José Teles de Mendonça

Revascularização do miocárdio sem circulação extracorpórea: resultados imediatos

Myocardial revascularization surgery without the use of cardiopulmonary bypass was performed by Trapp and Ankeney in the 1970s. However it fell to Buffolo in Brazil and Benetti in Argentina to introduce its systematic use, standardization and recommendation as a valid and safe alternative modality of treatment. With the aim of evaluating the techniques reproducibility, morbidity and mortality, its technical difficulties and the possibilities of incorporating it into routine practice, the authors present the results obtained in 182 patients submitted to myocardial revascularization with saphenous and/or thoracic internal bypass without the use of cardiopulmonary bypass. One hundred and eighty-two patients were operated on using this technique: 128 (70.3%) males and 54 (29.7%) females, whose ages ranged from 40 to 79 years (mean = 58.8 years), with lesions of coronary arteries: interventricular anterior (IA); right coronary (RD); diagonal artery (DI) and marginal artery (MG). Two hundred and seventy-seven arteries were revasculahsed: 159/277 IAs (57.4%), 62/277 CDs (22.4%), 44/277 DIs (15.9%) and 12/277 MGs (4.3%). The left thoracic internal artery was used on 60/277 (21.7%) occasions and the saphenous vein on 217/277 (78.3%). The duration of the ischemia ranged from 5 to 33 minutes with a mean of 14 minutes. The following conditions were noted in the study as complications: coronary spasm in 6/182 cases (3.3%), acute myocardial infarct in 3/182 (0.6%), bleeding in 2/182 (1.1%), pulmonary embolism in 1/182 (0.6%) and mediastinitis in 1/182 (0.6%). Five/182 patients (2.7%) died in the immediate postoperative period from causes unrelated to the technique employed. The authors conclude that the technique may be safely carried out by most surgeons in selected cases with good results. The technique reduces the costs of surgery and in some subgroups, such as the elderly and those suffering from systemic disease, it may be the best alternative.

Reconstructive surgery of the aortic valve

OBJECTIVE: Lacking an ideal valve substitute and motivated by the good results of mitral valve repair since 1990, we faced with determination aortic valve reconstruction surgery. The objective of this paper is to show our experience with this procedure. METHOD: Between January of 1990 and December of 2001; 136 aortic valve repair surgeries were performed. Seventy-five (55.1%) of the patients were female and the ages ranged from 4 to 70 years (mean 23.3 ± 1.2 years). Every patient had rheumatic valve disease and insufficiency was the most prevalent type (108 patients - 79.4%), followed by double aortic lesion in 16 (11.7%) patients and stenosis in 12 (8.8%). The surgical techniques used were: subcommissural annuloplasty in 74 (54.4%) patients, commissurotomy in 38 (27.9%), cusp extension with pericardium in 17 (12.5%), substitution of one cusp in 2 (1.4%), cusp suspension by annuloplasty in 37 (27.2%) and Valsalva sinus remodeling in 27 (19.8%). The surgery exclusively involved the aortic valve in 57 (41.9%) patients and was associated in 79 (mitral valve replacement in 12, mitral repair in 65, coronary artery bypass grafting in 1 and pulmonary commissurotomy in 1). RESULTS: Hospital mortality was 2.2% and 22 (16.2%) patients underwent a new surgery during the follow-up period (57.7 ± 3.5 months). CONCLUSIONS: Aortic valve repair is a safe surgical procedure that can be used in an increasing number of patients with promising results.

Cirurgia de revascularização do miocárdio através de minitoracotomia ântero-lateral esquerda

No periodo de outubro de 1995 a fevereiro de 1996, 16 pacientes selecionados foram submetidos a cirurgia de revascularizacao do miocardio atraves de minitoracotomia ântero-lateral esquerda. Em todos os casos a arteria toracica interna esquerda foi dissecada, para posterior anastomose com o ramo interventricular anterior (RIA) sem a utilizacao de circulacao extracorporea. A idade variou de 43 a 77, com media de 60 anos. Sessenta e dois por cento dos pacientes eram do sexo masculino. Nao houve complicacoes tais como: hemorragias, acidente vascular cerebral, insuficiencia renal aguda, mediastinite ou infarto agudo do miocardio. Nao houve mortalidade no grupo em questao. Em 4 (25%) pacientes foi realizado estudo hemodinâmico, que demostrou uma normalidade da anastomose da arteria toracica interna para o ramo interventricular anterior. Devido aos excelentes resultados iniciais, acreditamos que este procedimento possa ser empregado com maior frequencia e com a familiarizacao dos grupos cirurgicos, e que as arterias diagonais e marginais da circunflexa possam ser beneficiadas com este tipo de procedimento.

Accessory mitral leaflet: an uncommon form of subaortic stenosis

Three-years-old boy presenting with a subvalvar aortic stenosis without a precise definition by echocardiography, where the surgical approach revealed an accessory mitral leaflet.

