José Honório Palma

Implante transapical de valva aórtica: resultados de uma nova prótese brasileira

OBJETIVO: A troca valvar aortica e procedimento rotineiro com risco aceitavel. Em alguns casos, a mortalidade e elevada, levando a contraindicacao do procedimento, apesar dos sintomas. O implante minimamente invasivo transcateter de valva aortica parece ser uma alternativa, reduzindo a morbi-mortalidade. O objetivo deste estudo foi o desenvolvimento e implante de nova protese para implante transcateter. METODOS: Apos desenvolvimento em animais, uma protese transcateter, balao-expansivel foi utilizada em 14 casos de alto risco. O EuroSCORE medio foi de 43,7%. Quatro pacientes apresentavam disfuncao de bioproteses e o restante, estenose aortica calcificada. Todos os pacientes eram sintomaticos. Os procedimentos foram realizados em ambiente cirurgico hibrido, sob controle ecocardiografico e fluoroscopico. Com o uso de minitoracotomia esquerda, as proteses foram implantadas atraves do apice ventricular, sob estimulacao ventricular de alta frequencia ou choque hemorragico controlado, apos valvoplastia aortica. Foram realizados controles clinicos e ecocardiograficos seriados. RESULTADOS: A correta liberacao da protese foi possivel em 13 casos. Uma conversao ocorreu. Nao houve mortalidade operatoria. O gradiente de pico medio pos-implante foi de 25 mmHg. A fracao de ejecao apresentou aumento significativo apos o 7o pos-operatorio. Insuficiencia aortica residual nao significativa esteve presente em 71% dos casos, nenhuma significativa. Nao ocorreu complicacao vascular periferica. Nao houve necessidade de marcapasso definitivo. Um caso de acidente vascular cerebral ocorreu. A mortalidade geral foi de 42%. CONCLUSAO: O implante transapical de valva aortica transcateter e um procedimento possivel com esta nova protese. O comportamento hemodinâmico foi satisfatorio. Sao necessarios estudos de longo prazo e com maior poder amostral, no intuito de determinar a real eficacia e indicacao do procedimento alternativo.

Diretrizes para o tratamento cirúrgico das doenças da aorta da Sociedade Brasileira de Cirurgia Cardiovascular

1. Full member of the Brazilian Society of Cardiovascular Surgery. Master in Cardiology by the Federal University of Rio Grande do Sul. Cardiovascular surgeon of Hospital Sao LucasPUCRS, Porto Alegre-RS 2. Adjunct Director of the Postgraduation Course of the Medicine School in Sao Jose do Rio Preto (Famerp) Professor Livre Docente of Famerp and Unicamp Editor of BJCVS 3. Professor Livre Docente of Cardiovascular Surgery of Unifesp President of the Endovascular Section of the BSCVS 4. PhD. Professor of Cardiovascular Surgery of the Medicine School/ UFRGS. President of the Commission in favor of the Profession in BSCVS Editores: Luciano Cabral ALBUQUERQUE1, Domingo Marcolino BRAILE2, Jose Honorio PALMA3, Eduardo Keller SAADI4. Revisores: Walter Jose GOMES5, Enio BUFFOLO6 Braz J Cardiovasc Surg 2007; 22(2): 137-159 SPECIAL ARTICLE

Implante transapical de endoprótese valvada balão-expansível em posição aórtica sem circulação extracorpórea

