Guilherme Flora Vargas

Transplante cardíaco ortotópico: experiência na Universidade Federal de São Paulo

Foram realizados no periodo de novembro de 1986 a abril de 1997, 92 transplantes ortotopicos, com receptores na faixa etaria de 3 a 63 anos (media de 44,9 anos). Os diagnosticos pre-operatorios foram de miocardiopatia dilatada em 42 (44,6%) pacientes, isquemica em 23 (25,0%), chagasica em 21 (22,8%), valvar em 3 (3,2%) e outras miocardiopatias em 3 (3,2%) pacientes. A tecnica operatoria empregada (Lower e Shumway, em 1960) foi satisfatoria e sem complicacoes. O tempo de isquemia - mais longo nos transplantes com captacao a distância - foi sempre inferior a quatro horas. As complicacoes relacionadas ao uso cronico de imunossupressores foram, principalmente, hipertensao arterial (84,6%), hiperuricemia (75,4%) e dislipidemia (63,0%). Quanto as infeccoes, houve predominio das virais, com 42 (45,6%) casos, seguidas das bacterianas, com 35 (38,0%) casos, e das por protozoarios, com 15 (16,3%) casos. Dentre as infeccoes bacterianas, sete foram do sitio cirurgico, com boa evolucao. Das infeccoes por protozoarios, sete (46,6%) forma por reativacao do Trypanosoma cruzi. A mortalidade geral nos primeiros 30 dias do pos-operatorio foi de 17,3% e teve, como principais causas: infeccao, complicacoes neurologicas e rejeicao. Apos esses 30 dias e ate o primeiro ano, houve 10 (10,3%) obitos, com predominio de rejeicao e infeccao como causas. Apos o primeiro ano de pos-operatorio, houve 13 (14,0%) falecimentos, por causas diversas, como: morte subita, infeccao, rejeicao, alem de outras. A curva actuarial mostrou no 1o, 2o, 3o, 4o, 5o e 6o anos uma sobrevivencia de receptores de 71,6%, 66,6%, 60,5%, 54,4%, 54,4%, 54,4%, respectivamente. Nao houve perda de seguimento de paciente, e os sobreviventes ate a conclusao do trabalho encontravam-se bem, todos em classe funcional I da NYHA. Os autores concluem que e possivel a realizacao de transplante cardiaco em nossa comunidade com sobrevivencia e taxa de complicacoes pos-operatorias aceitaveis, porem diferentes das estatisticas internacionais.

Cryopreserved Aortic Homograft for Aortic Valve Replacement. Immediate Results

OBJECTIVE: To assess immediate clinical and echocardiographic results of the use of cryopreserved aortic homografts for aortic valve replacement. METHODS: Eighteen patients with aortic valve disease underwent aortic valve replacement, receiving a cryopreserved aortic homograft, 15 were male, 10 had aortic regurgitation, and 8 had aortic stenosis. Age ranged from 18 to 65 years (mean, 44.5 ± 18.14 years). Four patients had infective endocarditis, 12 patients were in functional class II, and 6 patients were in functional class III (NYHA). Left ventricular function was normal in 15 patients. RESULTS: Hospital mortality was 5.5% (1 patient) due to respiratory distress; the other patients were discharged from the hospital between the fifth and eighth postoperative days in functional class I. Maximal aortic transvalvular gradient, on echocardiography, ranged from 0 to 30 mmHg, with a mean of 10.9 ± 9.2 mmHg. Five patients did not have any degree of regurgitation through the aortic homograft, 11 patients (61.1%) had minimal regurgitation, and 2 had mild regurgitation. Duration of extracorporeal circulation ranged from 130 to 220 minutes (mean, 183.9 ± 36.7 minutes). Duration of aortic clamping ranged from 102 to 168 minutes (mean, 139.14 ± 25.10 minutes). Bleeding in the postoperative period ranged from 210 to 1220 mL, with a mean of 511.4 ± 335.1 mL. Reoperations were not necessary. Duration of orotracheal intubation ranged from 2 hours 50 minutes to 17 hours with a mean of 9.14 ± 3.6 hours. CONCLUSION: Cryopreserved aortic homografts may be routinely used with low hospital morbidity and mortality.

Cardiopulmonary bypass increases the risk of vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure

Objective Coronary artery bypass grafting is currently the best treatment for dialysis patients with multivessel coronary artery involvement. Vasoplegic syndrome of inflammatory etiology constitutes an important postoperative complication, with highly negative impact on prognosis. Considering that these patients have an intrinsic inflammatory response exacerbation, our goal was to evaluate the incidence and mortality of vasoplegic syndrome after myocardial revascularization in this group. Methods A retrospective, single-center study of 50 consecutive and non-selected dialysis patients who underwent myocardial revascularization in a tertiary university hospital, from 2007 to 2012. The patients were divided into 2 groups, according to the use of cardiopulmonary bypass or not (off-pump coronary artery bypass). The incidence and mortality of vasoplegic syndrome were analyzed. The subgroup of vasoplegic patients was studied separately. Results There were no preoperative demographic differences between the cardiopulmonary bypass (n=20) and off-pump coronary artery bypass (n=30) group. Intraoperative data showed a greater number of distal coronary arteries anastomosis (2.8 vs. 1.8, P<0.0001) and higher transfusion rates (65% vs. 23%, P=0.008) in the cardiopulmonary bypass group. Vasoplegia incidence was statistically higher (P=0.0124) in the cardiopulmonary bypass group (30%) compared to the off-pump coronary artery bypass group (3%). Vasoplegia mortality was 50% in the cardiopulmonary bypass group and 0% in the off-pump coronary artery bypass group. The vasoplegic subgroup analysis showed no statistically significant clinical differences. Conclusion Cardiopulmonary bypass increased the risk for developing postoperative vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure.

