Lafaiete Alves Junior

Risk factors for acute renal failure after heart surgery

OBJECTIVE The aim of the present study was to identify risk factors for acute renal failure in patients with normal levels of serum creatinine who had undergone coronary artery bypass graft (CABG) surgery and/or valve surgery. METHODS Data from a cohort of 769 patients were assessed using bivariate analyses and binary logistic regression modeling. RESULTS Three hundred eighty one patients underwent CABG, 339 valve surgery and 49 had undergone both simultaneously. Forty six percent of the patients were female and the mean age was 57 +/- 14 years (13 to 89 years). Seventy eight (10%) patients presented renal dysfunction postoperatively, of these 23% needed hemodialysis (2.4% of all patients). The mortality for the whole cohort was 10%. The overall mortality for patients experiencing postoperative renal dysfunction was 40% (versus 7%, P < 0.001), 29% for those who did not need dialysis and 67% for those who needed dialysis (P = 0.004). The independent risk factors found were: age (P < 0.000, OR: 1.056), congestive heart failure (P = 0.091, OR: 2.238), COPD (P = 0.003, OR: 4.111), endocarditis (P = 0.001, OR: 12.140), myocardial infarction < 30 days (P = 0.015, OR: 4.205), valve surgery (P = 0.016, OR: 2.137), cardiopulmonary bypass time > 120 min (P = 0.001, OR: 7.040), peripheral arterial vascular disease (P = 0.107, 2.296). CONCLUSION Renal dysfunction was the most frequent postoperative organ dysfunction in patients undergone CABG and/or valve surgery and age, congestive heart failure, COPD, endocarditis, myocardial infarction < 30 days, valve surgery, cardiopulmonary bypass time >120 min, and peripheral arterial vascular disease were the risk factors independently associated with acute renal failure (ARF).

Disfunção endotelial causada pela pressão aguda de distensão em veias safenas humanas utilizadas para revascularização do miocárdio

OBJECTIVE: To study morphofunctional alterations induced by brief pressure increases in human saphenous veins utilized in coronary artery bypass grafting. METHOD: Saphenous veins of 20 patients undergoing coronary artery bypass grafting, were distributed into four experimental groups, control, 100 mmHg, 200 mmHg and 300 mmHg, and submitted to pressure distention over 15 seconds using Krebs solution. The evaluation included CD34 immunohistochemistry and an In vitro vascular reactivity study in organ chambers. RESULTS: The main experimental findings were 1) From pressures of 200 mmHg there was a tendency to reduce the CD34 expression which became statistically significant at 300 mmHg; 2) There was no impairment of the contraction and relaxation as evidenced by in vitro vascular reactivity tests. CONCLUSION: Although vascular reactivity impairment was not demonstrated in vitro, the CD34 expression, measured by imunohistochemistry, shows there is endothelium dysfunction at pressures of 300 mmHg.

Retrograde autologous priming in cardiopulmonary bypass in adult patients: effects on blood transfusion and hemodilution

