Leonardo Augusto Miana

Resultados imediatos da artéria torácica interna direita e artéria radial como segundo enxerto arterial em revascularização do miocárdio

OBJECTIVE: We sought to compare early clinical outcomes in patients receiving a right internal thoracic artery or a radial artery as the second arterial graft in myocardial revascularization. METHODS: We retrospectively studied 58 consecutive patients who underwent coronary artery bypass surgery and received both a left internal thoracic artery graft and either a right internal thoracic artery (n=20) or a radial artery graft (n=38), between January 2004 and March 2006. Hospital mortality, pleural drainage, operative time and postoperative complications were analyzed. RESULTS: There were no significant preoperative differences between groups. There was only one (1.7%) in-hospital death which occurred in the Radial Group. Operative times was significantly higher in the Right Internal Thoracic Group (p-value = 0.0018), but were not associated with increased Intensive Care Unit stays, mechanical ventilation or other postoperative complications. We were able to perform significantly more distal anastomosis using the radial artery than the right internal thoracic artery (1.57 versus 1.05: p-value =0.003). CONCLUSION: In our group of patients, the use of a right internal thoracic artery as a second arterial graft was associated with a prolonged operative time, but had no interference with the immediate clinical outcomes.

Risk factors for postoperative bleeding after adult cardiac surgery

OBJECTIVE: To determine predictors of postoperative bleeding after cardiac surgery, in order to focus on preventive measures for high-risk populations. METHODS: From October 2001 to March 2002, 411 consecutive adult cardiac surgery patients were prospectively studied, with the exception of those submitted to heart transplantation. In order to determine risk factors for postoperative bleeding, 20 preoperative, 17 operative and six postoperative variables were analyzed using univariate methods and multiple linear regression. RESULTS: Operative procedures included coronary artery bypass grafting in 227 (55.2%) patients, valvar operations in 198 (48.2%), aortic surgery in 25 (6.1%) and combined procedures in 60 (14.6%). Cardiopulmonary bypass was used in 335 (81.5%) patients and anti-fibrinolysis agents in 148 (36%). The thirty-day mortality was 5.6% (23 patients). Mean 24-hour postoperative blood loss was 610 ± 500 ml (range 10-4900). Re-exploration for bleeding was required in 15 (3.7%) patients. Independent predictors of postoperative bleeding were emergency operations (p=0.049), postoperative metabolic acidosis (p=0.001), preoperative thrombocytopenia (p=0.034) and prolonged cardiopulmonary bypass (p=0.021). CCONCLUSIONS: When possible, preoperative stabilization and correction of coagulation disturbances should be achieved in patients requiring urgent or emergent surgery and in those with thrombocytopenias. The duration of cardiopulmonary bypass should be minimized as long as this is practical. Postoperative metabolic acidosis must be actively corrected, especially the main determining cause.

Transplante cardíaco pediátrico em vigência de choque cardiogênico refratário: análise crítica da viabilidade, aplicabilidade e resultados

BACKGROUND In children with dilated cardiomyopathy who are on the waiting list for heart transplantation, we evaluate the seriousness of their hemodynamic conditions. Some develop cardiogenic shock, and the mortality rate is high. Even with inotropic and respiratory support, heart transplantation is considered an extremely grave circumstance. OBJECTIVE The objective of this study is to report on our experience with children in this condition, in an attempt to analyze the viability, applicability and results of heart transplantation in these children. METHODS From March 2001 to February 2004, 22 children with dilated cardiomyopathy who were on the waiting list for heart transplantation developed cardiogenic shock, requiring transfer to pediatric intensive care unit (ICU), intubation and inotropic support. Their ages ranged from 11 months to 11 years (mean age: 4.3 years), 55% were males, 14 could be listed as clinical priority, and the remaining 8 were removed from the waiting list due to their unfavorable clinical conditions. RESULTS Eight heart transplantations were performed, and 6 children died while on the waiting list (42.9%). Two children died (25%) after transplantation and the remaining 6 were discharged from hospital in good clinical condition. The two main complications were organ rejection in 4 cases and infection in 5 cases. Two patients developed neurological complications, and one of them fully recovered. CONCLUSION Children with cardiomyopathy and cardiogenic shock require immediate heart transplantation; only 57.1% could be transplanted, with an early 25% mortality rate. Those who survived transplantation showed good clinical progress, similar to that of children transplanted on an elective basis.