Estudo evolutivo da anatomia das artérias coronárias em espécies de vertebrados com técnica de moldagem em acetato de vinil (vinilite)

Thirty anatomic models of vertebrate hearts were produced in order to study the right and left coronary arteries in different species such as fish, amphibians, reptiles, birds and mammals. The hearts were injected with vinyl acetate and then submited to corrosion and/or partial corrosion with hydrochloric acid to obtain the anatomical coronary artery model allowing correlation with the evolution of the species and its morphological adaptations. Based on these models we concluded that: the technique using vinyl acetate associated to corrosion produced models of coronary vessels with enough details to visualize the branches; the number of structures and the vascular complexity increased as the species evolved in the zoological scale. In the reptile Iguana iguana a three outlet double ventricle was found, which has not yet been reported as a human congenital disease in the literature surveied.

Tratamento das cardiopatias congênitas em Sergipe: proposta de racionalização dos recursos para melhorar a assistência

OBJECTIVE This study aims evaluate the treatment of congenital heart disease conducted from 2000 to 2009. METHODS The sample consisted of all patients undergoing surgical correction for congenital heart disease for ten years in Sergipe, Brazil. The patients were operated in three hospitals located in the city of Aracaju, capital of the state of Sergipe (Brazil). The study was divided into two periods defined by the start date of centralization of surgery. The variables collected were: age, sex, postoperative diagnosis, destination, type of surgery and hospital where the procedure was performed and the classification RACHS -1. RESULTS In the period I, the estimate deficit of surgery was 69% decrease occurring in the period II to 55.3%. The postoperative diagnosis was more frequent closure of the interventricular communication (20.5%), closure of patent ductus arteriosus (20.2%) and atrial septal defect (19%). There was a statistically significant correlation between the expected mortality RACHS-1 and observed in the sample. The evaluation of RACHS-1 as a predictor of hospital mortality by ROC curve showed area of 0.860 95% CI 0.818 to 0.902 with P <0.0001. CONCLUSION The results of this study indicate that the centralization and organization of existing resources are needed to improve the performance of surgical correction of congenital heart diseases.

Substituição da valva mitral por aloenxerto valvar aórtico preservado em glutaraldeído

No periodo de setembro de 1984 a dezembro de 1992, 145 pacientes selecionados foram submetidos a substituicao isolada de valva mitral, utilizando-se valvas aorticas de cadaver obtidas durante autopsia, processadas em glutaraldeido e montadas em suporte flexivel de Celcon recoberto com Dacron. Os pacientes apresentavam idade media de 22,5 anos, variando de 5 a 77 anos e 79 (54,5%) pacientes tinham idade igual ou inferior a 15 anos. Operacoes cardiacas previas haviam sido, realizadas em 26 (18%) pacientes e 20 (13,8%) deles eram portadores de bioproteses de porco, pericardico bovino ou dura-mater calcificadas. A mortalidade hospitalar (30 dias) foi de 3 (2,1 %) pacientes. A evolucao tardia coletou 709 pacientes-ano de seguimento total, correspondendo a um seguimento medio de 5 anos por paciente e maximo de 9 anos e 5 meses. Segmento completo foi obtido em 130 (91,5%) pacientes e parcial nos 12 pacientes restantes. Complicacoes relacionadas ao aloenxerto ocorreram em 48 pacientes, incluindo a fibrocalcificacao, tromboembolismo, endocardite e escape para-valvar, correspondendo a uma incidencia de 6,8% ± 0,9% por paciente-ano. A fibrocalcificacao levando a disfuncao valvar representou a principal complicacao, presente em 37 pacientes com uma incidencia de 5,2% ± 0,8% por paciente-ano. Todos os casos de calcificacao ocorreram em pacientes com idade igual ou inferiora 15 anos, com um intervalo medio entre o implante valvar e a calcificacao de 46 meses, variando de 14 a 100 meses. Reoperacoes foram realizadas em 44 pacientes com substituicao da alobioprotese em 39, representando uma incidencia de reoperacoes de 6,3% ± 0,9% por paciente-ano e uma incidencia de substituicao da alobioprotese de 5,5% ± 0,9% por paciente-ano. A principal causa da reoperacao foi a calcificacao, presente em 36 aloenxertos, sendo as outras causas representadas pela endocardite, escape para-valvar e insuficiencia aortica em valva natural. Ocorreram 15 obitos tardios, representando uma mortalidade tardia de 2,1 % ± 0,5% por paciente-ano, porem apenas 3 obitos estavam relacionados diretamente a alobioprotese, 10 a doenca cardiaca (ICC, miocardiopatia e morte subita) e 2 a outras causas (tuberculose e diabetes). A sobrevida atuarial em 10 anos foi de 82,9% ± 4,8%. A sobrevida atuarial em 10 anos livre de disfuncao valvar devido a fibrocalcificacao foi de 62,1 % ± 8,4% sendo de 100% para pacientes acima de 15 anos e 34,2% ± 11,2% para pacientes com idade igual ou inferior a 15 anos. Embora a fibrocalcificacao tenha representado a principal complicacao tardia ocorrida com as alobioproteses levando a disfuncao valvar e representando a principal indicacao para reoperacoes no grupo pediatrico, sua incidencia foi significativamente menor que a incidencia relatada na literatura para pacientes pediatricos portadores de xenobioproteses.

