José Carlos R Iglézias

Preditores de mortalidade hospitalar no paciente idoso portador de doença arterial coronária

Introduction: The trend in Brazil of erroneously delaying myocardial revascularization in the elderly determined this study. Three hundred consecutive elderly patients (mean age: 73.92, standard deviation: 3.32). Material and Methods: Between October 1992 and July 1995, 361 consecutive patients underwent isolated coronary artery bypass grafting, of whom 111 (30.7%) were females and 250 (69.35) males. There were 128 (35.5%) diabetic patients and 128 (36.7%) were in NYHA III/IV. Univariate analysis perioperatory of 19 factors followed by multivariate logistic regression analysis of the significant variables (p < 0.005) were done. Results: Major complication occurred in 178 (49.3%) and were independent predictors of operative morbidity: Diabetes mellitus, NYHA functional classification, urgent cases and DP2. There were 33 (9.1 %) in hospital deaths, and diabetes mellitus, NYHA functional classification, unstable preoperative angina and cerebral vascular accident, renal failure, infection and insufficiency respiratory failure were independent predictors of operative mortality. Conclusion: The coronary artery bypass grafting is possible in elderly patients with a favorable outcome, especially when done in patients with normal to moderately depressed left ventricular function.

Fatores prognósticos na revascularização do miocárdio em pacientes idosos

The trend in Brazil of erroneously delaying myocardial revascularization in the elderly determined this study. Three hundred consecutive elderly patients (mean age: 73,92, standard deviation: 3.32). Between October 1992 and July 1995, 361 consecutive patients underwent isolated coronary artery bypass grafting, of whom 111 (30,7%) were females and 250 (69,35) males. There were 128 (35,5%) diabetic patients and 128 (36,7%) were in NYHA III/IV. Univariate analysis per-operatory of 19 factors followed by multivariate logistic regression analysis of the significant variables (p 0.005) were done. Major complication ocurred in 178 (49.3%) and were independent predictors of operative morbidity: Diabetes mellitus, NYHA funcional classification, urgent cases and DP2. There were 33 (9,1%) in hospital deaths, and diabetes mellitus, NYHA functional classification, unstable pre-operative angina and cerebral vascular acidents, renal failure, infection and insufficiency respiratory failure were independent predictors of operative mortality. We concluded that coronary artery bypass grafting is possible in elderly patients with a favorable outcome, especially when done in patients with normal to moderately depressed left ventricular function.

Desfechos clínicos pós-revascularização do miocárdio no paciente idoso

OBJECTIVES Analyze the octogenarians patients submitted to the surgical myocardium revascularization (CABG) with and without extracorporeal comparing the clinical outcomes and its survival curves. METHODS Observational study of the cohort type involving 396 octogenarians submitted to the CABG between 01/01/ 2000 and 01/01/2007. Elaboration of an itinerary for collection of data of the handbooks containing 36 variables. Comparison between groups using t test for independent samples, chisquare and survival curves using Kaplan Meier. RESULTS We analyzed 290 patients that possessed appropriate information. The first group G1, of the patients operated without extracorporeal, was constituted of 111 patients and the second group G2, of the operated ones with extracorporeal was constituted of 179 patients. The univariate analyzes had presented statistics significance for the variables: cardiac insufficiency functional class preoperative (P=0.000), tobacco smoking (P=0.050), number of performed grafts (P=0.050), graft type (P=0,000), associates procedures (P=0.000), preoperative use of intra-aortic balloon (P=0.000), hospital mortality (P=0.000) and type of death (P=0.020). In the postoperative outcomes stroke (P=0,036), re-internment for angina (P=0,038). The analyze of the survival curves presented statistic difference (P=0,009). CONCLUSIONS Hospital mortality and stroke were bigger in the G2 In the long time the patients of the G1 had respectively presented greater number of re-internments for angina and the late mortality was larger in G2 for the largest prevalence of cardiac deaths.