Bandagem reversível do tronco pulmonar IV: análise da hipertrofia aguda do ventrículo direito em modelo experimental de sobrecarga intermitente

AbstractObjectives: Adjustable pulmonary trunk (PT) bandingdevice may induce a more physiologic ventricle retrainingfor the two-stage Jatene operation. This experimental studyevaluates the acute hypertrophy (96 hours) of the rightventricle (RV) submitted to an intermittent pressureoverload. Methods: Five groups of seven young goats were distributedaccording to RV intermittent systolic overload duration (0,24, 48, 72 and 96 hours). The zero-hour group served as acontrol group. Echocardiographic and hemodynamicevaluations were performed daily. After completing thetraining program for each group, the animals were sacrificedfor water content and cardiac masses evaluation. Results: There was a significant increase in RV free wallthickness starting with the 48-hour group (p<0.05). However,a decreased RV ejection fraction, associated with animportant RV dilation and a significant increase in the RVvolume to mass ratio was observed at 24-hour training period,when compared to 96-hour period (p=0.003), with subsequentrecovery throughout the protocol. A 104.7% increase in RVmass was observed in the 96-hour group, as compared to thecontrol group, with no differences in water content betweenthese two groups. The daily mean increase in RV mass duringthe study period was 21.6% ± 26.8%. The rate of RV massacquisition for the overall study period of intermittentsystolic overload was 0.084 g/h ± 0.035 g/h. Conclusion: Intermittent PT banding has allowed asignificant RV mass acquisition in the 96-hour trained group.No myocardial water content changes were observed in thisgroup, suggesting an increased myocardial protein synthesis.Descriptors: Heart ventricles/physiopathology. Hypertrophy/physiopathology. Right ventricular hypertrophy. Transpositionof great vessels/surgery. Cardiac surgical procedures/methods.Goats.

Intermittent systolic overload promotes better myocardial performance in adult animals

FUNDAMENTO: A transposicao corrigida das grandes arterias frequentemente evolui com disfuncao ventricular direita. O preparo ventricular para a correcao anatomica em pacientes adultos apresenta resultados desapontadores. OBJETIVO: Analisar a hipertrofia do ventriculo direito (VD) induzida por dois tipos de bandagem pulmonar (BP), convencional e intermitente em animais adultos. METODOS: Dezenove cabras adultas foram divididas em tres grupos: Convencional (seis animais), Intermitente (seis animais) e Controle (sete animais). O grupo Convencional foi submetido a BP fixa com fita cardiaca, enquanto no grupo Intermitente foi usado dispositivo de BP ajustavel, que gerava sobrecarga sistolica por 12 horas, alternada com 12 horas de descanso do VD. As pressoes de VD, tronco pulmonar e aorta foram medidas durante todo o estudo. Ecocardiograma foi realizado semanalmente. Apos quatro semanas, os animais foram eutanasiados para avaliacao morfologica dos ventriculos. O grupo Controle foi submetido a eutanasia para analise em condicoes basais. RESULTADOS: A sobrecarga pressorica foi menor no grupo Intermitente (p=0,001), comparada ao grupo Convencional. Houve aumento na espessura do VD do grupo Intermitente, medida pelo ecocardiograma, comparado ao seu momento basal (p<0,05). O indice de performance miocardica do VD foi melhor no grupo Intermitente (p=0,024), comparado ao Convencional. Os grupos estimulados apresentaram aumento da massa muscular em comparacao ao grupo Controle (p=0,001). Nao houve diferenca no conteudo de agua miocardica. CONCLUSAO: A BP intermitente desenvolveu hipertrofia de melhor desempenho funcional, sugerindo este protocolo como metodo preferencial de preparo ventricular.BACKGROUND Corrected transposition of great arteries often evolves with right ventricular dysfunction. The ventricular preparation for anatomic correction in adult patients has produced disappointing results. OBJECTIVE To assess right ventricular hypertrophy (RV) induced by conventional and intermittent pulmonary banding (PB) in adult animals. METHODS Nineteen adult goats were divided into three groups: conventional (six animals), intermittent (six animals) and control (seven animals). The Conventional group underwent fixed PB with cardiac tape, while the intermittent group received PB adjustable device, which generated systolic overload for 12 hours, alternated with 12 hours of rest of RV. The pressures of the RV, pulmonary artery and aorta were measured throughout the study. Echocardiography was performed weekly. After four weeks, the animals were euthanized for morphological evaluation of the ventricles. The Control group was put to euthanasia for analysis at baseline. RESULTS Pressure overload was lower in the intermittent group (p = 0.001), compared to the conventional group. There was an increase in the thickness of the RV of the Intermittent group measured by echocardiography compared to their baseline values (p < 0.05). The myocardial performance index in the RV group was better in the Intermittent group (p = 0.024), compared to the Conventional group. The groups stimulated showed increased muscle mass compared to the Control group (p = 0.001). There was no difference in myocardial water content. CONCLUSION The intermittent BP developed hypertrophy of better performance, suggesting this protocol as the preferred method of ventricular preparation.

