resultados promissores

Reversible pulmonary trunk banding. VI: Glucose-6-phosphate dehydrogenase activity in rapid ventricular hypertrophy in young goats

OBJECTIVE Increased myocardial glucose-6-phosphate dehydrogenase (G6PD) activity occurs in heart failure. This study compared G6PD activity in 2 protocols of right ventricle (RV) systolic overload in young goats. METHODS Twenty-seven goats were separated into 3 groups: sham (no overload), continuous (continuous systolic overload), and intermittent (four 12-hour periods of systolic overload paired with a 12-hour resting period). During a 96-hour protocol, systolic overload was adjusted to achieve a 0.7 RV/aortic pressure ratio. Echocardiographic and hemodynamic evaluations were performed before and after systolic overload every day postoperatively. After the study period, the animals were humanely killed for morphologic and G6PD tissue activity assessment. RESULTS A 92.1% and 46.5% increase occurred in RV and septal mass, respectively, in the intermittent group compared with the sham group; continuous systolic overload resulted in a 37.2% increase in septal mass. A worsening RV myocardial performance index occurred in the continuous group at 72 hours and 96 hours, compared with the sham (P < .039) and intermittent groups at the end of the protocol (P < .001). Compared with the sham group, RV G6PD activity was elevated 130.1% in the continuous group (P = .012) and 39.8% in the intermittent group (P = .764). CONCLUSIONS Continuous systolic overload for ventricle retraining causes RV dysfunction and upregulation of myocardial G6PD activity, which can elevate levels of free radicals by NADPH oxidase, an important mechanism in the pathophysiology of heart failure. Intermittent systolic overload promotes a more efficient RV hypertrophy, with better preservation of myocardial performance and and less exposure to hypertrophic triggers.

Risk factors for postoperative bleeding after adult cardiac surgery

OBJECTIVE: To determine predictors of postoperative bleeding after cardiac surgery, in order to focus on preventive measures for high-risk populations. METHODS: From October 2001 to March 2002, 411 consecutive adult cardiac surgery patients were prospectively studied, with the exception of those submitted to heart transplantation. In order to determine risk factors for postoperative bleeding, 20 preoperative, 17 operative and six postoperative variables were analyzed using univariate methods and multiple linear regression. RESULTS: Operative procedures included coronary artery bypass grafting in 227 (55.2%) patients, valvar operations in 198 (48.2%), aortic surgery in 25 (6.1%) and combined procedures in 60 (14.6%). Cardiopulmonary bypass was used in 335 (81.5%) patients and anti-fibrinolysis agents in 148 (36%). The thirty-day mortality was 5.6% (23 patients). Mean 24-hour postoperative blood loss was 610 ± 500 ml (range 10-4900). Re-exploration for bleeding was required in 15 (3.7%) patients. Independent predictors of postoperative bleeding were emergency operations (p=0.049), postoperative metabolic acidosis (p=0.001), preoperative thrombocytopenia (p=0.034) and prolonged cardiopulmonary bypass (p=0.021). CCONCLUSIONS: When possible, preoperative stabilization and correction of coagulation disturbances should be achieved in patients requiring urgent or emergent surgery and in those with thrombocytopenias. The duration of cardiopulmonary bypass should be minimized as long as this is practical. Postoperative metabolic acidosis must be actively corrected, especially the main determining cause.

Tratamento Cirúrgico da Embolização de Coil para Artéria Pulmonar Após Tentativa de Fechamento Percutâneo do Canal Arterial

bulha no foco pulmonar era hiperfonetica.Auscultava-se sopro continuo de grande intensidade no bordo esternalesquerdo alto, acompanhado de fremito de igual intensidade. A auscul-ta pulmonar era normal e nao havia visceromegalias.O eletrocardiograma demonstrou ritmo sinusal com frequenciacardiaca de 120 bpm, sinais de sobrecarga ventricular esquerda ealteracoes difusas da repolarizacao ventricular. A radiografia simplesde torax mostrava aumento discreto da area cardiaca, com abau-lamento do arco medio e acentuacao da vascularidade pulmonar,principalmente na regiao hilar.O ecocardiograma bidimensional com Doppler confirmou asuspeita clinica de persistencia do canal arterial com hiperfluxopulmonar, mensurando-o em 4,5mm de diâmetro e o caracteri-zando como de moderada repercussao hemodinâmica.Optou-se pelo fechamento do canal arterial atraves do trata-mento percutâneo. Em face da grande dimensao do canal arterial,foram utilizadas tres molas de Gianturco

