Maurício Marson Lopes

Eficiência da correção endoventricular com patch em pacientes com grande área acinética pós-infarto do miocárdio e severa disfunção ventricular

PURPOSE: Efficacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left ventricular dysfunction. METHODS: This study evaluated clinical and hemodynamic results of endoventricular circular patch plasty in patients with either large akinetic scar (n=9) or large dyskinetic scar (n=11) and depressed left ventricular function (ejection fraction < 35%). The difference between akinetic and dyskinetic left ventricular aneurysms was diagnosed by gated radionuclide ventriculography. Groups were comparable for symptons and by echocardiography and by hemodynamic before and after the surgery. RESULTS: Results showed an early improvement in New York Heart Association functional class. Statistically (the Student t test) an improvement occurred in left ventricle ejection fraction (from 25 ± 0.8% to 39 ± 1.6% in akinetic patients and from 27 ± 0.7% to 41 ± 1.6% in dyskinetic patients), decreased of capillary wedge pressure (20 ± 1.2 mmHg to 12 ± 1.2 mmHg in akinetics and 17 ± 0,5 mmHg to 11 ± 0.9 mmHg in dyskinetics patients), decrease end-diastolic volume index (226 ± 11 ml to 115 ± 7,8 ml in akinetics and 209 ± 11ml to 96 ± 5ml in dyskinetics) and end-systolic volume index (176 ± 9.2 ml to 77 ± 6.2 ml in akinetics and 160 ± 10ml to 66 ± 2ml in dyskinetics patients. Overall operative mortality was 10% (2 cases in akinetic group = 22.2%). CONCLUSION: We find that endoventricular circular patch plasty technique allows an effective correction and provides a significant improvement in cardiac function in patients with large postinfarction akinetic scar and severe left ventricular dysfunction.

Postoperative muscle training improves tidal volume and vital capacity in the postoperative period of CABG surgery

OBJECTIVE To evaluate lung function and respiratory muscle strength in the postoperative period and investigate the effect of inspiratory muscle training on measures of respiratory muscle performance in patients undergoing coronary artery bypass grafting. METHODS A randomized study with 47 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. They were divided into study group (SG) 23 patients and control group (CG) 24 patients, mean age 61.83 ± 8.61 and 66.33 ± 10.20 years, EuroSCORE SG 0.71 ± 0.0018 and CG 0.76 ± 0.0029, respectively. The study group underwent physical therapy and inspiratory muscle training with threshold IMT® and CG underwent conventional physiotherapy. We compared the maximal respiratory pressures (MIP and MEP), tidal volume (TV), vital capacity (VC) and peak expiratory flow (peak flow) preoperatively (Pre-OP), 1st (PO1) and 3rd (PO3) postoperative day. RESULTS There was a significant reduction in all variables measured on PO1 compared to preoperative values in both groups, MIP (P <0.0001), MEP (P <0.0001), TV SG (P <0.0004) and CG (P <0.0001) and VC SG (P <0.0001) and CG (P <0.0001) and peak flow (P <0.0001). At PO3, SG presented higher value of VC, GE 1230.4 ± 477.86 ml vs. GC 919.17 ± 394.47 ml (P=0.0222) and TV SG 608.09 ± 178.24 ml vs. CG 506.96 ± 168.31 ml (P= 0.0490). CONCLUSION Patients undergoing cardiac surgery experience reduced ventilatory capacity and respiratory muscle strength after surgery. Muscle training was performed to retrieve TV and VC in the PO3, in the trained group.OBJETIVO: Avaliar a funcao pulmonar e forca da musculatura respiratoria no periodo pos-operatorio e verificar o efeito do treinamento muscular inspiratorio sobre as medidas de desempenho da musculatura respiratoria em pacientes submetidos a revascularizacao do miocardio. METODOS: Estudo randomizado, incluindo 47 pacientes submetidos a revascularizacao do miocardio com circulacao extracorporea. Os pacientes foram divididos em grupo controle (GC), 24 pacientes, e grupo estudo (GE) 23 pacientes, com idade media de 66,33 ± 10,20 anos e 61,83 ± 8,61 anos, respectivamente. O GE foi submetido a fisioterapia convencional e ao treinamento muscular inspiratorio com threshold® IMT e o GC a fisioterapia convencional. Foram comparadas as pressoes respiratorias maximas (Pimax e Pemax), volume corrente (VC), capacidade vital (CV) e pico de fluxo expiratorio (Peak Flow) no pre-operatorio (Pre-OP), 1o e 3o dias de pos-operatorio (PO1) e (PO3). RESULTADOS: Observou-se reducao significativa em todas as variaveis mensuradas no PO1, quando comparadas ao pre-operatorio, nos dois grupos estudados, Pimax (P<0,0001), Pemax (P<0,0001), VC: GE (P<0,0004) e GC: (P< 0,0001) e CV GE: (P<0,0001) e GC: (P<0,0001) e peak flow (P<0,0001). No PO3, o GE apresentou em comparacao ao GC, maior valor de CV, GE 1230,4 ± 477,86 ml vs. GC 919,17 ± 394,47 ml (P= 0,0222) e VC GE 608,09 ± 178,24 ml vs. GC 506,96 ± 168,31 ml (P=0,0490). CONCLUSAO: Pacientes submetidos a cirurgia cardiaca sofrem reducao da CV e da forca muscular respiratoria apos a cirurgia. O treinamento muscular realizado foi eficaz em recuperar o VC e a CV no PO3, no grupo treinado.