Introduction: Retrograde autologous priming (RAP) is a cardiopulmonary bypass (CPB) method, at low cost. Previous studies have shown that this method reduces hemodilution and blood transfusions needs through increased intraoperative hematocrit. Objective: To evaluate RAP method, in r elation to standard CPB (crystalloid priming), in adult patients. Methods: Sixty-two patients were randomly allocated to two groups: 1) Group RAP (n = 27) of patients operated using the RAP and; 2) Control group of patients operated using CPB standard crystalloid method (n = 35). The RAP was performed by draining crystalloid prime from the arterial and venous lines, before CPB, into a collect recycling bag. The main parameters analyzed were: 1) CPB hemodynamic data; 2) Hematocrit and hemoglobin values; 3) The need for blood transfusions. Results: It was observed statistically significant fewer transfusions during surgery and reduced CPB hemodilution using RAP. The CPB hemodynamic values were similar , observing a tendency to use lower CPB flows in the RAP group patients. Conclusion: This investigation was designed to be a small-scale pilot study to evaluate the ef fects of RAP, which were demonstrated concerning the CPB hemodilution and blood transfusions.INTRODUCTION Retrograde autologous priming (RAP) is a cardiopulmonary bypass (CPB) method, at low cost. Previous studies have shown that this method reduces hemodilution and blood transfusions needs through increased intra-operative hematocrit. OBJECTIVE To evaluate RAP method, in relation to standard CPB (crystalloid priming), in adult patients. METHODS Sixty-two patients were randomly allocated to two groups: 1) Group RAP (n = 27) of patients operated using the RAP and; 2) Control group of patients operated using CPB standard crystalloid method (n = 35). The RAP was performed by draining crystalloid prime from the arterial and venous lines, before CPB, into a collect recycling bag. The main parameters analyzed were: 1) CPB hemodynamic data; 2) Hematocrit and hemoglobin values; 3) The need for blood transfusions. RESULTS It was observed statistically significant fewer transfusions during surgery and reduced CPB hemodilution using RAP. The CPB hemodynamic values were similar, observing a tendency to use lower CPB flows in the RAP group patients. CONCLUSION This investigation was designed to be a small-scale pilot study to evaluate the effects of RAP, which were demonstrated concerning the CPB hemodilution and blood transfusions.

Mitral insufficiency surgery to treat advanced heart failure

Dilated cardiomyopathy is characterized by severe, progressive myocardial dysfunction that is, irreversible. That syndrome leads to cardiac remodeling with augmentation of left ventricle volume and sphericity, dilation of the mitral annulus and dislocation of papillary muscles that pulls up the mitral cords thereby restraining leaflet excursion. These biomechanical modifications generate functional mitral valve regurgitation, a dismal prognostic sign. Mitral valve plasty or replacement was introduced as surgical coadjuvants to conventional medical treatment, with good symptomatic improvement. The long term survival benefit is yet to be demonstrated.

A variant "no-patch" technique for surgery of left ventricular aneurysms.

A variant “no-patch” technique for the surgical treatment of left ventricular aneurysms is described. The entire operation is performed using a single suture tied after the 2 encircling stitch adjustments and at the final external suture. Before the second encircling pursestring stitch, scar tissue circular plication is carried out. The final closure is completed by an out-out suture that ensures hemostasis. Finally, it is emphasized that the no-patch surgical strategy has the indirect advantage of saving time because the stitches are performed in a continuous manner.

Reflections on the 24 years durability of an isolate tricuspid bovine pericardium IMC/Braile bioprosthesis

We were challenged by the experience of one patient reoperation for a bioprosthetic bovine pericardium degenerative stenosis, 24 years after implantation. This bioprosthesis was implanted due to tricuspid valve bacterial staphylococcal endocarditis after septic abortion.

A variant technique for the surgical treatment of left ventricular aneurysms

OBJECTIVE To present a surgical variant technique to repair left ventricular aneurysms. METHODS After anesthesia, cardiopulmonary bypass, and myocardial protection with hyperkalemic tepic blood cardioplegia: 1) The left ventricle is opened through the infarct and an endocardial encircling suture is placed at the transitional zone between the scarred and normal tissue; 2) Next, the scar tissue is circumferentially plicated with deep stitches using the same suture thread, taking care to eliminate the entire septal scar; 3) Then, a second encircling suture is placed, completing the occlusion of the aneurysm, and; 4) Finally, the remaining scar tissue is oversewn with an invaginating suture, to ensure hemostasis. Myocardium revascularization is performed after correction of the left ventricle aneurysm. The same surgeon performed all the operations. RESULTS Regarding the post-surgical outcome 4 patients (40%) had surgery 8 eight years ago, 2 patients (20%) were operated on over 6 years ago, and 1 patient (10%) was operated on more than 5 years ago. Three patients (30%) were in functional class I, class II in 2 patients (20%) and 2 patients (20%) with severe comorbidities remains in class III of the NYHA. There were three deaths (at four days, 15 days and eight months) in septuagenarians with acute myocardial infarction, diabetes and pulmonary emphysema. CONCLUSION The technique is easy to perform, safe and it can be an option for the correction of left ventricle aneurysms.