OBJECTIVE The aortic valve replacement is a routine procedure, and involves replacement of the native valve/prosthesis. In most of the patients who undergo such procedure the risk is acceptable, but in some cases, such risk can justify contraindication. The minimally invasive transcatheter aortic valve implantation without cardiopulmonary bypass (CPB) has been shown to be viable, with lower morbidity and mortality. The aim of this study was to develop a catheter-mounted aortic bioprosthesis for implantation without CPB. METHODS After developing in animals, three patients with high EuroSCORE underwent implantation. Case 1: patients with bioprosthesis dysfunction; Case 2: severe aortic stenosis; Case 3: dysfunction of aortic bioprosthesis. After minithoracotomy and under echocardiographic and fluoroscopic control, a balloon catheter was placed on aortic position and inflated. After, a second balloon with valved endoprosthesis was positioned and released under high ventricular rate. Echocardiographic and angiographic controls were performed and the patients were referred to ICU. RESULTS In the first case, implantation without CPB was possible with appropriate results. The patient evolved with improvement of ventricular function. After, this patient developed bronchopneumonia, tracheoesophageal fistula and died due to mediastinitis. Autopsy confirmed proper valve positioning and leaflets preservation. The second case showed the device migration after inflation of the balloon, with the need for urgent median sternotomy, CPB and conventional valve replacement. This patient evolved well and was discharged from the ICU on the 14th postoperative day without complications. This patient developed respiratory infection, septic shock and died on the 60th postoperative day. The patient from the third case underwent successful implantation. CONCLUSION The off-pump transapical implantation of catheter-mounted bioprosthesis was shown to be a feasible procedure. Technical details and learning curve require further discussion.Objective: The aortic valve replacement is a routine procedure, and involves replacement of the native valve/ prosthesis. In most of the patients who undergo such

Tricuspid transcatheter valve-in-valve: an alternative for high-risk patients

Tricuspid valve disease is not uncommon. Some patients with tricuspid valve disease require tricuspid replacement with bioprosthesis and, over time, may require re-interventions. Transcatheter tricuspid valve-in-valve approach has emerged as an alternative to treat dysfunctional bioprosthesis. In this article, we report a case of a patient with four previous cardiac interventions presenting with tricuspid bioprosthesis dysfunction. The patient was treated with the transcatheter transatrial tricuspid valve-in-valve procedure. The procedure was successful with no residual leakage and a non-significant mean gradient. The patient recovered well and was discharged in 1 week. The procedure is a feasible alternative for high-risk patients. Selection and postoperative care are crucial for the outcome.

Implante transcateter de valva aórtica: resultados atuais do desenvolvimento e implante de um nova prótese brasileira

OBJECTIVE Aortic valve replacement is a routine procedure with acceptable risk, but in some cases, such risk can justify contraindication. Minimally invasive transcatheter aortic valve implantation has emerged as an alternative, with lower morbidity and mortality. The aim of this study was clinical, safety and efficacy assessment. METHODS Thirty-three high risk patients underwent transcatheter balloon expandable aortic valve implantation. Mean Logistic EuroScore risk was 39.30% and STS score 30.28%. Eight patients presented with dysfunctional bioprosthesis, remaining ones presented calcified aortic stenosis. Procedures were performed in a hybrid OR under fluoroscopic and echocardiography guidance. Using a left minithoracotomy the prosthesis were implanted trough the ventricular apex under rapid ventricular pacing or hemorrhagic shock. Echocardiographic and angiographic controls were performed. RESULTS Implant was feasible in 30 cases. Three conversions occured. There was only one case of operative death. Median transvalvular aortic gradient reduced from 43.58 mmHg to 10.54 mmHg. Left ventricular function improved in the first 7 postoperative days. Paravalvular aortic regurgitation was mild and present in 30.30%. One case presented major vascular complication and another one permanent pacemaker implant. One major stroke case occurred. Overall 30-day mortality was 18.18%. CONCLUSION The transapical implantation of catheter mounted bioprosthesis is a safe procedure with acceptable midterm results. Long term follow-up with increased sample power is mandatory in order to access hemodynamic, life quality and survival.OBJECTIVE: Aortic valve replacement is a routine procedure with acceptable risk, but in some cases, such risk can justify contraindication. Minimally invasive transcatheter aortic valve implantation has emerged as an alternative, with lower morbidity and mortality. The aim of this study was clinical, safety and efficacy assessment. METHODS: Thirty-three high risk patients underwent transcatheter balloon expandable aortic valve implantation. Mean Logistic EuroScore risk was 39.30% and STS score 30.28%. Eight patients presented with dysfunctional bioprosthesis, remaining ones presented calcified aortic stenosis. Procedures were performed in a hybrid OR under fluoroscopic and echocardiography guidance. Using a left minithoracotomy the prosthesis were implanted trough the ventricular apex under rapid ventricular pacing or hemorrhagic shock. Echocardiographic and angiographic controls were performed. RESULTS: Implant was feasible in 30 cases. Three conversions occured. There was only one case of operative death. Median transvalvular aortic gradient reduced from 43.58 mmHg to 10.54 mmHg. Left ventricular function improved in the first 7 postoperative days. Paravalvular aortic regurgitation was mild and present in 30.30%. One case presented major vascular complication and another one permanent pacemaker implant. One major stroke case occurred. Overall 30-day mortality was 18.18%. CONCLUSION: The transapical implantation of catheter mounted bioprosthesis is a safe procedure with acceptable midterm results. Long term follow-up with increased sample power is mandatory in order to access hemodynamic, life quality and survival

