Luciano de Figueiredo Aguiar

Coronary artery bypass grafting without cardiopulmonary bypass

BACKGROUND Coronary artery bypass grafting without cardiopulmonary bypass is now an accepted technique of myocardial revascularization. We herein report our total experience with this procedure. METHODS In a consecutive series of 8,751 patients operated on in our institution for coronary artery disease from 1981 to 1994, 1,274 patients received coronary artery bypass grafting without cardiopulmonary bypass. RESULTS Results indicate that the operation can be performed with an acceptable mortality (2.5%), and that all types of arterial conduits can be used. Most commonly the left anterior descending and right coronary arteries were bypassed. The incidence of arrhythmias and of pulmonary and neurologic complications were significantly lower in this group of patients compared with patients receiving coronary artery bypass grafting with cardiopulmonary bypass. Most importantly, there was decreased cost when the procedure was used because no extracorporeal circulation, cardioplegia sets, or other cannulas were used. CONCLUSIONS We conclude that the continuing use of coronary artery bypass grafting without cardiopulmonary bypass is justified and that, with proper selection of patients, the procedure is safe and cost-effective.

Transplante cardíaco e infecção

Objective: To evaluate the incidence of infection, the etiological agents, to present the clinical aspects and the surgical morbi-mortality in patients who underwent cardiac transplant at Federal University of Sao Paulo. Material and Methods: From November 1966 to June 1998, a total of 97 patients were operated by the UNIFESP Cardiovascular Surgery team and survived longer than 1 week after the transplantation and were studied retrospectively as far as infections. The age of the patients ranged from 3 to 63 years (average 44.4 ± 13 years). Most of the patients had dilated myocardiopathy (46), or Chagas (24) or ischemis (23). The follow up ranged from 0.33 to 119 months (36 ± 30.7 months) Results: Of the 97 patients, 16 (16.4%) had infection as the main cause of death, followed by rejection in 10 (10.3%). The causes of infection were: bacterial sepsis in 6 patients, pneumonia in 6, intra-abdominal infection in 2, toxoplasmosis in 1 and cytomegalovirus infection in 1. There were 142 infection episodes, bacterial 76 (52.5%), viral 34 (28.8%), fungi 20 (17.5%) and protozoa 12 (12.4%). There were 8 episodes of the reactivation were treated successfully with alopurinol. Conclusions: Our data showed the predominance of bacterial infections as the cause of most mortality. In transplanted patients suffering from Chagas´disease, the reactivation of the disease may be adequately controlled by means of alopurinol. Such data serve as orientation in our community for our programs of transplants, since they show particular aspects of our enviroment.

Transplante cardíaco ortotópico: experiência na Universidade Federal de São Paulo

Foram realizados no periodo de novembro de 1986 a abril de 1997, 92 transplantes ortotopicos, com receptores na faixa etaria de 3 a 63 anos (media de 44,9 anos). Os diagnosticos pre-operatorios foram de miocardiopatia dilatada em 42 (44,6%) pacientes, isquemica em 23 (25,0%), chagasica em 21 (22,8%), valvar em 3 (3,2%) e outras miocardiopatias em 3 (3,2%) pacientes. A tecnica operatoria empregada (Lower e Shumway, em 1960) foi satisfatoria e sem complicacoes. O tempo de isquemia - mais longo nos transplantes com captacao a distância - foi sempre inferior a quatro horas. As complicacoes relacionadas ao uso cronico de imunossupressores foram, principalmente, hipertensao arterial (84,6%), hiperuricemia (75,4%) e dislipidemia (63,0%). Quanto as infeccoes, houve predominio das virais, com 42 (45,6%) casos, seguidas das bacterianas, com 35 (38,0%) casos, e das por protozoarios, com 15 (16,3%) casos. Dentre as infeccoes bacterianas, sete foram do sitio cirurgico, com boa evolucao. Das infeccoes por protozoarios, sete (46,6%) forma por reativacao do Trypanosoma cruzi. A mortalidade geral nos primeiros 30 dias do pos-operatorio foi de 17,3% e teve, como principais causas: infeccao, complicacoes neurologicas e rejeicao. Apos esses 30 dias e ate o primeiro ano, houve 10 (10,3%) obitos, com predominio de rejeicao e infeccao como causas. Apos o primeiro ano de pos-operatorio, houve 13 (14,0%) falecimentos, por causas diversas, como: morte subita, infeccao, rejeicao, alem de outras. A curva actuarial mostrou no 1o, 2o, 3o, 4o, 5o e 6o anos uma sobrevivencia de receptores de 71,6%, 66,6%, 60,5%, 54,4%, 54,4%, 54,4%, respectivamente. Nao houve perda de seguimento de paciente, e os sobreviventes ate a conclusao do trabalho encontravam-se bem, todos em classe funcional I da NYHA. Os autores concluem que e possivel a realizacao de transplante cardiaco em nossa comunidade com sobrevivencia e taxa de complicacoes pos-operatorias aceitaveis, porem diferentes das estatisticas internacionais.