La preservación del aparato mitral y trombosis temprana en bioprótesis: una palabra de prudencia

Válvula mitral/cirugía; trombosis; bioprótesis. con 34 y 44 años, no mostraron efectos adversos durante la cirugía y se presentan los gradientes prostéticos en el postoperatorio: 12 mmHg (prótesis M-25, ASC = 1.672 m2) y 6 mmHg (prótesis M-27, ASC = 1.632 m2), respectivamente. Ninguna de las dos pacientes estaba recibiendo tratamiento anticoagulante. El caso de la paciente más joven era más dramático porque ella ingresó en la sala de urgencias con una historia que sugería fibrilación auricular aguda paroxística y signos neurológicos de la embolización de 18 días después de la cirugía. La ecocardiografía transesofágica (ETE) mostró trombosis en la aurícula izquierda, la pared auricular y la porción de la prótesis. Estos datos fueron confirmados en la reoperación de emergencia, cuando una nueva prótesis mecánica se implantó con la resección de las hojas y la fijación y anular de los músculos papilares), respectively. Neither of the patients was receiving anticoagulants. The case of the youngest patient was more dramatic, because she was admitted to the emergency room with history suggesting paroxysmal acute atrial fibrillation and neurological signs of embolization 18 days after surgery. The transesophageal echocardiogram (TEE) revealed thrombosis affecting the left auricle, atrial wall, and atrial face of the prosthesis. These data were confirmed at the emergency reoperation, when a new mechanical prosthesis was implanted with resection of the leaflets and annular fixation of the papillary muscles. The prosthesis-patient “mismatch” may be an independent predictor of mortality after mitral valve replacement. Unlike other independent risk factors, this problem can be avoided or its severity may be reduced by using a prospective strategy at the time of operation. For patients considered at risk of serious “mismatch”, every effort should be made to implant prosthesis with a larger area orifice, in order to preserve the continuity between the mitral annulus and the left ventricular wall. Both patients presented gradients consistent with mild to moderate mitral stenosis already taking place in the immediate postoperative period. Based upon previous experience, this observation was underestimated by erroneously considering that the interference of the preserved elements in the bioprosthetic valve is unlikely. Concerns about the possibility of mitral chordae interference on mechanical prostheses leaflets have been reported frequently, but not when bioprosthesis was used. However, despite having been reported separately, the preservation of both mitral valve leaflets can potentially contribute to possible thrombotic “pseudostenosis” and/or early bioprosthesis failure

Mitral valve apparatus preservation and early bioprosthetic thrombosis: a word of caution