Off-pump coronary artery bypass surgery in selected patients is superior to the conventional approach for patients with severely depressed left ventricular function

OBJECTIVES: Patients with coronary artery disease and left ventricular dysfunction have high mortality when kept in clinical treatment. Coronary artery bypass grafting can improve survival and the quality of life. Recently, revascularization without cardiopulmonary bypass has been presented as a viable alternative. The aim of this study is to compare patients with left ventricular ejection fractions of less than 20% who underwent coronary artery bypass graft with or without cardiopulmonary bypass. METHODS: From January 2001 to December 2005, 217 nonrandomized, consecutive, and nonselected patients with an ejection fraction less than or equal to 20% underwent coronary artery bypass graft surgery with (112) or without (off-pump) (105) the use of cardiopulmonary bypass. We studied demographic, operative, and postoperative data. RESULTS: There were no demographic differences between groups. The outcome variables showed similar graft numbers in both groups. Mortality was 12.5% in the cardiopulmonary bypass group and 3.8% in the off-pump group. Postoperative complications were statistically different (cardiopulmonary bypass versus off-pump): total length of hospital stay (days)—11.3 vs. 7.2, length of ICU stay (days)—3.7 vs. 2.1, pulmonary complications—10.7% vs. 2.8%, intubation time (hours)—22 vs. 10, postoperative bleeding (mL)—654 vs. 440, acute renal failure—8.9% vs. 1.9% and left-ventricle ejection fraction before discharge—22% vs. 29%. CONCLUSION: Coronary artery bypass grafting without cardiopulmonary bypass in selected patients with severe left ventricular dysfunction is valid and safe and promotes less mortality and morbidity compared with conventional operations.

Transcatheter aortic valve implantation: results of the current development and implantation of a new Brazilian prosthesis

