Mozart Escobar

Cirurgia de revascularização completa do miocárdio sem circulação extracorpórea: uma realidade

From January/95 to December/96 our surgical team (ICORP - Fortaleza - Ceara), has performed coronary artery surgery without cardiopulmonary bypass (CPB) as a routine. During this period, 385 operations were sequencially performed, 86 per cent of them (333) without CPB. The purpose of this study is to evaluate the results of these 333 patients regarding hospitalization time, age, gender, number of grafts, functional status and morbimortality. All patients were submitted to previous coronary arteriography. All coronaies were by-passed, including the circumflex marginal artery. The age of these patients ranged from 35 to 86 years with a mean age of 61. The average time of hospitalization was 7 days; 625 grafts were placed varying from 1 to 4 with an average of 1.9 by patient. The incidence of procedure related with complications was 2 per cent (7 patients). Ten patients died in the early postoperative course. Considering the data obtained herein we conclude that this procedure can be used in the great majority of patients that undergo coronary artery surgery.

Estudo comparativo entre cirurgia de revascularização miocárdica com e sem circulação extracorpórea em mulheres

AbstractBackground: It has been well documented that womenhave higher morbidity and mortality rates than menfollowing coronary artery bypass graft (CABG) surgery. Inview of this evidence, it is necessary to know if there isbenefit to off-pump CABG surgery in women in comparisonto on-pump CABG. Objectives: Compare outcomes between off-pump CABGand on-pump CABG in women. Methods: Retrospective study. Our investigation analyzescomparatively clinical profile, thirteen procedurecomplications and mortality of a population of 941consecutive women undergoing CABG surgery (549 off-pumpand 392 on-pump) at two hospitals for the period January2000 to December 2005. Results: Mortality rate for women undergoing off-pumpCABG surgery is lower than for women undergoing on-pumpsurgery, however, not statistically significant (3.1% vs 5.3%; P =0.134). The complication rates analyzed (hemorrhagicshock, neurologic, respiratory, acute renal failure, adultrespiratory distress syndrome, septicemia, pneumonia, atrialfibrillation) were lower (significant statistically difference)for women off-pump than women on-pump, with theexception of low cardiac output and wound infection.

Revascularização miocárdica em pacientes octogenários: estudo retrospectivo e comparativo entre pacientes operados com e sem circulação extracorpórea

OBJECTIVE: The purpose of the present study is to compare and analyze the benefits of this operation with and without cardiopulmonary bypass in octogenarian patients. METHOD: Retrospective data of the patients aged eighty years or more from December 1995 to December 2003 were analyzed. During this period 73 patients were submitted to coronary artery bypass grafting (CABG), 26 (35.6%) on-pump and 47 (64.4%) off-pump. A comparison was made of the demographic data, preoperative risks, concurrent morbid conditions, types of angina, postoperative complications and surgical outcomes between the on-pump and off-pump groups. The Student t-test was used to compare the groups and the level of significance was set at p-value < 0.05. RESULTS: Both groups showed a high preoperative risk, although the off-pump group presented less surgical mortality (11.5% vs 2.1%, p < 0.05). No strokes were observed in the patients operated on off-pump (11.5% vs 0.0%, p < 0.005). Atrial fibrillation (AF) in the immediate postoperative period was present less often in the off-pump group (30.8% vs 12.8%, p < 0.005). The postoperative mechanical ventilation time and the presence of respiratory failure were less in the off-pump group (p < 0.005). The presence of acute renal insufficiency (ARI) was 19.2% in the on-pump group and 0% in the off-pump group (p < 0.05). There was less need for transfusion of blood or blood derivatives in the off-pump group (69.2% vs 31.9%, p < 0.005). The mean sojourn in the intensive care unit (ICU) was shorter in the off-pump group (p < 0.05). The percentage of patients with no postoperative complications was higher in the off-pump group than in the on-pump group (89.4% vs 61.5%, p <0.001). CONCLUSIONS: The present study suggests that patients aged eighty years and over benefit when submitted to off-pump CABG and that this procedure is associated with low rates of postoperative complications such as stroke, AF, ARI and respiratory insufficiency, and with less time in the ICU, a shorter hospital sojourn, less use of blood derivatives and lower mortality. In octogenarian patients off-pump CABG surgery is a safe and effective technique, and may be the operation of choice when correctly indicated.