Cirurgia valvar na infância: um novo aspecto de açäo

From January 1978 to December 1991, 148 children (age < 15 years) were operated upon on our Service for the first time, to correct defects (rheumatic fever) on the cardiac valves. The material was divided in two times, according to the point of view of the group in an attempt to preserve a great number of valves, in especial in children. Last year 24 children were operated upon in whom mitral valve disease treatment was necessary twenty times, and in aortic valve eight times. In that group, 95% (28% before) surgery on the mitral valve and 62% (20% before) on the aortic valve were conservative procedures. There were neither deaths nor complications and all children have good evolution. We conclude that on rheumatic fever, cardiac valve disease treatment in children must be conservative and the best time for the surgery must be earlier, to avoid valvar disfunction due to disease. We also think that follow up must be effective in order to analyze if different available plastic techniques are better than valve substitution in children with rheumatic fever.

Disparities in Acute Myocardial Infarction Treatment Between Users of the Public and Private Healthcare System in Sergipe

Mailing Address: José Augusto Barreto-Filho Avenida Gonçalo Prado Rollemberg, 211, sala 202. Postal Code: 49010-410, Aracaju, SE Brazil. E-mail: joseaugusto.se@gmail.com, jasbf@cardiol.br Disparities in Acute Myocardial Infarction Treatment Between Users of the Public and Private Healthcare System in Sergipe Jussiely Cunha Oliveira1,2, Laís Costa Souza Oliveira1,3, Jeferson Cunha Oliveira3,4, Ikaro Daniel de Carvalho Barreto5, Marcos Antonio Almeida-Santos2,6, Ticiane Clair Remacre Munareto Lima1, Larissa Andreline Maia Arcelino1,7, Luiz Flávio Andrade Prado2,8, Fábio Serra Silveira8, Thiago Augusto Nascimento6,9, Eduardo José Pereira Ferreira6,8,10, Rafael Vasconcelos Barreto8, Enilson Vieira Moraes3, José Teles de Mendonça8,9,11, Antonio Carlos Sobral Sousa1,6,10,11, José Augusto Barreto-Filho1,6,10,11, em nome do grupo de pesquisadores do Registro VICTIM Núcleo de Pós-Graduação em Ciências da Saúde da Universidade Federal de Sergipe (UFS)1, São Cristóvão, SE Brazil Universidade Tiradentes (UNIT)2, Aracaju, SE Brazil Hospital Primavera3, Aracaju, SE Brazil Departamento de Farmácia da Universidade Federal de Sergipe (UFS)4, Lagarto, SE Brazil Departamento de Estatística da Universidade Federal de Sergipe (UFS)5, Aracaju, SE Brazil Centro de Ensino e Pesquisa da Fundação São Lucas6, Aracaju, SE Brazil Faculdade Estácio de Sá7, Aracaju, SE Brazil Fundação Beneficência Hospital de Cirurgia8, Aracaju, SE Brazil Hospital do Coração9, Aracaju, SE Brazil Departamento de Medicina da Universidade Federal de Sergipe (UFS)10, São Cristóvão, SE Brazil Divisão de Cardiologia do Hospital Universitário da UFS11, São Cristóvão, SE Brazil

The Brazilian Registry of Adult Patient Undergoing Cardiovascular Surgery, the BYPASS Project: Results of the First 1,722 Patients

Objective To report the early results of the BYPASS project - the Brazilian registrY of adult Patient undergoing cArdiovaScular Surgery - a national, observational, prospective, and longitudinal follow-up registry, aiming to chart a profile of patients undergoing cardiovascular surgery in Brazil, assessing the data harvested from the initial 1,722 patients. Methods Data collection involved institutions throughout the whole country, comprising 17 centers in 4 regions: Southeast (8), Northeast (5), South (3), and Center-West (1). The study population consists of patients over 18 years of age, and the types of operations recorded were: coronary artery bypass graft (CABG), mitral valve, aortic valve (either conventional or transcatheter), surgical correction of atrial fibrillation, cardiac transplantation, mechanical circulatory support and congenital heart diseases in adults. Results 83.1% of patients came from the public health system (SUS), 9.6% from the supplemental (private insurance) healthcare systems; and 7.3% from private (out-of -pocket) clinic. Male patients comprised 66%, 30% were diabetics, 46% had dyslipidemia, 28% previously sustained a myocardial infarction, and 9.4% underwent prior cardiovascular surgery. Patients underwent coronary artery bypass surgery were 54.1% and 31.5% to valve surgery, either isolated or combined. The overall postoperative mortality up to the 7th postoperative day was 4%; for CABG was 2.6%, and for valve operations, 4.4%. Conclusion This first report outlines the consecution of the Brazilian surgical cardiac database, intended to serve primarily as a tool for providing information for clinical improvement and patient safety and constitute a basis for production of research protocols.