OBJECTIVE Aortic valve replacement is a routine procedure with acceptable risk, but in some cases, such risk can justify contraindication. Minimally invasive transcatheter aortic valve implantation has emerged as an alternative, with lower morbidity and mortality. The aim of this study was clinical, safety and efficacy assessment. METHODS Thirty-three high risk patients underwent transcatheter balloon expandable aortic valve implantation. Mean Logistic EuroScore risk was 39.30% and STS score 30.28%. Eight patients presented with dysfunctional bioprosthesis, remaining ones presented calcified aortic stenosis. Procedures were performed in a hybrid OR under fluoroscopic and echocardiography guidance. Using a left minithoracotomy the prosthesis were implanted trough the ventricular apex under rapid ventricular pacing or hemorrhagic shock. Echocardiographic and angiographic controls were performed. RESULTS Implant was feasible in 30 cases. Three conversions occured. There was only one case of operative death. Median transvalvular aortic gradient reduced from 43.58 mmHg to 10.54 mmHg. Left ventricular function improved in the first 7 postoperative days. Paravalvular aortic regurgitation was mild and present in 30.30%. One case presented major vascular complication and another one permanent pacemaker implant. One major stroke case occurred. Overall 30-day mortality was 18.18%. CONCLUSION The transapical implantation of catheter mounted bioprosthesis is a safe procedure with acceptable midterm results. Long term follow-up with increased sample power is mandatory in order to access hemodynamic, life quality and survival.OBJECTIVE: Aortic valve replacement is a routine procedure with acceptable risk, but in some cases, such risk can justify contraindication. Minimally invasive transcatheter aortic valve implantation has emerged as an alternative, with lower morbidity and mortality. The aim of this study was clinical, safety and efficacy assessment. METHODS: Thirty-three high risk patients underwent transcatheter balloon expandable aortic valve implantation. Mean Logistic EuroScore risk was 39.30% and STS score 30.28%. Eight patients presented with dysfunctional bioprosthesis, remaining ones presented calcified aortic stenosis. Procedures were performed in a hybrid OR under fluoroscopic and echocardiography guidance. Using a left minithoracotomy the prosthesis were implanted trough the ventricular apex under rapid ventricular pacing or hemorrhagic shock. Echocardiographic and angiographic controls were performed. RESULTS: Implant was feasible in 30 cases. Three conversions occured. There was only one case of operative death. Median transvalvular aortic gradient reduced from 43.58 mmHg to 10.54 mmHg. Left ventricular function improved in the first 7 postoperative days. Paravalvular aortic regurgitation was mild and present in 30.30%. One case presented major vascular complication and another one permanent pacemaker implant. One major stroke case occurred. Overall 30-day mortality was 18.18%. CONCLUSION: The transapical implantation of catheter mounted bioprosthesis is a safe procedure with acceptable midterm results. Long term follow-up with increased sample power is mandatory in order to access hemodynamic, life quality and survival

Diretrizes para o tratamento cirúrgico das doenças da aorta da Sociedade Brasileira de Cirurgia Cardiovascular - Atualização 2009

DESCRICAO DO METODO DE COLETA DEEVIDENCIASO documento original de 2007 [1] foi contruido a partirde reunioes periodicas para elaboracao do texto cominclusao das citacoes bibliograficas, por uma comissao demembros titulares designados pela Diretoria da SociedadeBrasileira de Cirurgia Cardiovascular. A partir de um textobasico referencial, os participantes, divididos em gruposde trabalho, agregaram contribuicoes, correcoes, erecomendacoes aprovadas em consenso, que permitiram aedicao do texto preliminar. Em diferentes momentos foramrealizadas as buscas de referencias cruzadas e artigosrelacionados mais relevantes, como metanalises, revisoessistematicas, e estudos multicentricos classicos. Procurou-se indicar trabalhos relevantes de autores brasileiros,particularmente os gerados pela Revista Brasileira deCirurgia Cardiovascular e pelos Arquivos Brasileiros deCardiologia, orgaos de divulgacao oficial da Cardiologiabrasileira.Na presente atualizacao, os editores procuraram revisarsistematicamente as publicacoes mais relevantes, nos

Treatment of thoracoabdominal aneurysm with self-expandable aortic stent grafts

A 67-year-old man with a large thoracoabdominal aneurysm was treated utilizing the endovascular approach with multiple stent graft implantation. The proximal thoracic and distal abdominal necks of the aneurysm had favorable anatomy for insertion of multiple endovascular stents. The proximal end was located just distal to the left subclavian artery, and stents were placed to the region of the celiac axis. The infrarenal aneurysm was treated with a bifurcated stent graft to the iliac arteries. The patient has had a smooth post-stent insertion course and remains well after 3 months of follow-up.

Early complication after hybrid thoracic aortic aneurysm repair

This brief report describes an unusual hybrid approach complication of aortic arch disease. An acute stent kinking in the first post-operative day promoted ventricular fibrillation and death. Adequate oversizing was achieved and intraoperative angiogram showed no proximal or distal leaks. Unfavorable outcomes are highly under-reported and describing complications are a key instrument to improve this technique.