Tratamento cirúrgico da rotura de parede livre do ventrículo esquerdo após infarto agudo do miocárdio

MATERIAL AND METHODS: Between January 1983 and May 1999, 12.405 patients were treated by the surgical team of the Heart Institute (InCor) with the diagnosis of acute myocardial infarction (AMI). From these patients, 127 (1.02%) had left ventricular free wall rupture as an ischemic complication of the myocardial infarction. The cardiac rupture was acute in 98 patients (77.1%) and sub-acute in 29 (22.9%). RESULTS: Twenty-four patients were operated on, 5 on acute rupture with 80% of hospital mortality and 19 on sub-acute rupture with 15.8% of hospital mortality. The post-operative overall survival including both groups was 70.8%. CONCLUSION: The conclusion was drawn that left ventricular free wall rupture is a severe complication of acute myocardial infarction that needs an immediate action. In acute ruptures, most patients develop hemodynamic deterioration without enough time to try to proceed any surgical correction. The sub-acute cases can be detected and monitored through periodic ecocardiographic exams after the AMI. In these cases the early surgical intervention, many times without using extra-corporeal circulation, has been increasing the chances of survival of the majority of these patients.

Angiossarcoma de átrio direito

A 19 years-old-female with primary right atrial angiosarcoma partially obstructing the tricuspid valve, developed severe hypoxemia due-to-right to left shunting through a patent foramen ovale. This is the first report of such a clinical situation with this type of tumor. A complete resection of the tumor was attempted, and the right atrium had to be rebuilt with a bovine pericardial patch. Postoperative cranial, thoracic and abdominal CT scans and bone scintigraphy did not show metastatic spread. Chest radiation therapy was started on the third postoperative week. Chemotherapy was not used. The patient died a few months after surgery due to disseminated metastatic disease but no evidence of the tumor was found in the necroscopic study of the heart.

Degree of risk related to procedures performed in conjunction with surgical myocardial revascularization in octogenarians

INTRODUCTION/OBJECTIVES: We determined the degree of risk produced by the association of other surgical procedures with surgical myocardial revascularization in octogenarian patients and identified the risk factors that best explain hospital mortality. METHODS: This study was an observational analytical historical cohort study involving octogenarians operated on at our institution between January 1, 2000 and January 1, 2005. We stratified the objective population as follows: Group 1 comprised octogenarians revascularized without associated procedures, and Group 2 comprised octogenarians revascularized with associated procedures. Statistical analyses included the t test for independent samples and multiple logistic regression analysis. Significance was accepted with an alpha error of 5%. RESULTS: Univariate analyses revealed the following clinical and statistically significant variables: hospital mortality (P=0.002), diabetes mellitus (P=0.017), preoperative endocarditis (P=0.001), cardiogenic shock (P=0.019), use of an intra-aortic balloon pump (P=0.026), preoperative risk score (Parsonnet), P<0.001, procedure associated with revascularization (P<0.001), medium number of affected coronary arteries (P<0.001), use of extracorporeal circulation (P<0.001), time of extracorporeal circulation (P<0.001), number of distal anastomoses (P=0.002), graft type (P<0.001), postoperative breathing support (P<0.001), stroke (P<0.001), infection (P=0.002), creatinine level (P=0.018), and quality of life score (P=0.050). DISCUSSION/CONCLUSIONS: In octogenarian patients, the need for a procedure associated with surgical myocardial revascularization produces an absolute increase in hospital mortality risk of 45%. The variables that contributed to hospital mortality were preoperative endocarditis, preoperative cardiogenic shock, the use of extracorporeal circulation, the length of time of extracorporeal circulation, postoperative creatinine level, and postoperative need for prolonged respiratory support.