Revascularização do miocárdio sem circulação extracorpórea: resultados imediatos

Myocardial revascularization surgery without the use of cardiopulmonary bypass was performed by Trapp and Ankeney in the 1970s. However it fell to Buffolo in Brazil and Benetti in Argentina to introduce its systematic use, standardization and recommendation as a valid and safe alternative modality of treatment. With the aim of evaluating the techniques reproducibility, morbidity and mortality, its technical difficulties and the possibilities of incorporating it into routine practice, the authors present the results obtained in 182 patients submitted to myocardial revascularization with saphenous and/or thoracic internal bypass without the use of cardiopulmonary bypass. One hundred and eighty-two patients were operated on using this technique: 128 (70.3%) males and 54 (29.7%) females, whose ages ranged from 40 to 79 years (mean = 58.8 years), with lesions of coronary arteries: interventricular anterior (IA); right coronary (RD); diagonal artery (DI) and marginal artery (MG). Two hundred and seventy-seven arteries were revasculahsed: 159/277 IAs (57.4%), 62/277 CDs (22.4%), 44/277 DIs (15.9%) and 12/277 MGs (4.3%). The left thoracic internal artery was used on 60/277 (21.7%) occasions and the saphenous vein on 217/277 (78.3%). The duration of the ischemia ranged from 5 to 33 minutes with a mean of 14 minutes. The following conditions were noted in the study as complications: coronary spasm in 6/182 cases (3.3%), acute myocardial infarct in 3/182 (0.6%), bleeding in 2/182 (1.1%), pulmonary embolism in 1/182 (0.6%) and mediastinitis in 1/182 (0.6%). Five/182 patients (2.7%) died in the immediate postoperative period from causes unrelated to the technique employed. The authors conclude that the technique may be safely carried out by most surgeons in selected cases with good results. The technique reduces the costs of surgery and in some subgroups, such as the elderly and those suffering from systemic disease, it may be the best alternative.

Surgical results of coronary artery bypass grafting without cardiopulmonary bypass: analysis of 3,410 patients

OBJETIVO: Nos ultimos anos, tem-se observado um grande avanco na cirurgia de revascularizacao miocardica sem circulacao extracorporea (RMSCEC). Esse desenvolvimento deveu-se a combinacao dos avancos da tecnica cirurgica e ao desenvolvimento de instrumentos que possibilitam a realizacao deste procedimento nas mais variadas situacoes. Este e um estudo retrospectivo, que visa avaliar nossa experiencia com este procedimento nos ultimos 11,5 anos. Os autores enfatizam o rapido progresso do metodo nos ultimos anos, suas indicacoes, contra-indicacoes e resultados. METODO: No periodo de agosto de 1991 e dezembro de 2002, 3.410 pacientes consecutivos, portadores de angina do peito, foram submetidos a cirurgia de revascularizacao miocardica sem circulacao extracorporea. A idade variou de 13 a 93 anos (63 12,0 anos), sendo 58% dos pacientes do sexo masculino. A angina foi classificada segundo a Canadian Cardiovascular Society, sendo 6,1% na classe I, 6,8% na classe II, 46,3% na classe III e 40,8% na classe IV. RESULTADOS: A mortalidade intra-operatoria foi baixa (0,4%). A mortalidade hospitalar (trinta dias de pos-operatorio) foi de 2,58%. A mortalidade e morbidade, no grupo dos pacientes octogenarios, foram extremamente baixas em relacao aos pacientes operados com circulacao extracorporea (2,2% x 12,6%) (p<0,001). As complicacoes pos-operatorias que nao resultaram em obito foram de 7,6%. No ultimo ano, nao observamos diferenca entre o numero de condutos nos pacientes operados com e sem CEC [com CEC 2,81,2 e sem CEC 2,80,8 (NS)]. Infarto agudo do miocardio foi a complicacao nao fatal mais frequente, observada em 2,8% dos pacientes. O tempo medio de permanencia na UTI foi de 22,3 horas. CONCLUSOES: A RMSCEC, usada como tecnica de revascularizacao em pacientes multiarteriais, e um procedimento reproduzivel e apresenta resultados semelhantes aos obtidos com a operacao convencional com CEC. Nesta serie foi possivel revascularizar o miocardio sem circulacao extracorporea em mais de 95% dos pacientes, tornando assim, a principio, todos os pacientes, com indicacao de revascularizacao miocardica, potenciais candidatos a operacao de RMSCEC.

Endomyocardial Fibrosis: Report of 6 Patients and Review of the Surgical Literature

Six patients with endomyocardial fibrosis were treated by endocardium decortication and atrioventricular valve replacement. There were 5 female patients and 1 male patient ranging from 14 to 48 years old (mean, 30 years). Four patients had involvement of the right ventricle, 1 patient had involvement of the left ventricle, and 1 patient had biventricular disease. There was 1 operative death due to low cardiac output state (the patient with biventricular endomyocardial fibrosis), and there was 1 late noncardiac death. The surgical literature, which describes 19 previously reported cases, was reviewed. On the basis of the results of this series and those of the reported cases, it is concluded that surgical treatment of endomyocardial fibrosis is feasible and provides good clinical improvement.