A Cirurgia de Revascularização do Miocárdio sem Circulação Extracorpórea Minimiza o Sangramento Pós-Operatório e a Necessidade Transfusional

OBJECTIVE: To compare myocardial revascularization (MR) with and without extracorporeal circulation (ECC) in regard to postoperative bleeding and the need for blood and hemoderivate transfusion. METHODS: From November 2001 to February 2002, 186 patients undergoing myocardial revascularization were assessed, excluding those who underwent associated procedures. The patients were divided into 2 groups as follows: group A - comprising 116 patients undergoing MR with ECC; and group B - comprising 69 patients undergoing MR without ECC. Both groups were comparable in regard to pre- and intraoperative characteristics, except for the greater number of distal anastomoses (P=0.0004) in group A, and greater prothrombin activity (P=0.04) and INR (P=0.03) in group B. To avoid discrepancies between the groups, 140 patients with statistically similar characteristics were selected. RESULTS: Studying the paired groups, both the total bleeding volume in 24 hours (P=0.001) and the bleeding volume indexed for body surface (P=0.004) were greater in group A (609.6 ± 395.8 mL; 331.8 ± 225.8 mL/m2, respectively) than in group B (437.2 ± 315 mL; 241 ± 173.9 mL/m2, respectively). Although the need for transfusion was not significantly different between the groups (P=0.1), the amount of erythrocyte concentrate transfused was greater in group A (P=0.01). No statistical difference was observed in regard to transfusion of other hemocomponents and the need for surgical review of hemostasis. CONCLUSION: Myocardial revascularization without ECC was more advantageous than MR with ECC in regard to smaller postoperative blood loss and a lesser need for transfusion of erythrocyte concentrate. The repercussions of this finding may be innumerable, particularly in regard to minimization of morbid factors and hospital costs.

Post-cardiotomy ECMO in pediatric and congenital heart surgery: impact of team training and equipment in the results.

Introduction Post-cardiotomy myocardial dysfunction requiring mechanical circulatory support occurs in about 0.5% of cases. In our environment, the use of extracorporeal membrane oxygenation has been increasing in recent years. Objective To evaluate the impact of investment in professional training and improvement of equipment in the rate of weaning from extracorporeal membrane oxygenation and survival. Methods A retrospective study. Fifty-six pediatric and/or congenital heart patients underwent post-cardiotomy extracorporeal membrane oxygenation at our institution between November 1999 and July 2014. We divided this period into two phases: phase I, 36 cases (before the structuring of the extracorporeal membrane oxygenation program) and phase II, 20 cases (after the extracorporeal membrane oxygenation program implementation) with investment in training and equipment). Were considered as primary outcomes: extracorporeal membrane oxygenation weaning and survival to hospital discharge. The results in both phases were compared using Chi-square test. To identify the impact of the different variables we used binary logistic regression analysis. Results Groups were comparable. In phase I, 9 patients (25%) were weaned from extracorporeal membrane oxygenation, but only 2 (5.5%) were discharged. In phase II, extracorporeal membrane oxygenation was used in 20 patients, weaning was possible in 17 (85%), with 9 (45%) hospital discharges (P<0.01). When the impact of several variables on discharge and weaning of extracorporeal membrane oxygenation was analyzed, we observe that phase II was an independent predictor of better results (P<0.001) and need for left cavities drainage was associated with worse survival (P=0.045). Conclusion The investment in professional training and improvement of equipment significantly increased extracorporeal membrane oxygenation results.

Sobrecarga sistólica intermitente promove melhor desempenho miocárdico em animais adultos

