Francisco A. Alves

Efeitos do local de inserção do dreno pleural na função pulmonar no pós-operatório de cirurgia de revascularização do miocárdio

OBJECTIVE: To analyze the pulmonary function changes and pain in patients undergoing off-pump coronary artery bypass grafting utilizing a left internal thoracic artery graft, comparing the pleural drain insertion through the intercostal space and subxyphoid approach. METHODS: Twenty eight patients (mean age 57.4 ± 8.4 years) were divided into two groups, according to the pleural drain site. Group IL (n=15) had the pleural drain inserted through the sixth left intercostal space at the mid-axillary line and in the IM group (n=13) the drain was placed through the subxyphoid region. All the patients underwent pre- and post-operative evaluation of pulmonary function tests as well as arterial blood gas analysis. Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were recorded in the preoperative period, and in the first, third and fifth postoperative days. The pain sensation was evaluated using a standard score from 0 to 10. RESULTS: In both groups falls in FVC and FEV1 were noted, up to the fifth postoperative day (P<0.001). However, the decrease was higher in the IL group, when compared to the IM group (p<0.05). Also arterial blood gas analysis showed a decline of the partial oxygen pressure in both groups on the fist postoperative day, but more significantly in the IL group (p=0.021). The pain sensation was higher in the IL group (p=0.002). CONCLUSION: Off-pump coronary artery bypass grafting with using of left internal thoracic artery, disregarding the pleural drain site, leads to a significant decrease of postoperative pulmonary function. However, the subxyphoid technique of drain insertion has shown a better preservation of the lung function when compared to the intercostal drain site.

Evaluation of pulmonary function in patients following on and off-pump coronary artery bypass grafting

OBJECTIVE: To evaluate and compare the pulmonary function in patients following on- and off-pump coronary artery bypass grafting (CABG). METHOD: Thirty patients (mean age 56.76 ± 10.20 years) were allocated to two groups, according to the use or not of cardiopulmonary bypasses: group A (n=15) off-pump and group B (n=15) on-pump, with all patients undergoing pre- and post-operative evaluation of the pulmonary function as well as arterial blood gases analysis. Forced vital capacity (FVC) and forced expiratory volume at 1 second (FEV1) were recorded in the preoperative period, and on the first, third and fifth postoperative days. Blood gases were evaluated in the preoperative period and on the first postoperative day. RESULTS: In both groups, significant falls in the FVC and FEV1 were detected up to the fifth postoperative day (p<0.05). When both groups were compared, the decreases in FCV and VEF1 were higher in group B (p<0.05). PaO2 values and the PaO2/FiO2 ratio presented significant drops on the first postoperative day in both groups, however the fall was higher in group B (p<0.05). CONCLUSION: Patients who undergo CABG, regardless of the use of CPB, display a significant reduction in the postoperative pulmonary function. However, patients who undergo off-pump CABG have a better preservation of the lung function compared to on-pump CABG.

Ministernotomy in myocardial revascularization preserves postoperative pulmonary function

BACKGROUND In coronary artery bypass graft (CABG) surgery, the need to perform a midsternotomy has been considered a factor for the decrease in postoperative pulmonary function. OBJECTIVE To prospectively evaluate early postoperative (PO) pulmonary function in patients submitted to off-pump CABG, comparing the conventional midsternotomy with the ministernotomy approach. METHODS A total of 18 patients were evaluated and assigned to the two groups: Group Conventional Midsternotomy (CMS, n=10) and Group Ministernotomy (MS, n=8). Spirometric results of the forced vital capacity (FVC) and the Forced Expiratory Volume in one second (FEV1) were obtained on the 1st, 3rd and 5th PO days and the arterial gasometry was obtained before and on the 1st PO day. The pulmonary shunt percentage and the pain score were also assessed. RESULTS When compared in terms of percentage of the preoperative value, the FVC was higher in the MS group than in the CMS group on the 1st, 3rd and 5th PO days (p<0.001). Similar results were obtained for FEV1. The recovery of the FVC between the 1st and the 5th PO days was higher in the MS than in the CMS group (p=0,043). The PaO2 decreased on the 1st PO day in both groups (p<0.05), with a higher decrease in the CMS group (p=0.002). The shunt increased in the two groups on the 1st PO day (p<0.05); however, it was lower in the MS group (p=0.02). The reported pain score was lower and the duration of the hospital stay was shorter in the MS group. CONCLUSION Patients submitted to CABG by MS present better preservation and recovery of pulmonary function than those submitted to CMS.