Avaliação hemodinâmica intra-operatória na cirurgia de revascularização miocárdica sem auxílio da circulação extracorpórea

BACKGROUND: To analyze the hemodynamic behavior of the heart in revascularization of the myocardium without use of extracorporeal circulation. MATERIAL AND METHODS: From August 1991 to June 1999, 616 patients suffering from angina of the chest underwent revascularization of the myocardium without use of extracorporeal circulation. In 18 patients the intraoperative hemodynamic parameters were studied. RESULTS: Heart rate remained high at all times during positioning of the heart (p=0.0007). Cardiac output throughout the procedure presented a very slight variation at different moments of positioning of the heart and exposure of the coronary arteries. However, once the heart was in its final normal position a major increase in output was noted (p=0.010). Mean blood pressure was found to be decreased throughout the procedure for exposing the coronary arteries (p=0.022). Arterial pulmonary pressure proved to be reduced at all times during mobilization, but without statistical significance. Pulmonary capillary pressure showed considerable, but statistically insignificant variation during exposure of the arteries. Central venous pressure behaved in a more varied fashion during exposure of the arteries, but again without statistical significance. Systemic vascular resistance proved to be diminished throughout the procedure (p=0.0001). Pulmonary vascular resistance remained reduced at all times during the procedure (p=0.002). Stroke volume was unchanged during anastomosis of the anterior interventricular artery and statistically significant differences were observed only in the right coronary (p=0.002) and right circumflex (p=0.0006) artery and its branches. The cardiac index was shown to be diminished throughout the procedure (p=0.0011). CONCLUSIONS: A) The present technique allows for maximum mobilization of the heart without inducing hemodynamic instability. B) The improvement of a number of hemodynamic parameters at the end of the procedure may be accounted for by: (1) the response to the myocardial revascularization; (2) the release of catecholamines following manipulation of the heart in the different positions and (3) the release of vasoactive mediators following prolonged traction of the pericardium.

Cirurgia de revascularização do miocárdio através de minitoracotomia ântero-lateral esquerda

No periodo de outubro de 1995 a fevereiro de 1996, 16 pacientes selecionados foram submetidos a cirurgia de revascularizacao do miocardio atraves de minitoracotomia ântero-lateral esquerda. Em todos os casos a arteria toracica interna esquerda foi dissecada, para posterior anastomose com o ramo interventricular anterior (RIA) sem a utilizacao de circulacao extracorporea. A idade variou de 43 a 77, com media de 60 anos. Sessenta e dois por cento dos pacientes eram do sexo masculino. Nao houve complicacoes tais como: hemorragias, acidente vascular cerebral, insuficiencia renal aguda, mediastinite ou infarto agudo do miocardio. Nao houve mortalidade no grupo em questao. Em 4 (25%) pacientes foi realizado estudo hemodinâmico, que demostrou uma normalidade da anastomose da arteria toracica interna para o ramo interventricular anterior. Devido aos excelentes resultados iniciais, acreditamos que este procedimento possa ser empregado com maior frequencia e com a familiarizacao dos grupos cirurgicos, e que as arterias diagonais e marginais da circunflexa possam ser beneficiadas com este tipo de procedimento.

Tratamento cirúrgico da coarctação da aorta: experiência de três décadas

Objective: To make a 30-year review of the immediate results of coarctation of the aorta (CoAo) operation, between 1974 and 2004. All the patients under went CoAo whether in isolation or associated with other congenital defects. Methods: The following data was investigated: age at the time of surger y , gender , associated lesions, and type of surgical technique, and immediate surgical outcome, particularly focusing the presence of systemic arterial hypertension. Results: One hundred and four patients underwent CoAo. Of the 104 enrolled patients, 75 (72%) were pediatric patients and 29 (28%) adults patients. In the pediatric group, 23 (22%) were considered neonates, 17 (16%) infants, and 35 (34%) children. The associated defects were present in 66 (63.5%) patients, 54 (51.9%) in the pediatric group and 12 (1 1.3%) in the adult gr oup. Seven (6.7%) deaths wer e observed in the immediate postoperative period. Among the various surgical techniques employed, aortoplasty was used in 80 patients (76.9%); end-to-end anastomosis in 15 (14.4%); T eles technique in seven (6.7%), W aldhausen technique in one (1%), and it was not possible to identify the technique in one patient (1%). Conclusions: Despite the limitations of the pr esent study , it may be noted that the results were good with the corrective surgery being performed safely and with a low mortality rate. Medium- and long-term follow-up was impaired by the well-known structural deficiencies in Brazil.

Correction of transposition of the great arteries using homologous dura mater: a preliminary report.

were present. His blood pressure was 100/70 mm Hg, and the pulse regular at 100/minute. The heart showed a hyperdynamic right ventricular impulse. A Grade II/VI systolic murmur was heard in the second and third intercostal spaces at the left sternal edge. The second heart sound was loud at the pulmonic area. The ECG showed right ventricular hypertrophy. On the chest x-rays, the heart appeared slightly enlarged and an increase in pulmonary vascular markings could be noted. Cardiac catheterization data is given in Table I. The cineangiograms (Fig. 1) established the diagnosis of simple transposition of the great arteries.