Paulo Roberto Dutra da Silva

Age influences outcomes in 70-year or older patients undergoing isolated coronary artery bypass graft surgery

OBJECTIVE To analyze the results of isolated on-pump coronary artery bypass graft surgery (CABG) in patients >70 years-old in comparison to patients <70 years-old. METHODS Patients undergoing isolated CABG were selected for the study. The patients were grouped in G1 (age > 70 years-old) and G2 (age <70 years-old). The endpoints were in-hospital mortality, acute myocardial infarction (AMI), stroke, reexploration for bleeding, intra-aortic balloon for circulatory shock, respiratory complications, acute renal failure, mediastinitis, sepsis, atrial fibrillation, and complete atrioventricular block (CAVB). RESULTS 1,033 patients were included, 257 (24.8%) in G1 and 776 (75.2%) in G2. Patients in G1 were more likely to have in-hospital mortality than G2 (8.9% vs. 3.6%, respectively; P=0.001), while the incidence of AMI was similar (5.8% vs. 5.5%; P=0.87) than G2. More patients in G1 had re-exploration for bleeding (12.1% vs. 6.1%; P=0.003). G1 had more incidence of respiratory complications (21.4% vs. 9.1%; P<0.001), mediastinitis (5.1% vs. 1.9%; P=0.013), stroke (3.9% vs. 1.3%; P=0.016), acute renal failure (7.8% vs. 1.3%; P<0.001), sepsis (3.9% vs. 1.9%;P=0.003), atrial fibrillation (15.6% vs. 9.8%; P=0.016), and CAVB (3.5% vs. 1.2%; P=0.023) than G2. There was no significant difference in the use of intra-aortic balloon. In the forward stepwise multivariate logistic regression analysis age > 70-year-old was an independent predictive factor for higher in-hospital mortality (P=0.004), reexploration for bleeding (P=0.002), sepsis (P=0.002), respiratory complications (P<0.001), mediastinitis (P=0.016), stroke (P=0.029), acute renal failure (P<0.001), atrial fibrillation (P=0.021) and CAVB (P=0.031). CONCLUSION This study suggests that patients > 70 years-old were at increased risk of death and other complications in the CABGs postoperative period in comparison to younger patients.

High Mortality Associated With Precluded Coronary Artery Bypass Surgery Caused by Severe Distal Coronary Artery Disease

Background—Patients with extensive coronary artery disease (CAD) have better prognosis when treated with coronary artery bypass grafting surgery (CABG), especially when left ventricular dysfunction (LVD) is present. However, there are scanty data about the clinical course of patients not referred to CABG because of extensive and severe atherosclerotic involvement of distal coronary arteries (ENDCAD). The aim of this study was to evaluate patients with multivessel (MV) or left main CAD (LM) who had CABG precluded because of ENDCAD. Methods and Results—Between August 1999 and July 2001, 51 patients who had clinical indication but were not eligible for CABG because of ENDCAD were followed for at least 12 months or until death. There were 32 men and 19 women (age 61±9 years). Previous acute myocardial infarction (AMI) was present in 31 (60.8%), diabetes mellitus (DM) in 28 (54.9%), systemic arterial hypertension in 37 (72.5%), LVD (left ventricular ejection fraction <40%) in 26 (51%), 3 vessel CAD in 31 (60.8%), and LM in 4 (7.8%). During follow-up there were 20 cardiac (39.2%) deaths, 19 (37.2%) AMI, and 3 (5.8%) patients developed congestive heart failure. There were 2 (3.9%) noncardiac deaths. Patients with DM (60.7% versus 13%; P=0.001; odds ratio [OR], 10.30; 95% confidence interval [CI], 2.46 to 43.09), LVD (76.9% versus 0%; P<0.0001; OR, 4.33; 95% CI, 2.14 to 8.74), 3-vessel CAD (51.6% versus 20%; P=0.039; OR, 4.26; 95% CI, 1.16 to 15.69), and LM (100% versus 34%; P=0.019; OR, 1.25; 95% CI, 1.004 to 1.556) were more likely to die. There was no deaths in patients with 2-vessel CAD but they had more nonfatal AMI (43.8% versus 14.3%; OR, 4.667; 95% CI, 1.188 to 18.332). Conclusions—Patients in whom CABG could not be performed because of ENDCAD had high mortality, especially in the presence of LVD. DM (particularly insulin-dependent), LM CAD, and 3-vessel CAD were independent markers of increased risk.

