Ricardo Ribeiro Dias

Collagen is reduced and disrupted in human aneurysms and dissections of ascending aorta

In ascending aorta aneurysms, there is an enlargement of the whole vessel, whereas aortic dissections (ADs) are characterized by the cleavage of the wall into 2 sheets at the external half. We searched if alterations in collagen could be related to these diseases. Sections of aortas from 14 case patients with acute dissections, 10 case patients with aneurysms, and 9 control subjects were stained with picrosirius. Slides were analyzed under polarized microscopy to evaluate the structure of collagen fibers. The proportion of collagen was calculated in each half of the medial layer by color detection in a computerized image analysis system. Collagen appearance under polarized light was consistent with collagenolysis. The mean collagen proportions at the inner and outer halves, respectively, were 0.50 +/- 0.13 and 0.40 +/- 0.08 in the control group, 0.20 +/- 0.10 and 0.18 +/- 0.12 in the AD group, and 0.33 +/- 0.12 and 0.19 +/- 0.12 in the aneurysm group. The AD (P < .01) and control (P = .04) groups had less collagen at the external half; no difference was found in the aneurysm group (P = .71). In both halves, there was less collagen in the case patients than in the control subjects (all P < .01), but at the internal half, the decrease was significantly greater in the case patients with aneurysms than in those with dissections (P = .03; at the external half, P = .99). Aortic dissections and aneurysms show a decrease in collagen content that could be related to a weakness of the wall underlying the diseases, but the locations of the decrease differ: in dissections, it is situated mostly at the external portion of the media (site of cleavage), whereas in aneurysms, it is more diffuse, consistent with the global enlargement.

Os escores 2000 Bernstein-Parsonnet e EuroSCORE são similares na predição da mortalidade no Instituto do Coração-USP

OBJECTIVE: To evaluate the performance of 2000 Bernstein-Parsonnet (2000BP) and additive EuroSCORE (ES) for predicting surgical mortality at the Heart Institute, University of Sao Paulo. METHODS: A prospective observational design. Seven hundred and seventy four patients were operated for coronary artery bypass graft, valve or combined procedure between May and October, 2007, were analyzed. The mortality was estimated with the 2000BP and ES. The correlation between expected mortality and observed mortality was validated through calibration and discrimination test. RESULTS: The patients were stratified into five groups for the 2000BP and three for the ES. The Hosmer-Lemeshow test for 2000BP (P = 0.70) and for ES (P = 0.39) indicate a good calibration. The ROC curve for the 2000BP = 0.84 and for the ES = 0.81 confirms that the models are good predictors (P<0.001). CONCLUSION: Both models are similar and adequate in predicting surgical mortality at the InCor-USP.

Proteção cerebral: sítios de canulação arterial e vias de perfusão do cérebro

Brain perfusion for adequate cerebral protection has changed over the years. The limitations of the time during total circulatory arrest with deep hypotermia, the inefficient cerebral metabolism during retrograde perfusion and special care to prevent cerebral embolism during antegrade perfusion have resulted in the development of different methods of cerebral protection during the evolution of aortic arch operations. Antegrade cerebral perfusion associated with moderate hypothermia is today, considered the best option for cerebral protection.

Risk Factor Analysis of Late Survival After Heart Transplantation According to Donor Profile: A Multi-Institutional Retrospective Study of 512 Transplants

INTRODUCTION Patients with terminal heart failure have increased more than the available organs leading to a high mortality rate on the waiting list. Use of Marginal and expanded criteria donors has increased due to the heart shortage. OBJECTIVE We analyzed all heart transplantations (HTx) in Sao Paulo state over 8 years for donor profile and recipient risk factors. METHOD This multi-institutional review collected HTx data from all institutions in the state of Sao Paulo, Brazil. From 2002 to 2008 (6 years), only 512 (28.8%) of 1777 available heart donors were accepted for transplantation. All medical records were analyzed retrospectively; none of the used donors was excluded, even those considered to be nonstandard. RESULTS The hospital mortality rate was 27.9% (n = 143) and the average follow-up time was 29.4 ± 28.4 months. The survival rate was 55.5% (n = 285) at 6 years after HTx. Univariate analysis showed the following factors to impact survival: age (P = .0004), arterial hypertension (P = .4620), norepinephrine (P = .0450), cardiac arrest (P = .8500), diabetes mellitus (P = .5120), infection (P = .1470), CKMB (creatine kinase MB) (P = .8694), creatinine (P = .7225), and Na+ (P = .3273). On multivariate analysis, only age showed significance; logistic regression showed a significant cut-off at 40 years: organs from donors older than 40 years showed a lower late survival rates (P = .0032). CONCLUSIONS Donor age older than 40 years represents an important risk factor for survival after HTx. Neither donor gender nor norepinephrine use negatively affected early survival.

Aneurysmal dilation of the reimplant segment of the visceral vessels after thoracoabdominal aneurysm correction

We present a case of aneurysmal dilation of the aortic residual segment, involving abdominal vessels in corrective surgeries for thoracoabdominal aortic aneurysm, through the identification of risk groups for recurrent dilation, aiming at using a specific operative technique with a branched graft, to prevent aneurysm relapse.