A Cirurgia de Revascularização do Miocárdio sem Circulação Extracorpórea Minimiza o Sangramento Pós-Operatório e a Necessidade Transfusional

OBJECTIVE: To compare myocardial revascularization (MR) with and without extracorporeal circulation (ECC) in regard to postoperative bleeding and the need for blood and hemoderivate transfusion. METHODS: From November 2001 to February 2002, 186 patients undergoing myocardial revascularization were assessed, excluding those who underwent associated procedures. The patients were divided into 2 groups as follows: group A - comprising 116 patients undergoing MR with ECC; and group B - comprising 69 patients undergoing MR without ECC. Both groups were comparable in regard to pre- and intraoperative characteristics, except for the greater number of distal anastomoses (P=0.0004) in group A, and greater prothrombin activity (P=0.04) and INR (P=0.03) in group B. To avoid discrepancies between the groups, 140 patients with statistically similar characteristics were selected. RESULTS: Studying the paired groups, both the total bleeding volume in 24 hours (P=0.001) and the bleeding volume indexed for body surface (P=0.004) were greater in group A (609.6 ± 395.8 mL; 331.8 ± 225.8 mL/m2, respectively) than in group B (437.2 ± 315 mL; 241 ± 173.9 mL/m2, respectively). Although the need for transfusion was not significantly different between the groups (P=0.1), the amount of erythrocyte concentrate transfused was greater in group A (P=0.01). No statistical difference was observed in regard to transfusion of other hemocomponents and the need for surgical review of hemostasis. CONCLUSION: Myocardial revascularization without ECC was more advantageous than MR with ECC in regard to smaller postoperative blood loss and a lesser need for transfusion of erythrocyte concentrate. The repercussions of this finding may be innumerable, particularly in regard to minimization of morbid factors and hospital costs.

Experience of ECMO in Primary Graft Dysfunction after Orthotopic Heart Transplantation

Background Primary graft dysfunction is the main cause of early mortality after heart transplantation. Mechanical circulatory support has been used to treat this syndrome. Objective Describe the experience with extracorporeal membrane oxygenation to treat post-transplant primary cardiac graft dysfunction. Methods Between January 2007 and December 2013, a total of 71 orthotopic heart transplantations were performed in patients with advanced heart failure. Eleven (15.5%) of these patients who presented primary graft dysfunction constituted the population of this study. Primary graft dysfunction manifested in our population as failure to wean from cardiopulmonary bypass in six (54.5%) patients, severe hemodynamic instability in the immediate postoperative period with severe cardiac dysfunction in three (27.3%), and cardiac arrest (18.2%). The average ischemia time was 151 ± 82 minutes. Once the diagnosis of primary graft dysfunction was established, we installed a mechanical circulatory support to stabilize the severe hemodynamic condition of the patients and followed their progression longitudinally. Results The average duration of extracorporeal membrane oxygenation support was 76 ± 47.4 hours (range 32 to 144 hours). Weaning with cardiac recovery was successful in nine (81.8%) patients. However, two patients who presented cardiac recovery did not survive to hospital discharge. Conclusion Mechanical circulatory support with central extracorporeal membrane oxygenation promoted cardiac recovery within a few days in most patients.