Can patients with left main coronary artery disease wait for myocardial revascularization surgery

OBJECTIVE: To assess the occurrence of cardiac events in patients diagnosed with left main coronary artery disease on diagnostic cardiac catheterization and waiting for myocardial revascularization surgery. METHODS: All patients diagnosed with left main coronary artery disease (stenosis ³50%) consecutively identified on diagnostic cardiac catheterization during an 8-month period were selected for the study. The group comprised 56 patients (40 males and 16 females) with a mean age of 61±10 years. The cardiac events included death, nonfatal acute myocardial infarction, acute left ventricular failure, unstable angina, and emergency surgery. RESULTS: While waiting for surgery, patients experienced the following cardiac events: 7 acute myocardial infarctions and 1 death. All events occurred within the first 60 days after the diagnostic cardiac catheterization. More patients, whose indication for diagnostic cardiac catheterization was unstable angina, experienced events as compared with those with other indications [p=0.03, relative risk (RR) = 5.25, 95% confidence interval = 1.47 - 18.7]. In the multivariate analysis of logistic regression, unstable angina was also the only factor that independently contributed to a greater number of events (p = 0.02, OR = 8.43, 95% CI =1.37 - 51.7). CONCLUSION: Unstable angina in patients with left main coronary artery disease acts as a high risk factor for cardiac events, emergency surgery being recommended in these cases.

Assistência circulatória com oxigenação por membrana extracorpórea (ECMO) no adulto: um conceito falido ou esquecido?

FUNDAMENTO: A oxigenacao por membrana extracorporea (ECMO) em recem-nascidos e criancas tem resultados excelentes. A experiencia em adultos e mais modesta e os resultados imediatos sao inferiores. Entretanto, a sobrevida em cinco anos de pacientes que sobrevivem a esse metodo e bastante promissora. Nao ha relato na literatura brasileira de experiencias com esse sistema nesse contexto. OBJETIVO: Relatar a experiencia com o uso da oxigenacao por membrana extracorporea no adulto que se apresenta em choque cardiogenico agudo e refratario. METODOS: Analise retrospectiva de prontuarios medicos de pacientes submetidos a implante do sistema de oxigenacao por membrana extracorporea para a assistencia circulatoria no choque cardiogenico agudo e refratario. RESULTADOS: Onze pacientes (63,5 anos; 45,5% homens) foram considerados para analise no periodo de 2005 a 2007. O tempo medio de suporte circulatorio foi de 77 horas (10-240h) e cinco pacientes estavam vivos em 30 dias (45,5%). Dois pacientes foram subsequentemente submetidos a implante de assistencia circulatoria prolongada apos um periodo de ressuscitacao em ECMO, um dos quais foi submetido ao transplante cardiaco. As causas de morte durante a assistencia com ECMO (seis pacientes) incluiram falencia multiorgânica (66,6%) ou sangramento refratario (33,4%). CONCLUSAO: O sistema ECMO e uma opcao de assistencia circulatoria temporaria para pacientes adultos com falencia cardiaca aguda refrataria, podendo ser utilizado como ponte para a recuperacao ou com o intuito de selecionar candidatos a assistencia circulatoria prolongada (ponte para a ponte).

Comparative study of the results of coronary artery bypass grafting and angioplasty for myocardial revascularization in patients with equivalent multivessel disease

OBJECTIVE To investigate the relative efficacy of different therapeutic strategies in patients with symptomatic multivessel coronary artery disease with preserved ventricular function. The primary objectives were defined as a combination of death of cardiac origin, acute myocardial infarction (AMI), and refractory angina that required revascularization, and the secondary objectives were defined as anginal state and exercise-induced ischemia. METHODS Of the 20,769 patients assessed on cine coronary angiography at InCor, 210 were chosen for this study and were randomized either for coronary artery bypass grafting (CABG, n = 105) or transluminal coronary angioplasty (TCA, n = 105). RESULTS A mean of 3.2 +/- 0.8 vessels received anastomoses and 2.1 +/- 0.8 were successfully dilated in the CABG and TCA groups, respectively. In a 5-year follow-up, the rates of events in the CABG and TCA groups were, respectively: mortality, 9.52% and 12.38%; acute myocardial infarction, 2.85% and 8.57% (P = 0.0668); and additional intervention, 2.85% and 24.76% (P < 0.001). The survival rate was 88.39% for CABG and 84.93% for TCA; the respective AMI-free percentages were 84.40% and 77.40%. In the CABG and TCA groups, 62% and 60% of the patients had no angina, respectively. The exercise tests were considered nonischemic in 62.5% and 62.1% of the patients in the CABG and TCA groups, respectively. CONCLUSION In multivessel patients, compared with angioplasty, coronary artery bypass grafting was associated with a lower incidence of long-term events and a reduced need for new interventions (P = 0.001).