Treinamento muscular melhora o volume corrente e a capacidade vital no pós-operatório de revascularização do miocárdio

OBJECTIVE To evaluate lung function and respiratory muscle strength in the postoperative period and investigate the effect of inspiratory muscle training on measures of respiratory muscle performance in patients undergoing coronary artery bypass grafting. METHODS A randomized study with 47 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. They were divided into study group (SG) 23 patients and control group (CG) 24 patients, mean age 61.83 ± 8.61 and 66.33 ± 10.20 years, EuroSCORE SG 0.71 ± 0.0018 and CG 0.76 ± 0.0029, respectively. The study group underwent physical therapy and inspiratory muscle training with threshold IMT® and CG underwent conventional physiotherapy. We compared the maximal respiratory pressures (MIP and MEP), tidal volume (TV), vital capacity (VC) and peak expiratory flow (peak flow) preoperatively (Pre-OP), 1st (PO1) and 3rd (PO3) postoperative day. RESULTS There was a significant reduction in all variables measured on PO1 compared to preoperative values in both groups, MIP (P <0.0001), MEP (P <0.0001), TV SG (P <0.0004) and CG (P <0.0001) and VC SG (P <0.0001) and CG (P <0.0001) and peak flow (P <0.0001). At PO3, SG presented higher value of VC, GE 1230.4 ± 477.86 ml vs. GC 919.17 ± 394.47 ml (P=0.0222) and TV SG 608.09 ± 178.24 ml vs. CG 506.96 ± 168.31 ml (P= 0.0490). CONCLUSION Patients undergoing cardiac surgery experience reduced ventilatory capacity and respiratory muscle strength after surgery. Muscle training was performed to retrieve TV and VC in the PO3, in the trained group.OBJETIVO: Avaliar a funcao pulmonar e forca da musculatura respiratoria no periodo pos-operatorio e verificar o efeito do treinamento muscular inspiratorio sobre as medidas de desempenho da musculatura respiratoria em pacientes submetidos a revascularizacao do miocardio. METODOS: Estudo randomizado, incluindo 47 pacientes submetidos a revascularizacao do miocardio com circulacao extracorporea. Os pacientes foram divididos em grupo controle (GC), 24 pacientes, e grupo estudo (GE) 23 pacientes, com idade media de 66,33 ± 10,20 anos e 61,83 ± 8,61 anos, respectivamente. O GE foi submetido a fisioterapia convencional e ao treinamento muscular inspiratorio com threshold® IMT e o GC a fisioterapia convencional. Foram comparadas as pressoes respiratorias maximas (Pimax e Pemax), volume corrente (VC), capacidade vital (CV) e pico de fluxo expiratorio (Peak Flow) no pre-operatorio (Pre-OP), 1o e 3o dias de pos-operatorio (PO1) e (PO3). RESULTADOS: Observou-se reducao significativa em todas as variaveis mensuradas no PO1, quando comparadas ao pre-operatorio, nos dois grupos estudados, Pimax (P<0,0001), Pemax (P<0,0001), VC: GE (P<0,0004) e GC: (P< 0,0001) e CV GE: (P<0,0001) e GC: (P<0,0001) e peak flow (P<0,0001). No PO3, o GE apresentou em comparacao ao GC, maior valor de CV, GE 1230,4 ± 477,86 ml vs. GC 919,17 ± 394,47 ml (P= 0,0222) e VC GE 608,09 ± 178,24 ml vs. GC 506,96 ± 168,31 ml (P=0,0490). CONCLUSAO: Pacientes submetidos a cirurgia cardiaca sofrem reducao da CV e da forca muscular respiratoria apos a cirurgia. O treinamento muscular realizado foi eficaz em recuperar o VC e a CV no PO3, no grupo treinado.

