Luis Sérgio Fragomeni

Revascularização cirúrgica do miocárdio em pacientes com stents coronários

Objective: To observe the surgical characteristics of patients operated on after percutaneous coronary interventions (PCI). Method: Fifty-six patients (41 M and 15 F), at the time of coronary artery bypass grafting (CABG), had already been submitted to coronary stenting procedures. In 101 PCI, 116 stents were implanted. At the time of the first PCI, 32 patients had three or more coronaries affected by severe stenosis. Six patients were treated with PCI for severe left coronary trunk stenosis. After the implantation of the first stent, 12 patients developed severe de novo lesions of the left coronary trunk. In 6 of these, stenosis developed within 6 months of stent implantation. Diabetes was present in 35.7% of the patients. In 22 patients (39.2%), at the time of CABG, the left ventricular function was reduced (p<0.001). During surgery, 160 grafts were implanted. Surgical studies included coronary and muscle biopsies. Results: Surgical observation showed more arteritis and inflammatory tissues adjacent to the stent when compared to other areas. Seventeen patients that could not have platelet antiaggregates withdrawn needed more blood transfusions. There were no hospital deaths. Conclusion: In patients operated on after stent implantation, facts like loss in LV function or de novo vascular lesions complicate surgical procedures and may impair longterm results. Due to endothelial dysfunction caused by stents, grafts may obstruct earlier. In addition the efficiency of clinical therapy may not be the same.

Relação entre tempo de isquemia e performance pós-operatória no transplante cardíaco

A presente dificuldade na obtencao de doadores adequados para o transplante cardiaco obriga a necessidade da utilizacao de orgaos removidos a distância, prolongando, assim, o tempo de isquemia total (TIT). Os efeitos do TIT sobre a funcao cardiaca no pos-operatorio imediato e a necessidade de agentes inotropicos ainda sao controversos, devendo os limites de seguranca serem determinados. As manifestacoes do TIT no indice cardiaco, durante os primeiros tres dias pos transplante cardiaco ortotopico (I/C 1-3), o periodo total do suporte inotropico (SIT), a dose total/kg de dopamina e dobutamina (D + D/kg), a necessidade inotropica maxima e picos dos niveis de CPK-MB (CPK-MB) foram medidos em 96 receptores de transplante cardiaco, na Universidade de Minnesota, para determinar a relacao destas variaveis com o TIT. O TIT variou entre 61 e 288 minutos (media 171,7, D.P. 51,9). A populacao foi dividida entre grupos representando intervalos de 30 minutos. Embora os niveis de CPK-MB fossem inferiores nos grupos de TIT menores, nao houve diferenca nos parâmetros de funcao cardiaca, tempo de suporte e necessidade inotropica. Concluimos que tempos de isquemia ate cinco horas sao bem tolerados e que outros fatores, como funcao cardiaca do doador previamente a remocao do orgao, ou possivel dano isquemico durante a remocao, sao mais importantes na determinacao da performance pos-operatoria imediata.

Tratamento cirúrgico da endocardite infecciosa

The indication, surgical pathology and the results of surgical treatment of 28 patients operated on for infectious endocarditis between 1983 and 1994 are here evaluated. The clinical diagnosis was confirmed by echocardiography and cineangiography. Seventy-five percent of the patients were male and 25% female, with the mean age of 35.2 (14 to 67) years old. Ninety three percent were in functional class III or IV (N Y H A). Elapsed time between diagnosis and surgery was around 4 weeks (1-363 days). A positive hemoculture was present in 25% of the cases and the commonest bacteria found were streptococcus and staphilococcus. The aortic valve was the one usualy affected and vegetations was the usual finding. Surgical treatment consisted of valvuloplasty in 2 cases and valve replacement in 26. Complications were present in 39.28% of the cases, which resulted in the death of five of them (18%). We conclude that, although rare, the infectious endocarditis is a serious disease; if not prevented with adequate antibiotic prophilaxis or treated in due time, serious complications or even death might occur.

Cardiopulmonary transplantation: current practice

Abstract. Heart‐lung transplantation has become an effective form of therapy for end‐stage cardiopulmonary disease. Early results have steadily improved, and a 1‐year survival rate of over 60% is now expected. The fact that lungs can be preserved for an extended period allows organs to be procured almost anywhere and this, in turn, has slightly improved the availability of organs for transplant. A diagnosis of lung rejection remains imprecise and progress still needs to be made in this area. Obliterative bronchiolitis of a variable degree remains the major medium‐term complication, probably representing chronic graft rejection. Although long‐term progress cannot yet be predicted, heart‐lung transplantation remains the only option for a normal life for this special group of patients.

Canine Double-Lung Allotransplantation: Operative Technique and Results for 12-h Preservation Studies

A canine double-lung allotransplantation model was developed to study the effects of 12-h static pulmonary preservation. This model has not been used extensively for such experiments but allows a detailed evaluation of the quality of preservation. An operative technique is described in which cautery dissection and preliminary devascularization of the recipient right lung allows the period of cardiopulmonary bypass to be limited and reduces postoperative bleeding. Six double-lung blocks were successfully orthotopically transplanted and recipient animals were studied for 12 h postoperatively. All animals survived the study period and had a mean PO2 (FIO2 0.4) of 141 mm Hg, 12 h following reimplantation suggesting adequate pulmonary preservation. There was no evidence of pulmonary edema at any time following implantation, although airway pressures and pulmonary vascular resistance were elevated. The role of this model in lung preservation studies is discussed.

Transplantes cardiopulmonar e pulmonar com doador em localidade distante

In special situations, clinical heart-lung and lung transplantation are today established methods of therapy for end stage cardiopulmonary and pulmonary disease. Adequate donor availability remains a major problem and distant organ procurement is today a necessity. Although many methods of lung preservation can be used, for periods of up to 5 hours, hypothermic storage with cardioplegic arrest and pulmonary artery flush with modified Collins solution has proven to be a simple and reliable method of heart-lung preservation. We here describe our current method of heart-lung block protection, in which heart-lung and double lung transplantation were performed followed by excelent cardiac and pulmonary function.