Revascularização do miocárdio no paciente octogenário

Five-hundred and three patients, with age equal or above 80 years, were surgically treated at the Heart Institute from January 78 to July 90. Aiming to characterize this octogenarian population submitted to myocardial revascularization, data were retrospectively pursued. This study analyzed clinical,radiological, hemodynamic, operative and postoperative factors; there was no statistical analysis of the material. Hospital mortality was 2/15 (13.33%) and in a mean follow-up of 24.7 months (5-50) five patients evoluted to death due to hemorrhagic vascular cerebral accident, urinary tract infection, mesenteric thrombosis, pulmonary infection and diabetis dysfunction, secondary to urinary tract infection. All of the survivals improved as to the sintomatology related to angina and cardiac insufficiency. Observations based on the data collected reveal that 1) there was no operative death; 2) hospital mortality was related to infectious processes; 3) in late follow-up the great majority of patients referred improvement as to the sintomatology and therefore in the quality of life, and 4) isolatedly, age did not represent a risk factor for surgical treatment.

Fibroma cardíaco mimetizando cardiomiopatia hipertrófica

A 33 year-old woman was seen, for the first time, ten years ago, for evaluation of a recurrent chest pain, dyspnea and arrhythmia. She was submitted to echocardiographic studies and a cardiac catheterization. The diagnoses was endomyocardial fibrosis at first, and hypertrophic cardiomyopathy after. Despite treatment with propranolol and quinidine, the episodes of dyspnea and tachyarrhythmias became more frequent and severe, and the patient was guided to our Service. Cardiac re-catheterization, echocardiographic and computed tomography studies identified in traumural cardiac fibroma and the patient was referred for surgical treatment. The cardiac fibroma was successfully resected on extracorporeal bypass and with cardioplegic arrest of the heart. Repair of the heart was accomplished with a patch placed to close the left ventricular cavity. The postoperative course was uncomplicated, and she remains assymptomatic two years later. We have emphazied tha this tumor often produces clinically obscure disease, simulating particularly the left ventricle hypertrophic cardiomiopathy.

Revascularização do miocárdio no paciente octogenário: 15 anos de observação

This is a retrospective study where 47 patients submitted to the conventional revascularization of the myocardium were analysed at InCor in a period covering January/78 to January/93; 47 patients were analysed. Thirty-tive (74.46%) were male and 12 (25.33%) female. The mean age was 81.85 (80-80) years. The operatory indication was due to unstable angina in 29 (61.70%), stable angina in 17 (36.17%) and dissection of the atheromatous plaque during angioplasty in 1 (2.12%). The operation was carried out eletively in 33 (70.21 %), in caracter of urgency in 10 (21.27%) and in emergency in 4 (8.51 %). All of them were operated on through median thoracotomy with extracorporeal circulation and moderate hypotermia. The saphenous vein was used as a graft in 41 (87.23%) patients and the internal thoracic artery in 6 (12.76%). Hospital mortality was 8.5% and the mean follow-up time was 17,6 months. From among the early and late deaths only one of each group was related to cardiopathy. Analysis of the cases revealed that in the period of 1991, 1992 and January/1993, hospital mortality fell down to zero. Surgical conventional revascularization of the myocardium represents a good alternative for the octogenarian patient, not only due to the present operative low risk, but as well as the reduction or elimination of the symptoms during the late follow-up.

Tratamento cirúrgico da artéria coronária direita intra-atrial

An intracavitary location of a coronary artery is rare in our surgical experience with revascularization. This variant has occured in the right coronary artery (0.01%) and in left anterior descending coronary artery (0.2%). The location of the lesion and the pathological condition, length and size of the coronary may dictate exposure of an intracavitary coronary artery for proper revascularization; more commonly surgeons are anaware of the intracavitary position and during intramyocardial dissection of an artery will open a cardiac chamber where the vessel traverses the cavity. Problems that arise are introducion of air, dificulty in exposure due to blood and depth of position and obstruction of the coronary artery during closure of the myotomy. Three patients are presented who required revascularization of intracavitary vessels (three right coronary arteries). The location and lenght of the intracavitary portion of the artery determined the surgical management the methods used to close the cavity varied. The techniques employed were simple closure moving the artery into an aerial position with cavitary closure using bovine pericardium; anastomosis in the intracavitary position with closure of the myotomy, or selection of an alternate distal site for anastomosis.