Increased expression and phosphorylation of focal adhesion kinase correlates with dysfunction in the volume-overloaded human heart

FAK (focal adhesion kinase) has been shown to mediate the hypertrophic growth of the left ventricle. Experimental results also suggest that FAK may contribute to the structural and functional deterioration of the chronically overloaded left ventricle. In the present study, we postulated that FAK expression and phosphorylation may be altered in the volume-overloaded heart in humans. FAK expression and phosphorylation at Tyr(397) were detected by Western blotting and immunohistochemistry in samples from endomyocardial biopsies from patients with MR (mitral regurgitation; n=21) and donor subjects (n=4). Hearts from patients with MR had degenerated cardiac myocytes and areas of fibrosis. In this group, the myocardial collagen area was increased (18% in MR hearts compared with 3% in donor hearts respectively) and correlated negatively with left ventricular ejection fraction (r=-0.74; P>0.001). FAK expression and phosphorylation at Tyr(397) (a marker of the enzyme activity) were increased in samples from MR hearts compared with those from donor hearts (3.1- and 4.9-fold respectively). In myocardial samples from donor hearts, anti-FAK staining was almost exclusively restricted to cardiac myocytes; however, in myocardial samples from MR hearts, staining with the anti-FAK antibody was found to occur in myocytes and the interstitium. There was a positive correlation between collagen and the interstitial areas stained with the anti-FAK antibody (r=0.76; P>0.001). Anti-FAK and anti-vimentin staining of the interstitial areas of samples from MR hearts were extensively superimposed, indicating that most of the interstitial FAK was located in fibroblasts. In conclusion, FAK expression and phosphorylation are increased and may contribute to the underlying structural and functional abnormalities in the volume-overloaded heart in humans.

O impacto de mudanças nas medidas de prevenção e no tratamento de infecções incisionais em cirurgia de revascularização do miocárdio