Results of the establishment of an organizational model in a cardiovascular surgery service

OBJECTIVE Increasing complexity of patients referred to cardiac surgery demands more effective heart centers, in order to maintain the same quality. The aim of this study is to examine the short-term effect of adoption of an organizational model on surgical outcomes. METHODS From January 2006 to June 2007, 367 consecutive adult patients underwent cardiovascular surgery. Pre-, intra- and postoperative data were prospectively collected and transferred to an institutional database. Organizational model was established in August 2006, and based on integrated multiprofessional team work patient-centered, evidence-based medicine with standardized patient care and personal conflict management. The outcomes studied were hospital mortality and combined adverse events (death, stroke, acute myocardial infarction and acute renal failure), by using multivariate logistic regression analysis. RESULTS After establishment of such model, there was reduction of hospital mortality (from 12% to 3.6%, relative risk= 0.3; P=0.003) and combined events (from 22% to 15%, relative risk=0.68; P=0.11). Operations performed previously to the model were independently associated with higher mortality (OR=2.5; P=0.04), adjusted to preoperative characteristics and Euroscore risk stratification system. Other predictors of mortality were age > 65 years (OR=6.36; 95%CI 2.57 - 17.21; P<0.0001) and cardiopulmonary bypass time > 145 minutes (OR=8.57; 95%CI 3.55 - 21.99; P<0.0001). CONCLUSION Marked improvements in surgical outcomes depend on development of cardiac surgery centers based on organizational models similar to the model proposed in this study.

Emprego do suporte cardiopulmonar com bomba centrífuga e oxigenador de membrana em cirurgia cardiovascular pediátrica

BACKGROUND Extracorporeal membrane oxygenation is a well-documented resuscitation method in patients with severe hemodynamic and/or respiratory impairment. OBJECTIVE To describe several aspects related to the use of extracorporeal membrane oxygenation in a pediatric heart center and determine its immediate and late outcomes. METHODS Between October 2005 and January 2007, 10 patients who were submitted to pediatric cardiac surgery underwent extracorporeal membrane oxygenation implant. Median age was 58.5 days (40% neonates) and median body weight was 3.9 kg. Circulatory assistance was initiated aiming at the recovery and the weaning protocols followed daily clinical and echocardiographic criteria. Support was discontinued when transplant was contraindicated, when the patient was unable to recover or when survival was considered to be limited by a multidisciplinary team. RESULTS Extracorporeal membrane oxygenation was employed after corrective or palliative heart surgery in 80% and preoperatively in the remaining ones. It was most often indicated for irresponsive hemodynamic instability (40%), post-cardiotomy shock (20%) and post-cardiac arrest (20%). The mean duration on support was 58 +/- 37 hours. Weaning was successfully in 50% of the cases and 30% were discharged home. Actuarial survival was 40%, 30% and 20% at 30 days, 3 months and 24 months, respectively. CONCLUSION Extracorporeal membrane oxygenation is an effective and useful tool for the resuscitation of patients presenting severe hemodynamic and/or respiratory failure in the perioperative period of pediatric cardiovascular surgery.

Fatores prognósticos da revascularização na fase aguda do infarto agudo do miocárdio

OBJECTIVES: To determine the predictors of bad evolution in patients submitted to myocardial revascularization (MR) in the acute myocardial infarction (AMI). MATERIAL E METHODS: Between March 1998 and November 1999, 49 patients were submitted to MR in AMI. Patients with mechanical complications of the AMI and those submitted to associated procedures to MR were excluded. The patients were divided into two groups: Group I - 29 cases without AMI related complications and Group II - 20 cases with one or more complications. The later ones included persistent ischemia (18 patients), congestive heart failure (11), cardiogenic shock (9), hypotension (7), recurrent AMI (4), sustained ventricular tachycardia (4) and ventricular fibrillation (3). Both groups were considered comparable in terms of preoperative demografics, except for older patients in Group II. In order to determine the prognostic factors for early mortality, the patients profiles and AMI complications were analysed by multivariate and variance tests. RESULTS: The overall mortality was 6.12% (3 patients), all of them in Group II. The multivariate analysis identified as predictors of hospital mortality arterial hypotension (p=0.045), cardiogenic shock (p=0.001) and ventricular fibrillation (p=0.012). CONCLUSIONS: MR in AMI is a safe procedure in patients without preoperative complications, with no deaths. The presence of preoperative complications such as cardiogenic shock, ventricular fibrillation and hypotension were considered predictors of bad evolution in this condition.