Tratamento cirúrgico das valvopatias aórticas com bioprótese de pericárdio bovino sem suporte: resultados imediatos

OBJECTIVE To present the immediate results and assess the clinical and hemodynamic performance of stentless bovine pericardial bioprostheses in aortic position. METHODS Twenty patients were operated who were indicated for surgery for valve replacement with biological prosthesis. Eleven patients were male; sixteen had aortic stenosis; four, insufficiency; the mean age was 66.3 +/- 8.8 years. The surgical technique used was subcoronary implant. Associated procedures were performed in five patients. Postoperative morbidity, mortality and hemodynamic performance were assessed on transthoracic echocardiogram. RESULTS Mean time of cardiopulmonary bypass was 136.5 +/- 24.41 minutes and mean anoxic time was 105.2 +/- 21.62 minutes. Hospital mortality was 5% (one patient). Mean time of intensive care unit stay was 3.65 +/- 3.23 days. Mean postoperatively transvalvular gradient was was 25.39 +/- 7.82 mmHg. Left ventricle ejection fraction was 67 +/- 13.49% preoperatively and 63.24 +/- 16.06% postoperatively (p = 0.45). Eleven patients did not present any degree of valve regurgitation, eight presented mild regurgitation and one ,mild to moderate regurgitation. CONCLUSION Stentless prostheses can be used for the surgical treatment of aortic valve diseases, with in hospital mortality and morbidity similar to the mortality and morbidity described in the literature for similar procedures, with satisfactory hemodynamic performance.

Acido tranexâmico e hemostasia em cirurgia de revascularização do miocárdio com circulação extracorpórea

The synthetic antif ibrinolytic drug tranexamic acid was evaluated in its hemostatic and blood saving effects, in patients submitted to myocardial revascularization with extracorporeal circulation. To 40 patients were administered placebo and to 55 tranexamic acid I.V. in a dosage of 10 g in the operative period (2 g in the anesthetic induction and the remaining 8 g in a continuous way during the operative procedure). Tranexamic acid, in this dosage, has proved to have a very impressive hemostatic effect, leadir g to a reduction in post operative bleeding of 47% in 12 h, 42,5% in 24 h and 40,5% when drains were taken off, related to the control group (p < 0.05). Tranexamic acid have led to less utilization for homologous paked red cells per patient, but statistical significance was found only in the 24 h of post operative period, with 1,025 units/patient in control group and 0,333 units/ patient in treated group. Concerning post operative complications, there have been more neurological alterations without sequelae (2.5% against 12.7%) and creatinin alterations (5% against 10.9%) in the tranexamic acid group. Such alterations were attributed to the high dosage used. As a conclusion, we do not recommend routine use of tranexamic acid to patients submitted to myocardial revascularization in the dosage of 10 g I.V., but, owing to the evident hemostatic effect of the drug, we recommend more investigations concerning the ideal dosage and way of administration.

Echocardiography in Fever Investigation in Patient with Long Term Central Venous Catheter

O Ecocardiograma Transtoracico (ETT), por ser um metodo de facil acesso, nao invasivo, de baixo custo e rapida disponibilidade, tornou-se o exame de imagem mais frequentemente utilizado como meio inicial para avaliar nao apenas as doencas cardiovasculares, como tambem investigar complicacoes relacionadas a presenca de cateteres. Porem, essas complicacoes nem sempre sao visiveis ao ETT, necessitando, muitas vezes, da complementacao diagnostica com o Ecocardiograma Transesofagico (ETE)2.

Myocardial Revascularization in Dyalitic Patients: In-Hospital Period Evaluation

Background Coronary artery bypass grafting currently is the best treatment for dialytic patients with multivessel coronary disease, but hospital morbidity and mortality related to procedure is still high. Objective Evaluate results and in-hospital outcomes of coronary artery bypass grafting in dialytic patients. Methods Retrospective unicentric study including 50 consecutive and not selected dialytic patients, who underwent coronary artery bypass grafting in a tertiary university hospital from 2007 to 2012. Results High prevalence of cardiovascular risk factors was observed (100% hypertensive, 68% diabetic and 40% dyslipidemic). There was no intra-operative death and 60% of the procedures were performed off-pump. There were seven (14%) in-hospital deaths. Postoperative infection, previous heart failure, cardiopulmonary bypass, abnormal ventricular function and surgical re-exploration were associated with increased mortality. Conclusion Coronary artery bypass grafting is feasible to dialytic patients although high in-hospital morbidity and mortality. It is necessary better understanding about metabolic aspects to plan adequate interventions.

Sildenafil improves right ventricular function in a cardiac transplant recipient

We report the case of a male patient who underwent orthotopic cardiac transplantation. A marginal donor was used, because the recipients clinical condition was critical. He experienced cardiogenic shock due to right ventricular dysfunction secondary to pulmonary hypertension associated with vasoplegia. After the introduction of sildenafil, the patient recovered hemodynamically, his pulmonary vascular resistance decreased, the vasoactive drugs were withdrawn, and his right ventricular function improved.