Objective: To assess the impact of new preventive measures of surgical site infections after coronary artery bypass graft (CABG) surgery. Method: A retrospective study of 468 patients who underwent CABG surgery with cardiopulmonary bypass was performed. These patients were distributed into two groups: Group A (n=224) and Group B (n=244), respectively before and after a new protocol. The two groups were compared by statistical analysis to determine differences in risk factors, the incidence of sternotomy surgical site infections (superficial and deep), recurrent infections and hospital readmission. Results: There was a greater use of internal thoracic artery grafts (p=0.003) and a shorter time of mechanical ventilation (p=0.001) in Group B. Surgical site infections occurred in 44 patients of Group A (19.6%); 33 superficial (14.7%) and 11 deep (4.9%) while in Group B only 13 patients had this complication (5.3%); 10 superficial (4.1%) and 3 deep (1.2%) surgical site infections. Significant improvements were seen in the total number of surgical site infections (p<0.001), of superficial infections (p<0.001) and of deep infections (p=0.037). There were 36.3% and 7.7% of recurrent infections in Groups A and B, respectively (p=0.102). Hospital readmissions due to surgical site infections were 21 in Group A and 3 in Group B (p<0.001). Conclusion: The new preventive measures and treatment for surgical site infections after CABG surgery in this series of patients significantly reduced the incidence of sternotomy surgical site infections and hospital readmissions related to this complication.

Proporção entre os segmentos do anel da valva tricúspide normal: um parâmetro para realização da anuloplastia valvar

Objective: The purpose of this study was to determine the proportions among the segments of the human tricuspid valve annulus. Methods: A descriptive autopsy study was made of 30 human hearts without fixation, within six hours of death, without congenital or acquired lesions and without tricuspid regurgitation. Tricuspid valve insufficiency was excluded by the infusion of pressurized water in the right ventricle with the pulmonary valve closed. Digital images of the tricuspid ring in its anatomical position and after flattening were analyzed by specific software. The mean measurements and ratios were compared in the two different situations. Results: The mean measurements of the perimeter, septal and antero-posterior segments of the tricuspid ring in the anatomical position were: 105 mm (± 12.7), 30.6 mm (± 3.7) and 74 mm (± 9.4), respectively. When flattened, the mean measurement of the perimeter was 117.5 mm (± 13.3) and the sizes of the septal, anterior and posterior segments were 32 mm (± 3.7), 46.3 mm (± 8.3) and 39.1 mm (± 8.5), respectively. The mean ratio between the antero-posterior and septal segments was 2.43 (± 0.212) in the anatomical position and when flattened it was 2.67 (± 0.304). Statistical differences were observed in the measurements of the perimeter (p<0.0001), septal segment (p=0.003) and antero-posterior segment (p<0.0001) in both situations. Statistical differences also occurred in the ratios between the antero-posterior and septal segments (p=0.0005). Conclusions: The proportion between the septal and antero-posterior segments of the normal human tricuspid valve is 1:2.43. Flattening the tricuspid ring to measure the segments, changes the values and the ratios between them.

Importance of the area of fibrosis at midterm evolution of patients submitted to ventricular reconstruction