Physiologic left ventricular reconstruction: the concept of maximum ventricular reduction and minimum inflammatory reaction

INTRODUCAO: A sobrevida em pacientes com insuficiencia cardiaca, assim como apos a cirurgia de reconstrucao do ventriculo esquerdo (VE), esta relacionada ao tamanho da cavidade ventricular esquerda. Tambem o uso de materiais sinteticos na reconstrucao ventricular poderia induzir uma reacao inflamatoria cronica. Relatamos a modificacao da tecnica de reconstrucao ventricular que elimina a necessidade de retalhos intra-cavitarios e de uso de material sintetico no fechamento do VE. METODO: Onze pacientes consecutivos com aneurisma de VE, evoluindo em classe funcional (CF) III e IV da New York Heart Association foram submetidos a cirurgia de reconstrucao ventricular direta sem utilizacao de retalhos intra-cavitarios ou materiais proteticos no fechamento da incisao ventricular. RESULTADOS: Nao houve mortalidade cirurgica ou necessidade de suporte circulatorio mecânico. A permanencia hospitalar pos-operatoria variou de 4 a 7 dias (media de 5,3 ± 1,1 dias). O ecocardiograma de controle, realizado em media 4,6 ± 1,5 meses apos a operacao, evidenciou reducao do diâmetro diastolico de VE de 69,0 ± 7,5 mm, no pre-operatorio, para 62,6 ± 5,1 mm, no pos-operatorio. A fracao de ejecao do VE mostrou aumento de 47,3% ± 6,6% para 56,3% ±10,5%. Com um ano de seguimento, 8 pacientes encontram-se em CF I e 3 em CF II. CONCLUSAO: Esta tecnica, com eliminacao de uso de material sintetico, pode contribuir para a melhora dos resultados clinicos de pacientes submetidos a reconstrucao ventricular esquerda, proporcionando virtual eliminacao das areas acineticas do VE e potencialmente atenuando, no pos-operatorio tardio, a reacao inflamatoria cronica do miocardio.

Revascularização da artéria marginal com uso da artéria torácica interna direita pediculada retroaórtica sem circulação extracorpórea

Objective: Off-pump coronary artery bypass surgery (OPCAB) has demonstrated to provide reduction of cardiovascular events and mortality. Also the bilateral use of the internal thoracic arteries (ITAs) can offer additional benefits, improving survival. We present the technique of OPCAB using both pedicled ATI grafts, with the right ITA (RITA) routed retro-aortically through the transverse sinus, to revascularize the branches of the circumflex artery (Cx). Method: Twenty-six patients underwent OPCAB with bilateral ATI grafts have been studied, where the left ATI (LITA) was used to revascularize the left anterior descending artery (LAD) and the pedicled RITA, routed through the transverse sinus, anastomosed to the branches of the Cx. Twenty-one patients were male and five female, the age ranging between 42 and 74 years. The morbidities observed in this cohort were previous myocardial infarction in 18 (69%) patients, diabetes mellitus in 10 (38%), renal failure in four (7.7%) and AIDS in one (3.8%) patient. Results: No patient presented ECG changes or enzymatic rise in the postoperative one. The grafts per patient varied from 2 to 4 (average 3.0 grafts/patient). No cases of sternal infection or dehiscence were observed. One patient had a stroke on the 4o PO day and died. The postoperative hospital stay varied between 3 to 12 days (average 5.8 ± 2.0 days). No late deaths or cardiovascular events were recorded. Conclusions: This technique, making possible the offpump grafting of the circumflex artery branches using the pedicled RITA, potentially enhances the benefits of the coronary artery bypass surgery.

The renewed concept of the Batista operation for ischemic cardiomyopathy: maximum ventricular reduction

OBJECTIVES The reconstruction of the left ventricle (LV) is effective in the treatment of ischemic cardiomyopathy with large akinetic or dyskinetic areas. However, late survival outcomes are related to the remnant left ventricular cavity size, thus eliminating intracavitary patch placement provides additional LV reduction. The aim of this study was to analyze the results with left ventricular reconstruction surgery using the concept of maximum ventricular reduction, with systematic patch abolition. METHODS Seventy-six consecutive patients with ischemic heart disease (age 30-78 years, mean 57.6 ± 10.1), evolving in functional class III and IV underwent surgical ventricular reconstruction with no use of intracavitary patches or Teflon strips for closing the left ventriculotomy. RESULTS The left ventricular end-systolic diameter decreased from 52.3 ± 5.4 in the preoperative period to 45.2 ± 6.9 mm in the postoperative period. LV ejection fraction increased from 34.2% ± 10.4% to 45.5% ± 9.4%. Associated CABG was performed in 75/76 patients with a mean of 2.4 grafts per patient. The 30-day mortality was 3/76 (3.9%). At an average follow up of 39 months, the majority of the patients (91.4%) remain in functional class I and II. CONCLUSION The concept of maximizing LV reduction with systematic patchless reconstruction is feasible, safe and effective, the early and late outcomes comparing favorably to previous series reported in the medical literature. Additionally, the concept meets the contemporary pathophysiologic basis of heart failure.

