Henrique Murad

One-stage management of infected sternotomy wounds using bilateral pectoralis major myocutaneous advancement flap

OBJECTIVE To assess the results of single-stage treatment of infected sternotomy wounds using bilateral pectorals major myocutaneous advancement flaps. METHODS Between January 2000 and July 2007, 1972 heart surgeries with median transesternal thoracotomy were performed. Thirteen (0.65%) patients presented wound infections and dehiscence after sternotomy. To treat those patients we adopted exclusively single-stage management, drainage, early intervention and immediate wounds closure using bilateral pectoralis major myocutaneous advancement flaps to the medium line of the sternum. Two patients with superficial wounds infection and other two who underwent torsion adjustment of the steel wire were not included in this study. RESULTS There was one death in the 30-day postoperative period. There was no intraoperative death. Four patients needed additional surgical intervention to drain residual seroma or local infection. There was total resolution of the sternal infection in 12 patients. CONCLUSION The authors recommend the single-stage early management of sternotomy infected wounds with debridement, drainage and immediate closure of the wound using bilateral pectoralis major myocutaneous advancement flaps to the medium line of the sternum. The procedure is effective and may contribute to decrease the morbidity.

Myocardial revascularization surgery using composite Y-graft of the left internal thoracic artery: blood flow analysis

OBJECTIVE: To assess the left internal thoracic artery (LITA) flow pattern, when it was used to supply the left anterior descending artery (LADA) and another branch from the left coronary artery system (LCAS). METHODS: In the following study, the left internal thoracic artery flow was investigated by echocardiography Doppler, at rest and under dobutamine stress, in two twenty-patient groups. Group A consisted of patients who received only a pedicled LITA graft to the LADA. Group B consisted of patients who received a pedicled LITA graft associated with a vein graft to supply the LADA and another artery from the LCAS. The angiographic study showed graft patency in all patients from both groups. The following parameters were used: systolic flow (SF), diastolic flow, total flow, total flow in stress/total flow at rest ratio (TFS/TFR), systolic peak velocities (SPV), diastolic peak velocities and systolic peak velocity/diastolic peak velocity ratio. RESULTS: All analysed parameters were considered statistically significant, except SF, TFS/TFR and SPV. CONCLUSIONS: We concluded that in the same conditions and methodology, the LITA flow in the composite graft (group B) is higher than in the free graft (group A), which shows the great flow adaptability of LITA to respond to flow demand.

Quality control in cardiovascular surgery: a new paradigm

The objective is to write a literature review of the relevant information related to quality control in cardiovascular surgery. The authors have studied several parameters to allow quality control in cardiovascular surgery: 1. Construction of a database as complete as possible to the similar ones of the Society of Thoracic Surgeons and the European Association for Cardio-thoracic Surgery; 2. To create a surgical risk model like the Euroscore; 3. To make an analysis of the different reasons for a poor surgical outcomes and try to correct them; 4. To study the human factor as an important element to the surgical outcome and discuss methods to avoid erros in an action similar to the ones used in aviation. Enabling a tight control of quality in cardiovascular surgery it is possible to obtain a major improvement in surgical outcomes.

Molecular evaluation of the great vessels of patients with bicuspid aortic valve disease

OBJETIVO: A valva aortica bicuspide (VAB) esta associada a maior prevalencia de ectasia anulo-aortica, aneurisma e disseccao da aorta ascendente. Este estudo investigou a quantidade de fibrilina-1 e elastina nos grandes vasos de portadores de VAB. METODO:Amostras de tecidos foram colhidas da aorta ascendente e tronco da arteria pulmonar de 22 portadores de VAB e 16 portadores de valva aortica tricuspide (VAT) submetidos a cirurgia cardiaca, incluindo seis portadores de valva aortica normal, provenientes do programa de transplante. Imunofluorescencia indireta e analise computadorizada de imagens foram utilizadas para quantificacao das proteinas na camada media dos vasos, expressas como densidade optica integrada media (DOI). RESULTADOS: Na aorta, a DOI especifica para fibrilina-1 foi 15 ± 8 no grupo bicuspide e 24 ± 7 no grupo tricuspide (p=0,001). Na arteria pulmonar, a DOI especifica para fibrilina-1 foi 18 ± 10 no grupo bicuspide e 25 ± 9 no grupo tricuspide (p=0,07). A DOI especifica para elastina na aorta foi 34 ± 13 no grupo bicuspide e 36 ± 19 no grupo tricuspide (p=0,31). Na arteria pulmonar, a DOI para elastina foi 30 ± 12 no grupo bicuspide e 29 ± 14 no grupo tricuspide (p=0,34). CONCLUSOES: Os portadores de VAB apresentaram menor quantidade de fibrilina-1, mas nao elastina, na aorta ascendente e arteria pulmonar que os portadores de VAT normal ou doente. Estes achados podem explicar a maior incidencia de dilatacao e disseccao da aorta ascendente em portadores desta ma-formacao da valva aortica.