BACKGROUND Although it is acknowledged that the ventricular reconstruction surgery (VRS) can promote reverse remodeling, new studies are necessary to define the influence of the left ventricular (LV) area of fibrosis. OBJECTIVE To evaluate whether the extension of the area of fibrosis of the LV is important in the LV functional recovery after the surgery and correlate it with clinical factors. METHODS Prospective analysis of 82 patients with ventricular dysfunction submitted to VRS. We analyzed the importance of the clinical characteristics and the amount of fibrosis was assessed, measured by cardiac magnetic resonance (CMR) as small, medium and large. RESULTS All patients were followed for 36 months, with a mortality of 6%. The amount of medium fibrosis was 25.8% +/- 13.6%. There was improvement in the left ventricular ejection fraction (LVEF), from 36.9% +/- 6.8% to 48.2% +/- 8.2% (p < 0.001). There was an inverse association between the amount of fibrosis and the increase in LVEF (r = -0.83, p < 0.0001). There was a decrease in the LV end-systolic volume of 43.3 +/- 8.2 ml/m(2) (p < 0.001). There was an improvement in heart failure symptoms, except in patients with large areas of fibrosis (p = 0.45). The independent predictors for events were: fibrotic area (p = 0.01), age (p = 0.01), LV end-systolic volume (p = 0.03) and LVEF (p = 0.02). The event-free follow-up was different in relation to the area of fibrosis (p < 0.01). CONCLUSION In patients with ventricular dysfunction, the extension of the area of fibrosis was an independent predictor of the LV functional recovery after the VRS. The combination of cardiac MRI and clinical parameters can help in the indication for VRS.FUNDAMENTO: Si bien se reconoce que la cirugia de reconstruccion ventricular (CRV) promueve remodelacion reversa, son necesarios nuevos estudios para definir la influencia del area de fibrosis del ventriculo izquierdo (VE). OBJETIVO: Evaluar si la extension del area de fibrosis del VI es importante en la recuperacion funcional ventricular tras la CRV y correlacionarlo con factores clinicos. METODO: Analisis prospectivo de 82 pacientes con disfuncion ventricular sometidos a CRV. Se analizo la importancia de las caracteristicas clinicas y se evaluaron las areas de fibrosis, medidas por resonancia magnetica y ponderadas como pequena, mediana y grande. RESULTADOS: Se realizo un seguimiento de 36 meses a todos los pacientes, con mortalidad del 6%. La cantidad de fibrosis promedio fue del 25,8% ± 13,6%. Existio una mejora de la fraccion de eyeccion del VI (FEVI), del 36,9% ± 6,8% al 48,2% ± 8,2% (p < 0,001). Existio relacion inversa entre la cantidad de fibrosis y el incremento de la FEVI (r = -0,83, p < 0,0001). Hubo una disminucion del volumen de fin de sistole del VI de 43,3 ± 8,2ml/m² (p < 0,001). Se produjo una mejoria en los sintomas de insuficiencia cardiaca, excepto en los pacientes con gran area de fibrosis (p = 0,45). Los predictores independientes para eventos fueron: area de fibrosis (p = 0,01), edad (p = 0,01), volumen de fin de sistole del VI (p = 0,03) y fraccion de eyeccion (p = 0,02). El seguimiento libre de eventos fue diferente en relacion con el area de fibrosis (p < 0,01). CONCLUSION: En pacientes con disfuncion ventricular, la extension del area de fibrosis fue un predictor independiente de la recuperacion funcional del VI luego de la CRV. La combinacion de RMC y parametros clinicos puede auxiliar en la indicacion de CRV.

Benefício da revascularização do miocárdio em pacientes com disfunção ventricular e músculo viável: remodelamento ventricular reverso e prognóstico

OBJECTIVES: To evaluate the integration of both viability and clinical parameters on the improvement in systolic performance, symptoms and prognosis, with post-revascularization reverse remodeling. METHOD: One hundred and fifteen patients underwent thallium-201 imaging before myocardial revascularization. Left ventricular ejection fraction, left ventricular end-systolic volume index and left ventricular end-diastolic volume index were determined before and at each 6 months post-revascularization for 3 years. RESULTS: Patients with > 4 viable segments on thallium-201 imaging demonstrated an improvement in left ventricular ejection fraction from 34±6 to 44±4%, p<0.001), left ventricular end-systolic volume decreased from 78.3±11 to 57±17 mL/m2, p<0.001; left end-diastolic volume decreased from 113±31 to 91±22 ml/m2, p<0.001). Patients with < 4 viable segments failed to demonstrate an improvement of the left ventricle ejection fraction, 33.4±4 vs. 35.1±5% (p=0.19), and exhibited ongoing left ventricle end-systolic remodeling, 72±23 vs. 73±12 mL/m2 (p= 0.81), and the left ventricle end-diastolic volume increased from 112±24 to 118±16 mL/m2 (p=0.34), without improvement in NYHA class, and worse long-term prognosis (event; log rank test, p=0.0053). The multivariable analysis demonstrated clinical variables related to the unfavorable evolution showed diabetes, more than one myocardial infarction, and time interval between myocardial infarction and surgery were associated with worse prognosis. CONCLUSION: The benefits of myocardium revascularization in patients with viable muscle, as well as an improvement in the left ventricular ejection fraction, provide reverse remodeling, improvement in functional class and favorable long-term prognosis.