Revascularização do miocárdio sem circulação extracorpórea: resultados da experiência de 18 anos de sua utilização

Introduction: Myocardial revascularization without cardiopulmonary bypass is today an increasing alternative of revascularization although the limits of applicability are still to be defined. The authors review a series of cases and discuss its indications based upon their results. Patients and Methods: There were analyzed 2495 patients who underwent direct myocardial revascularization without extracorporeal circulation in the period from October 1981 to September 1999, from a total of 10656 patients, submitted to coronary bypass surgery during this period (23.4%). The age varied from 32 to 90 years (medium = 59) with most males (67%). Chronic coronary insufficiency was the most common surgical indication (70.8%) and the majority of the patients received 2 grafts (51.5%). Results: The global mortality rate (30 days) was 1.9% (48/ 2495) and only 45% of these patients needed blood transfusion. The global applicability of this technique was around 23%, however in the last 3 years the applicability was 32.8%, 35.1% and 42.2%. Conclusions: Myocardial revascularization without extracorporeal circulation is a safe tactical alternative for coronary insufficiency and has increased in the last years. This treatment is indicated in this subgroup of lower mortality and small incidence of postoperative complications. In the next years the use of this technique will increase with the use of stabilizers, special manipulation and functional revascularization.

Revascularização do miocárdio sem circulação extracorpória: análise dos resultados em 15 anos de experiência

Myocardial revascularization without cardiopulmonary bypass is now a subject of increasing interest. The purpose of this paper is to present the results obtained during 15 years of experience. From September 1981 till March 1996,1549 patients we operated on without the use of cardiopulmonary bypass with an applicability of this alternative around 18% of the total revascularized patients in this period. The ages varied from 28 to 86 years (medium 57) with 1126 males and 423 females. The number of grafts varied from 1 to 5 (medium 1.7 grafts/patient). The technique did not constitute special limitation to use arterial grafts. The thoracic internal arteries were used 1140 times. In 1515 patients the revascularization was achieved through medsternotomy and in 34 through a minor left anterior thoracotomy. The mortality rate was 2.4% (38/1549) the main primary cause of death, low cardiac output in patients operated under acute ischemia after failed angioplasty or evolving mycardial infarction. In 8 patients the revascularization was performed under intraaortic balloon pump. The results of this 15 years experience permit the conclusion that myocardial revascularization without extracorporeal circulation is an excelent alternative of surgical treatment of coronary artery disease for a subset of patients with lower mortality and morbidity being specially indicated in high risk patients.

Revascularização direta do miocárdio sem circulação extracorpórea: estudo crítico dos resultados em 391 pacientes