Valva aórtica bicúspide: fundamentos teóricos e clínicos para substituição simultânea da aorta ascendente

Bicuspid aortic valve (BAV) is associated with annuloaortic ectasia, dissection and ascending aortic aneurysm. The high incidence of this congenital malformation and aortic disease suggests a close correlation between the two phenomena. Abnormalities in different phases of cell migration of the neural crest might be responsible for the occurrence of abnormalities in the aortic valve, media layer of the ascending aorta and vessels of the aortic arch. Previous studies have shown that patients with normal BAV or slight dysfunction may present with dilation of the aortic root. The hemodynamic changes caused by BAV without stenosis or insufficiency seem to be an insufficient explanation for these findings. Several mechanisms have been proposed to explain the molecular and hystological aspects of this disease. We found a reduced fibrillin-1 content in both ascending aorta and pulmonary trunk as a possible cause. Histologically, the ascending aorta can present cystic medial necrosis and elastic fragmentation, similar to Marfans disease. Some authors concluded that many patients, mainly those with aortic regurgitation, should have the aortic valve and the ascending aorta replaced at the same procedure, even if a mild dilatation (45 mm) is present in patients with BAV if life expectancy is anticipated to be greater than 10 years to prevent further aneurysms or ruptures.Bicuspid aortic valve (BAV) is associated with annuloaortic ectasia, dissection and ascending aortic aneurysm. The high incidence of this congenital malformation and aortic disease suggests a close correlation between the two phenomena. Abnormalities in different phases of cell migration of the neural crest might be responsible for the occurrence of abnormalities in the aortic valve, media layer of the ascending aorta and vessels of the aortic arch. Previous studies have shown that patients with normal BAV or slight dysfunction may present with dilation of the aortic root. The hemodynamic changes caused by BAV without stenosis or insufficiency seem to be an insufficient explanation for these findings. Several mechanisms have been proposed to explain the molecular and hystological aspects of this disease. We found a reduced fibrillin-1 content in both ascending aorta and pulmonary trunk as a possible cause. Histologically, the

Plastia valvar mitral na doença cardíaca reumática e degeneração mixomatosa: estudo comparativo

The differential pressure/pressure transmitter of the present invention detects overpressures by using pre-loading diaphragms. The differential pressure/pressure transmitter of the present invention is provided with a high pressure-side diaphragm assembly 24 having a high pressure-side process diaphragm 34, which transfers high pressure from a process to the high pressure-side transfer oil, and a high pressure-side pre-loading diaphragm 32. The differential pressure/pressure transmitter is also provided with a low pressure-side diaphragm assembly 25 having a low pressure-side process diaphragm 38 and a low pressure-side pre-loading diaphragm 36. A differential pressure sensor assembly is provided to detect the pressure difference between the high pressure-side transfer oil from the high pressure-side diaphragm assembly and the above low pressure-side transfer oil from the low pressure-side diaphragm assembly.

Surgical treatment of mitral valve insufficiency by valve repair

OBJECTIVE: To analyze the short term results of mitral valve repair in a consecutive series of mitral insufficiency patients from different ethiologies. METHODS: A retrospective study was made of 86 patients with mitral insufficiency operated on between May 1992 and May 2001 for mitral valve repair. Mitral insufficiency was severe in 77 patients and moderate in 9. The functional class of the patients was I in 4, II in 48, III in 29 and IV in 5 patients. The etiology was rheumatic in 47 (54.6%) cases. RESULTS: Mitral valve repair was performed by only one procedure on the mitral valve in 6 patients, two procedures in 29, and three or more procedures in 51 (59.3%) patients. Mitral annuloplasty was performedin 81 patients, with the Braile posterior pericardial ring being the mostcommonly used (87.2%). Hospital mortality was 3.5%. There was improvement in the funcional class in 79 (91.8%) patients. Mitral valve function was normal in 80 (93%) patients and moderate mitral insufficiency occurred in 6 patients. CONCLUSION: Mitral valve repair can be performed with low mortality (3.5%) and high probability of valve function recovery (93%). It should be the procedure of choice in patients with mitral insufficiency.