Importancia del área de fibrosis en la evolución a mediano plazo de pacientes sometidos a reconstrucción ventricular

BACKGROUND Although it is acknowledged that the ventricular reconstruction surgery (VRS) can promote reverse remodeling, new studies are necessary to define the influence of the left ventricular (LV) area of fibrosis. OBJECTIVE To evaluate whether the extension of the area of fibrosis of the LV is important in the LV functional recovery after the surgery and correlate it with clinical factors. METHODS Prospective analysis of 82 patients with ventricular dysfunction submitted to VRS. We analyzed the importance of the clinical characteristics and the amount of fibrosis was assessed, measured by cardiac magnetic resonance (CMR) as small, medium and large. RESULTS All patients were followed for 36 months, with a mortality of 6%. The amount of medium fibrosis was 25.8% +/- 13.6%. There was improvement in the left ventricular ejection fraction (LVEF), from 36.9% +/- 6.8% to 48.2% +/- 8.2% (p < 0.001). There was an inverse association between the amount of fibrosis and the increase in LVEF (r = -0.83, p < 0.0001). There was a decrease in the LV end-systolic volume of 43.3 +/- 8.2 ml/m(2) (p < 0.001). There was an improvement in heart failure symptoms, except in patients with large areas of fibrosis (p = 0.45). The independent predictors for events were: fibrotic area (p = 0.01), age (p = 0.01), LV end-systolic volume (p = 0.03) and LVEF (p = 0.02). The event-free follow-up was different in relation to the area of fibrosis (p < 0.01). CONCLUSION In patients with ventricular dysfunction, the extension of the area of fibrosis was an independent predictor of the LV functional recovery after the VRS. The combination of cardiac MRI and clinical parameters can help in the indication for VRS.FUNDAMENTO: Si bien se reconoce que la cirugia de reconstruccion ventricular (CRV) promueve remodelacion reversa, son necesarios nuevos estudios para definir la influencia del area de fibrosis del ventriculo izquierdo (VE). OBJETIVO: Evaluar si la extension del area de fibrosis del VI es importante en la recuperacion funcional ventricular tras la CRV y correlacionarlo con factores clinicos. METODO: Analisis prospectivo de 82 pacientes con disfuncion ventricular sometidos a CRV. Se analizo la importancia de las caracteristicas clinicas y se evaluaron las areas de fibrosis, medidas por resonancia magnetica y ponderadas como pequena, mediana y grande. RESULTADOS: Se realizo un seguimiento de 36 meses a todos los pacientes, con mortalidad del 6%. La cantidad de fibrosis promedio fue del 25,8% ± 13,6%. Existio una mejora de la fraccion de eyeccion del VI (FEVI), del 36,9% ± 6,8% al 48,2% ± 8,2% (p < 0,001). Existio relacion inversa entre la cantidad de fibrosis y el incremento de la FEVI (r = -0,83, p < 0,0001). Hubo una disminucion del volumen de fin de sistole del VI de 43,3 ± 8,2ml/m² (p < 0,001). Se produjo una mejoria en los sintomas de insuficiencia cardiaca, excepto en los pacientes con gran area de fibrosis (p = 0,45). Los predictores independientes para eventos fueron: area de fibrosis (p = 0,01), edad (p = 0,01), volumen de fin de sistole del VI (p = 0,03) y fraccion de eyeccion (p = 0,02). El seguimiento libre de eventos fue diferente en relacion con el area de fibrosis (p < 0,01). CONCLUSION: En pacientes con disfuncion ventricular, la extension del area de fibrosis fue un predictor independiente de la recuperacion funcional del VI luego de la CRV. La combinacion de RMC y parametros clinicos puede auxiliar en la indicacion de CRV.