Miniesternotomia na cirurgia de revascularização miocárdica sem circulação extracorpórea

Objective: Patients with isolated lesions of the proximal left anterior descending artery (LAD) have been demonstrated to benefit more from surgical treatment than percutaneous coronary interventions (PCI). However, with the less invasiveness of PCI, the majority of the patients have been referred for this latter procedure. We report herein on the inferior ministernotomy approach for the treatment of patients with single LAD lesions, with off-pump anastomosis of the left internal thoracic artery graft. Method: Fourteen patients, consecutively operated on using this technique with the LITA graft anastomosed to the LAD, were examined. The mean age of the patients was 56.7 ± 10.1 years. The length of the skin incision varied from 7 to 9 cm and only the distal sternum was split lengthwise. The anastomosis was facilitated with the use of an Octopus-3 stabilizer (Medtronic). Results: All patients had satisfactory postoperative outcomes, the length of postoperative hospital stay ranged from 2 to 6 days (median 3 days). No ECG changes or enzymatic rises were seen in this series. One patient was readmitted for wound infection. Conclusion: The ministernotomy approach allows safe accomplishment of off-pump LAD grafting, providing the longterm benefits of using the LITA.

O conceito renovado da operação de Batista na cardiomiopatia isquêmica: máxima redução ventricular

OBJECTIVES The reconstruction of the left ventricle (LV) is effective in the treatment of ischemic cardiomyopathy with large akinetic or dyskinetic areas. However, late survival outcomes are related to the remnant left ventricular cavity size, thus eliminating intracavitary patch placement provides additional LV reduction. The aim of this study was to analyze the results with left ventricular reconstruction surgery using the concept of maximum ventricular reduction, with systematic patch abolition. METHODS Seventy-six consecutive patients with ischemic heart disease (age 30-78 years, mean 57.6 ± 10.1), evolving in functional class III and IV underwent surgical ventricular reconstruction with no use of intracavitary patches or Teflon strips for closing the left ventriculotomy. RESULTS The left ventricular end-systolic diameter decreased from 52.3 ± 5.4 in the preoperative period to 45.2 ± 6.9 mm in the postoperative period. LV ejection fraction increased from 34.2% ± 10.4% to 45.5% ± 9.4%. Associated CABG was performed in 75/76 patients with a mean of 2.4 grafts per patient. The 30-day mortality was 3/76 (3.9%). At an average follow up of 39 months, the majority of the patients (91.4%) remain in functional class I and II. CONCLUSION The concept of maximizing LV reduction with systematic patchless reconstruction is feasible, safe and effective, the early and late outcomes comparing favorably to previous series reported in the medical literature. Additionally, the concept meets the contemporary pathophysiologic basis of heart failure.

Surgical myocardial revascularization: off-pump use of bilateral internal thoracic artery grafting.

BACKGROUND Advances in surgical myocardial revascularization (MR) have introduced additional benefits with the off-pump (OP) technique and the use of bilateral internal thoracic artery (ITA) grafting. Off-pump surgical MR has been associated with improved immediate outcomes and reduced incidence of perioperative complications, and the use of bilateral ITA grafts provides increased survival and decreased cardiovascular events in the long term. OBJECTIVE To present the initial experience with the combined use of these advances in surgical MR. METHODS A total of 35 consecutive patients undergoing off-pump MR with bilateral ITA grafting were studied; the left ITA was directed toward the anterior descending artery and the right ITA was anastomosed to the circumflex artery branches. The predominant comorbidities were previous myocardial infarction in 71.4% of the patients, diabetes mellitus in 34.2%, and renal failure in 14.2%. RESULTS No patients presented electrocardiographic changes or enzyme elevation in the postoperative period. The number of bypasses per patient ranged from two to four (median of three bypasses/patient). Postoperative hospital stay ranged from three to 12 days (mean of 4.7 + 1.7 days). No cases of sternal dehiscence or infection were observed, but one patient suffered a stroke on the fourth postoperative day and died. Late follow-up lasted from four to 48 months. No late deaths occurred, 31 patients are asymptomatic, and three have residual angina. CONCLUSION The combination of these technical advances in surgical myocardial revascularization proved efficient and able to contribute to improved benefits in the long term.

Cirurgia de revascularização miocárdica em pacientes com artéria circunflexa anômala

The anomalous origin of the circumflex artery (Cx) is uncommon and presents course variations that might make the coronary artery bypass surgery (CABG) difficult. Two patients presenting unstable angina were submitted to coronary angiography that disclosed tri-vessel disease and presence of Cx with an anomalous origin and retroaortic course with severe stenosis. Both patients underwent CABG with use of bilateral internal thoracic artery (ITA) grafts. Therefore, CABG with bilateral ITA use is feasible in cases of an anomalous origin of the Cx artery. However, this finding may constitute an additional technical setback.