Circulação extracorpórea com desvio veno-arterial e baixa pressão parcial de oxigênio

PURPOSE: This study is divided into 2 parts, an experimental study to establish a technique of extracorporeal circulation with low oxygen partial pressure and a clinical study to show the feasibility in humans. MATERIAL AND METHODS: Experimental surgery with extracorporeal circulation was performed in 20 dogs divided into 2 groups of ten. In group I, cannulation was done first in the superior vena cava, then in the inferior vena cava, keeping normal heartbeat and breathing, controlled by a respirator and pure oxygen. After passing through a heat exchanger, the blood of each vena cava was injected in the femoral artery. Blood samples from the aorta were taken above the diaphragm in every 30 minutes to check gasometric values. In group II, the right atrium was drained and half of the blood injected in the pulmonary artery with another pump and picked up through the left ventricle to the reservoir that also works as a heat exchanger. The mixed blood (50% arterial and 50% venous) was re-injected by another pump in the arterial circulation. The heart was maintained fibrillating and the breathing controlled by the respirator. In the clinical study, 40 patients were divided into 2 groups of 20 each. In group A the patients were bypassed in the conventional manner, that is, compressed air and oxygen in the oxigenator with high arterial pO2. In group B, pure oxygen was used in the membrane oxigenator and venous-arterial shunt, performed between 40% to 50%. RESULTS: In both groups, from a physiologic point of view there was shunting of 50% of venous blood to the arterial circulation and arterial blood flow was maintained high (around 100 ml\kg\min). It was observed that the arterial pO2 in both groups remained between 50 and 100 mmHg and venous saturation between 50 and 70%. All animals woke up at end of the experiment. In the clinical study, the arterial pO2 was a low 60 mmHg. Comparison of the clinical results showed there was no mortality difference between both groups, but in the group B, with the low pO2 and venous-arterial shunt, the post-operative bleeding was significantly smaller, having been used three times less blood and no need to use the blender.

Gradiente residual em operação de valva aórtica

OBJECTIVES: Evaluate residual pressure gradients after aortic valve replacement surgery in our Institution. MATERIAL AND METHODS: Between January 1988 and December 1998, 44 patients with isolated aortic stenosis underwent surgery and received a valve prosthesis size 23 or smaller. Echocardiographic studies were performed at our Institution before surgery and six months postoperatively. There were 28(63.6%) males, with an average age of 53.9, and an average body surface area of 1.67 m2. Preoperative average transvalvar pressure gradient was 95.8 mmHg. Twelve patients were in functional class II, 28 in class III, and 4 in class IV. Bioprostheses were implanted in 25 patients, and mechanic prostheses in the other 19, 11 of which received a bileaflet prostheses. RESULTS: Six months after surgery 35 (79.5%) patients were in functional class I, and 9 (20.5%) in class II. Average gradient variation was 62.9 mmHg. The average residual postoperative gradient was 32.9 mmHg. The gradient reduction was not influenced by sex, age, body surface area, or size of the valve prosthesis. The gradient variation was directly proportional to the preoperative gradient. Regarding type of valve prosthesis, the average residual gradient was 24.3 mmHg for the bileaflet mechanical prosthesis, 33.7 mmHg for the bioprosthesis, and 42.3 mmHg for the single leaflet mechanical prosthesis. CONCLUSION: Gradient variation was directly influenced by the preoperative gradient. The best results regarding residual gradients were achieved with bileaflet mechanical prostheses, followed by bioprostheses and single leaflet mechanical prostheses. Use of a smaller than recommended for body surface area prosthesis, avoiding aortic annulus enlargement procedures, was not related to higher residual gradients in this group of patients.

The Role of Age in the Abdominal Aortic Aneurysm Repair

ge is a factor to be considered in any minimally invasive new surgical procedure like endovascular aneurysm repair (EVAR). There is a growing policy of using less invasive procedures looking for rapid recovery, less blood transfusion, less surgical trauma, less morbidity and less mortality. The two major questions that need to be answered when we are faced with endovascular treatment of aneurysms (AAA) are: 1. Can we offer surgical treatment to older patients, otherwise not candidates for surgery, with low surgical mortality and morbidity?; 2. Are the results equivalent to those obtained with the open procedure, so we can offer EVAR even to younger patients? Those questions are issued in the paper “Is age a determinant factor in EVAR as a predictor of outcomes or in the selection procedure? Our experience”