FUNDAMENTO: A transposicao corrigida das grandes arterias frequentemente evolui com disfuncao ventricular direita. O preparo ventricular para a correcao anatomica em pacientes adultos apresenta resultados desapontadores. OBJETIVO: Analisar a hipertrofia do ventriculo direito (VD) induzida por dois tipos de bandagem pulmonar (BP), convencional e intermitente em animais adultos. METODOS: Dezenove cabras adultas foram divididas em tres grupos: Convencional (seis animais), Intermitente (seis animais) e Controle (sete animais). O grupo Convencional foi submetido a BP fixa com fita cardiaca, enquanto no grupo Intermitente foi usado dispositivo de BP ajustavel, que gerava sobrecarga sistolica por 12 horas, alternada com 12 horas de descanso do VD. As pressoes de VD, tronco pulmonar e aorta foram medidas durante todo o estudo. Ecocardiograma foi realizado semanalmente. Apos quatro semanas, os animais foram eutanasiados para avaliacao morfologica dos ventriculos. O grupo Controle foi submetido a eutanasia para analise em condicoes basais. RESULTADOS: A sobrecarga pressorica foi menor no grupo Intermitente (p=0,001), comparada ao grupo Convencional. Houve aumento na espessura do VD do grupo Intermitente, medida pelo ecocardiograma, comparado ao seu momento basal (p<0,05). O indice de performance miocardica do VD foi melhor no grupo Intermitente (p=0,024), comparado ao Convencional. Os grupos estimulados apresentaram aumento da massa muscular em comparacao ao grupo Controle (p=0,001). Nao houve diferenca no conteudo de agua miocardica. CONCLUSAO: A BP intermitente desenvolveu hipertrofia de melhor desempenho funcional, sugerindo este protocolo como metodo preferencial de preparo ventricular.BACKGROUND Corrected transposition of great arteries often evolves with right ventricular dysfunction. The ventricular preparation for anatomic correction in adult patients has produced disappointing results. OBJECTIVE To assess right ventricular hypertrophy (RV) induced by conventional and intermittent pulmonary banding (PB) in adult animals. METHODS Nineteen adult goats were divided into three groups: conventional (six animals), intermittent (six animals) and control (seven animals). The Conventional group underwent fixed PB with cardiac tape, while the intermittent group received PB adjustable device, which generated systolic overload for 12 hours, alternated with 12 hours of rest of RV. The pressures of the RV, pulmonary artery and aorta were measured throughout the study. Echocardiography was performed weekly. After four weeks, the animals were euthanized for morphological evaluation of the ventricles. The Control group was put to euthanasia for analysis at baseline. RESULTS Pressure overload was lower in the intermittent group (p = 0.001), compared to the conventional group. There was an increase in the thickness of the RV of the Intermittent group measured by echocardiography compared to their baseline values (p < 0.05). The myocardial performance index in the RV group was better in the Intermittent group (p = 0.024), compared to the Conventional group. The groups stimulated showed increased muscle mass compared to the Control group (p = 0.001). There was no difference in myocardial water content. CONCLUSION The intermittent BP developed hypertrophy of better performance, suggesting this protocol as the preferred method of ventricular preparation.

Use of Short-term Circulatory Support as a Bridge in Pediatric Heart Transplantation

Background Heart transplantation is considered the gold standard therapy for the advanced heart failure, but donor shortage, especially in pediatric patients, is the main limitation for this procedure, so most sick patients die while waiting for the procedure. Objective To evaluate the use of short-term circulatory support as a bridge to transplantation in end-stage cardiomyopathy. Methods Retrospective clinical study. Between January 2011 and December 2013, 40 patients with cardiomyopathy were admitted in our Pediatric Intensive Care Unit, with a mean age of 4.5 years. Twenty patients evolved during hospitalization with clinical deterioration and were classified as Intermacs 1 and 2. One patient died within 24 hours and 19 could be stabilized and were listed. They were divided into 2 groups: A, clinical support alone and B, implantation of short-term circulatory support as bridge to transplantation additionally to clinical therapy. Results We used short-term mechanical circulatory support as a bridge to transplantation in 9. In group A (n=10), eight died waiting and 2 patients (20%) were transplanted, but none was discharged. In group B (n=9), 6 patients (66.7%) were transplanted and three were discharged.The mean support time was 21,8 days (6 to 984h). The mean transplant waiting list time was 33,8 days. Renal failure and sepsis were the main complication and causeof death in group A while neurologic complications were more prevalent en group B. Conclusion Mechanical circulatory support increases survival on the pediatric heart transplantation waiting list in patients classified as Intermacs 1 and 2.

Reversible Pulmonary Trunk Banding VIII: Intermittent Overload Causes Harmless Hypertrophy in Adult Goat

BACKGROUND Traditional pulmonary artery banding (PAB) is not always suitable for mature subpulmonary ventricle retraining. We sought to assess in detail the myocardial morphologic adaptations of two different protocols for inducing right ventricular (RV) hypertrophy in an adult animal model. METHODS Eighteen adult goats were distributed into three groups: sham (no systolic overload), traditional (continuous systolic overload), and intermittent (daily 12-hour systolic overload). Systolic overload was adjusted to achieve a 0.7 RV-to-aortic pressure ratio. All animals underwent weekly echocardiographic studies, and hemodynamic evaluations were performed 3 times a week. After 4 weeks, the animals were humanely killed for morphologic assessment. RESULTS A 37.2% increase was observed in the RV wall thickness of the intermittent group (p<0.05), but no significant echocardiographic changes were observed in the other two groups. The intermittent and traditional groups had a 55.7% and 36.7% increase in RV mass, respectively, compared with the sham group (p<0.05). No differences were observed in myocardial water content of the three groups (p=0.27). RV myocardial fiber and nuclei diameters were increased in the intermittent group compared with the sham group (p<0.05). The area of collagen deposition in the RV interstitium was increased 98% in traditional group compared with the sham group (p<0.05). No significant cellular proliferation occurred in any group. CONCLUSIONS This study suggests that a more effective and harmless hypertrophy can be achieved in adult animals using intermittent PAB compared with the traditional approach.