Válvula mitral/cirugía; trombosis; bioprótesis. con 34 y 44 años, no mostraron efectos adversos durante la cirugía y se presentan los gradientes prostéticos en el postoperatorio: 12 mmHg (prótesis M-25, ASC = 1.672 m2) y 6 mmHg (prótesis M-27, ASC = 1.632 m2), respectivamente. Ninguna de las dos pacientes estaba recibiendo tratamiento anticoagulante. El caso de la paciente más joven era más dramático porque ella ingresó en la sala de urgencias con una historia que sugería fibrilación auricular aguda paroxística y signos neurológicos de la embolización de 18 días después de la cirugía. La ecocardiografía transesofágica (ETE) mostró trombosis en la aurícula izquierda, la pared auricular y la porción de la prótesis. Estos datos fueron confirmados en la reoperación de emergencia, cuando una nueva prótesis mecánica se implantó con la resección de las hojas y la fijación y anular de los músculos papilares), respectively. Neither of the patients was receiving anticoagulants. The case of the youngest patient was more dramatic, because she was admitted to the emergency room with history suggesting paroxysmal acute atrial fibrillation and neurological signs of embolization 18 days after surgery. The transesophageal echocardiogram (TEE) revealed thrombosis affecting the left auricle, atrial wall, and atrial face of the prosthesis. These data were confirmed at the emergency reoperation, when a new mechanical prosthesis was implanted with resection of the leaflets and annular fixation of the papillary muscles. The prosthesis-patient “mismatch” may be an independent predictor of mortality after mitral valve replacement. Unlike other independent risk factors, this problem can be avoided or its severity may be reduced by using a prospective strategy at the time of operation. For patients considered at risk of serious “mismatch”, every effort should be made to implant prosthesis with a larger area orifice, in order to preserve the continuity between the mitral annulus and the left ventricular wall. Both patients presented gradients consistent with mild to moderate mitral stenosis already taking place in the immediate postoperative period. Based upon previous experience, this observation was underestimated by erroneously considering that the interference of the preserved elements in the bioprosthetic valve is unlikely. Concerns about the possibility of mitral chordae interference on mechanical prostheses leaflets have been reported frequently, but not when bioprosthesis was used. However, despite having been reported separately, the preservation of both mitral valve leaflets can potentially contribute to possible thrombotic “pseudostenosis” and/or early bioprosthesis failure

Preservação do aparato da valva mitral e trombose precoce de bioprótese: uma palavra de prudência

Válvula mitral/cirugía; trombosis; bioprótesis. con 34 y 44 años, no mostraron efectos adversos durante la cirugía y se presentan los gradientes prostéticos en el postoperatorio: 12 mmHg (prótesis M-25, ASC = 1.672 m2) y 6 mmHg (prótesis M-27, ASC = 1.632 m2), respectivamente. Ninguna de las dos pacientes estaba recibiendo tratamiento anticoagulante. El caso de la paciente más joven era más dramático porque ella ingresó en la sala de urgencias con una historia que sugería fibrilación auricular aguda paroxística y signos neurológicos de la embolización de 18 días después de la cirugía. La ecocardiografía transesofágica (ETE) mostró trombosis en la aurícula izquierda, la pared auricular y la porción de la prótesis. Estos datos fueron confirmados en la reoperación de emergencia, cuando una nueva prótesis mecánica se implantó con la resección de las hojas y la fijación y anular de los músculos papilares), respectively. Neither of the patients was receiving anticoagulants. The case of the youngest patient was more dramatic, because she was admitted to the emergency room with history suggesting paroxysmal acute atrial fibrillation and neurological signs of embolization 18 days after surgery. The transesophageal echocardiogram (TEE) revealed thrombosis affecting the left auricle, atrial wall, and atrial face of the prosthesis. These data were confirmed at the emergency reoperation, when a new mechanical prosthesis was implanted with resection of the leaflets and annular fixation of the papillary muscles. The prosthesis-patient “mismatch” may be an independent predictor of mortality after mitral valve replacement. Unlike other independent risk factors, this problem can be avoided or its severity may be reduced by using a prospective strategy at the time of operation. For patients considered at risk of serious “mismatch”, every effort should be made to implant prosthesis with a larger area orifice, in order to preserve the continuity between the mitral annulus and the left ventricular wall. Both patients presented gradients consistent with mild to moderate mitral stenosis already taking place in the immediate postoperative period. Based upon previous experience, this observation was underestimated by erroneously considering that the interference of the preserved elements in the bioprosthetic valve is unlikely. Concerns about the possibility of mitral chordae interference on mechanical prostheses leaflets have been reported frequently, but not when bioprosthesis was used. However, despite having been reported separately, the preservation of both mitral valve leaflets can potentially contribute to possible thrombotic “pseudostenosis” and/or early bioprosthesis failure