Os autores analisam os resultados obtidos em 391 pacientes consecutivos e nao selecionados e submetidos a revascularizacao direta do miocardio sem o circuito cardiopulmonar, operados de setembro de 1981 a fevereiro de 1985. Neste mesmo periodo, foram realizadas um total de 1568 cirurgias de revascularizacao, sendo esta alternativa tatica aplicavel em 24,9% dos casos. Da casuistica apresentada, 318 (81,3%) eram do sexo masculino e 73 (18,7%), do feminino e as idades de 35 a 76 anos, oscilando em torno da mediana 56. As condicoes pre-operatorias indicativas da cirurgia foram as seguintes: insuficiencia coronaria cronica 286 (73,1%) casos; pos trombolise coronaria 42 (10,7%); infarto agudo em evolucao 18 (4,6%); pos angioplastia mal sucedida 18 (4,6%); reoperacoes 14 (3,6%); sindrome intermediaria 12 (3,1%) e revascularizacao em disseccao aortica cronica 1 caso. Pontes unicas foram realizadas em 175 (44,7%) pacientes, duplas em 192 (49,1%) e triplas em 24 (6,1%), com a media de 1,6 pontes/paciente. A arteria mamaria foi usada para 109 casos, arteria mamaria heterologa bovina em 2, sendo, nos demais, utilizada a veia safena. A mortalidade hospitalar foi de 2,5% (10/391), o que difere, significativamente, da mortalidade de 5% verificada para um grupo de 1177 pacientes operados no mesmo periodo, com a circulacao extracorporea. Comparamos, prospectivamente, as complicacoes pos-operatorias observadas em um grupo de 378 pacientes operados sem a circulacao extracorporea, contra um grupo controle de 689 pacientes tratados da maneira convencional, no que diz respeito a incidencia de arritmias, infarto per-operatorio, complicacoes pulmonares, neurologicas, infecciosas e hemorragicas. Verificamos uma incidencia menor, estatisticamente significante, para as complicacoes pulmonares, neurologicas e de arritmias no grupo operado sem a circulacao extracorporea, nao diferindo das demais complicacoes entre os dois grupos. Concluem os autores que a revascularizacao do miocardio sem utilizacao da extracorporea se consolidou, ao longo destes 4 anos de experiencia, como tatica de eleicao em lesoes da coronaria direita, descendente anterior, ou ambas, face as vantagens que apresenta.

Transplante cardíaco e neoplasias: experiência na Escola Paulista de Medicina da Universidade Federal de São Paulo

OBJECTIVE To study the occurrence and types of neoplasms developed by patients who underwent an orthotopic cardiac transplantation under the Program of Cardiac Transplantation of Escola Paulista de Medicina, Federal University of São Paulo. METHODS This is an observational study of 106 patients who underwent orthotopic cardiac transplantation from November 1986 to September 2002 and survived at least thirty days following the procedure. The triple immunosuppressive regimen given included cyclosporin A, azathioprine and a corticosteroid agent. Only two patients received OKT3 in addition to the regimen established. Mean follow-up was 61.4 months (ranging from two months to 192 months). RESULTS Twenty-three patients (21.3%) developed neoplasms--56.5% of these were skin neoplasm, 30.1%, solid tumors, and 13.4% of post-transplant lymphoproliferative disease (PTLD). Mean interval between transplantation and diagnosis of neoplasm was: 54.9 months for skin neoplasm; 24.8 months for solid tumors and 70.3 months for PTLD. CONCLUSION Malignant neoplasms are relatively common in the population studied. Skin cancer was the most common type compared to the other types of neoplasms. Solid tumors were more frequently diagnosed than the lymphoproliferative diseases in the population examined.

End‐Stage Cardiomyopathy and Secondary Mitral Insufficiency Surgical Alternative with Prosthesis Implant and Left Ventricular Remodeling

Abstract Secondary mitral insufficiency is a strong risk factor for death in end‐stage cardiomyopathies. The possible correction of mitral regurgitation is now being accepted as an alternative to cardiac transplantation in a special subset of patients. We proposed a new surgical approach that consisted of implantation of a mitral prosthesis smaller than the annulus, as well as preservation and traction of the papillary muscles to reduce sphericity of the left ventricle. Between December 1995 and August 2001, 71 cases were operated on including the following etiologies: ischemic (38), idiopathic (29), Chagas disease (2), viral (1), and postpartum (1). All patients were in an end‐stage phase with more than two hospital admissions in the last three months; seven were in intensive care units receiving drugs and intra‐aortic balloon counterpulsation, and one was in cardiogenic shock. The patients were analyzed according to clinical criteria, echocardiographic findings, and morphology of the left ventricle. Hospital mortality was 16.9% (12/71) and mid‐term follow‐up showed evidence of improvement in clinical status and some echocardiographic parameters. This technique, despite a high mortality rate (due to other clinical conditions at the time of surgery), offers a promising therapeutic alternative for the treatment of patients in refractory heart failure with cardiomyopathy associated with secondary mitral regurgitation.(J Card Surg 2003;18:201‐205)

Sildenafil improves right ventricular function in a cardiac transplant recipient

We report the case of a male patient who underwent orthotopic cardiac transplantation. A marginal donor was used, because the recipients clinical condition was critical. He experienced cardiogenic shock due to right ventricular dysfunction secondary to pulmonary hypertension associated with vasoplegia. After the introduction of sildenafil, the patient recovered hemodynamically, his pulmonary vascular resistance decreased, the vasoactive drugs were withdrawn, and his right ventricular function improved.