Valor preditivo da angina em detectar doença coronariana em pacientes com estenose aórtica grave a partir da quinta década de vida

OBJECTIVE The objective of this study is to evaluate the value of angina pectoris as a predictor of CAD (coronary artery disease) in patients with AS (aortic stenosis) during and beyond the 5th decade of life. METHODS The study population consisted of 186 consecutive patients with AS and > or = 50 years of age, referred for surgical aortic valve replacement (AVR) between June 1989 and September 2004. Routine coronary angiography was performed for all patients. One hundred and one patients were males (54.3%) and 85 were females (45.7%), and the mean age was 66 +/- 8 years. One hundred and twenty-four patients (66.7%) had angina. The maximum transvalve gradient was 89.4 +/- 27.6 mmHg, and the aortic valve area measured 0.59 +/- 0.17 cm2. We calculated the sensitivity, specificity, positive and negative predictive values, as well as the likelihood ratio of a positive test result for angina in predicting the presence of CAD. RESULTS Ninety-three patients (50%) had CAD. Of the 124 patients with angina, 68 (54.8%) had CAD, whereas of the 62 patients without angina, 25 had CAD (40.3%) (p=0.087). Therefore, the diagnostic sensitivity of angina to detect CAD was 73.1%, specificity was 39.7%, positive predictive value was 54.8%, negative predictive value was 59.6%, and the likelihood ratio of a positive test result was 1.6. CONCLUSION Angina pectoris is not a good predictor of CAD in patients with AS who are more than 50 years of age.

Aortic stenosis. Gender influence on left ventricular geometry and function in patients under 70 years of age

OBJECTIVE To verify if adaptive left ventricle (LV) characteristics are also present in individuals under 70 years of age with severe aortic stenosis (AS). METHODS The study comprised 40 consecutive patients under 70 years of age with AS and no associated coronary artery disease, referred for valve surgery. Out of the 40 patients, 22 were men and 18 women, and the mean age was 49.8 +/- 14.3 years. Cardiac symptoms, presence of systemic hypertension (SH), functional class according to the New York Heart Association (NYHA), and valve lesion etiology were considered. LV cavity dimensions, ejection fraction (EF), fractional shortening (FS), mass (MS), and relative diastolic thickness (RDT) were examined by Doppler echocardiography. RESULTS Fourteen (63.6%) men and 11 (61.6%) women were classified as NYHA class III/IV (p = 0.70). There was no difference in the frequency of angina, syncope or dyspnea between genders. The incidence of SH was greater in women than in men (10 versus 2, p = 0.0044). Women had a smaller LV end-diastolic diameter index (32.1 +/- 6.5 x 36.5 +/- 5.3 mm/m2, p = 0.027), LV end-systolic diameter index (19.9 +/- 5.9 x 26.5 +/- 6.4 mm/m2, p = 0.0022) and LV mass index (MS) (211.4 +/- 71.1 x 270.9 +/- 74.9 g/m2, p = 0.017) when compared with men. EF (66.2 +/- 13.4 x 52.0 +/- 14.6%, p = 0.0032), FS (37.6 +/- 10.7 x 27.9 +/- 9.6%, p = 0.0046) and RDT (0.58 +/- 0.22 x 0.44 +/- 0.09, p = 0.0095) were significantly greater in women than in men. CONCLUSION It is the patient gender rather than age that influences left ventricular adaptive response to AS.

Improvement in left ventricular dysfunction after surgical correction of mitral regurgitation

OBJECTIVE To evaluate whether left ventricular end-systolic (ESD) diameters < or = 51mm in patients (pt) with severe chronic mitral regurgitation (MR) are predictors of a poor prognosis after mitral valve surgery (MVS). METHODS Eleven pt (aged 36 +/- 13 years) were studied in the preoperative period (pre), median of 36 days; in the early postoperative period (post1), median of 9 days; and in the late postoperative period (post2), mean of 38.5 +/- 37.6 months. Clinical and echocardiographic data were gathered from each pt with MR and systolic diameter > or = 51 mm (mean = 57 +/- 4mm) to evaluate the result of MVS. Ten patients were in NYHA Class III/IV. RESULTS All but 2 pt improved in functional class. Two pt died from heart failure and infectious endocarditis 14 and 11 months, respectively, after valve replacement. According to ejection fraction (EF) in post2, we identified 2 groups: group 1 (n=6), whose EF decreased in post1, but increased in post2 (p=0.01) and group 2 (n=5), whose EF decreased progressively from post1 to post2 (p=0.10). All pt with symptoms lasting < or = 48 months had improvement in EF in post2 (p=0.01). CONCLUSION ESD > or = 51 mm are not always associated with a poor prognosis after MVS in patients with MR. Symptoms lasting up to 48 months are associated with improvement in left ventricular function.

Transcatheter mitral valve repair, mitraclip, in a nonagenarian patient with acute regurgitation

Acute volume overload on the left ventricle causes pulmonary congestion and low cardiac output. If this volume overload is not tolerated, despite full drug treatment, emergency surgery should be performed1. These patients, however, face high surgical risk inherent in the procedure, which can become prohibitive in the presence of old age and comorbidities2. In such circumstances, non-surgical treatment options, such as transcatheter mitral repair, appear as less invasive and lower risk treatment alternatives2. This report describes the case of a nonagenarian patient with acute MR and high surgical risk who underwent successful MitraClip transcatheter implant.