Mortality and Embolic Potential of Cardiac Tumors

Background Cardiac tumors are rare, mostly benign with high embolic potential. Objectives To correlate the histological type of cardiac masses with their embolic potential, implantation site and long term follow up in patients undergoing surgery. Methods Between January 1986 and December 2011, we retrospectively analyzed 185 consecutive patients who underwent excision of intracardiac mass (119 females, mean age 48±20 years). In 145 patients, the left atrium was the origin site. 72% were asymptomatic and prior embolization was often observed (19.8%). The diagnosis was established by echocardiography, magnetic resonance and histological examination. Results Most tumors were located in the left side of the heart. Myxoma was the most common (72.6%), followed by fibromas (6.9%), thrombi (6.4%) and sarcomas (6.4%). Ranging from 0.6cm to 15cm (mean 4.6 ± 2.5cm) 37 (19.8%) patients had prior embolization, stroke 10.2%, coronary 4.8%, peripheral 4.3% 5.4% of hospital death, with a predominance of malignant tumors (40% p < 0.0001). The histological type was a predictor of mortality (rhabdomyomas and sarcomas p = 0.002) and embolic event (sarcoma, lipoma and fibroelastoma p = 0.006), but not recurrence. Tumor size, atrial fibrillation, cavity and valve impairment were not associated with the embolic event. During follow-up (mean 80±63 months), there were 2 deaths (1.1%) and two recurrences 1 and 11 years after the operation, to the same cavity. Conclusion Most tumors were located in the left side of the heart. The histological type was predictor of death and preoperative embolic event, while the implantation site carries no relation with mortality or to embolic event.

Analysis of aortic root surgery with composite mechanical aortic valve conduit and valve-sparing reconstruction.

OBJECTIVE Comparative analysis of early and late results of aortic root reconstruction with aortic valve sparing operations and the composite mechanical valve conduit replacement. METHODS From November 2002 to September 2009, 164 consecutive patients with mean age 54 ± 15 years, 115 male, underwent the aortic root reconstruction (125 mechanical valve conduit replacements and 39 valve sparing operations). Sixteen percent of patients had Marfan syndrome and 4.3% had bicuspid aortic valve. One hundred and forty-four patients (88%) were followed for a mean period of 41.1 ± 20.8 months. RESULTS The hospital mortality was 4.9%, 5.6% in operations with valved conduits and 2.6% in the valve sparing procedures (P <0.05). There was no difference neither in survival (95% CI = 86% - 96%, P= 0.1) nor in reoperation-free survival (95% CI = 85% - 90%, P = 0.29). The survival free of complications such as bleeding, thromboembolism and endocarditis were favorable to the valve sparing operations, respectively (95% CI = 70% - 95%, P = 0.001), (95% CI = 82% - 95% P = 0.03) and (95% CI = 81% - 95%, P = 0.03). Multivariate analysis showed that creatinine greater than 1.4 mg/dl, Cabrol operation and renal dialysis were predictors of mortality, respectively, with occurrence chance of 6 (95% CI = 1.8 - 19.5, P = 0.003), 12 (95% CI = 3 - 49.7, P = 0.0004) and 16 (95% CI = 3.6 - 71.3, P = 0.0002). CONCLUSIONS The aortic root reconstruction has a low early and late mortality, high survival free of complications and low need for reoperation. During the late follow-up, valve sparing aortic root reconstructions presented fewer incidences of bleeding, thromboembolic events and endocarditis.

Cirurgia da valva aórtica: estudo prospectivo e randomizado da miniesternotomia versus cirurgia convencional

Objetivos: A cirurgia minimamente invasiva objetiva, atraves de menor trauma cirurgico no paciente, recuperacao mais rapida, menor tempo de internacao em unidade de terapia intensiva e hospitalar, assim como menor dor e custo hospitalar. Atraves de estudo clinico prospectivo e randomizado, visamos avaliar as vantagens da cirurgia minimamente invasiva da valva aortica sobre a cirurgia convencional. Material e Metodos: Foram 40 pacientes consecutivos, portadores de doenca da valva aortica, com idade inferior a 80 anos, submetidos a primeira cirurgia, de forma prospectiva, randomizados por computador em 2 grupos (miniesternotomia em L invertido e de forma convencional), no periodo de junho de 1997 a agosto de 1998. Todos os pacientes foram operados seguindo-se protocolos cirurgicos pre estabelecidos, Ambos os grupos eram clinicamente semediantes. As seguintes variaveis foram avaliadas: tamanho da incisao, tempos de isquemia, de circulacao extracorporea e de cirurgia, tempo de internacao hospitalar e em UTI, tempo de extubacao, sangramento, dor e mortalidade. Os dados foram submetidos a analise estatistica pelos testes T de Student, de Mann Whitney e o Exato de Fisher. Resultados: O grupo submetido a cirurgia minimamente invasiva para a troca da valva aortica apresentou tempos de isquemia e de circulacao extracorporea significativamente maiores que o grupo convencional (respectivamente p=0,006 e p=0,041). O tamanho da incisao foi significativamente menor (p<0,001). As demais variaveis analisadas nao apresentaram diferencas estatisticamente significativas. Conclusoes: Observou-se efeito cosmetico melhor devido a incisao menor pela tecnica da miniesternotomia e menores tempos de isquemia e circulacao extracorporea atraves da cirurgia convencional. As demais variaveis estudadas apresentaram resultados semelhantes para ambos os grupos.

Ruptured thoracic aortic aneurysm in patient with systemic lupus erythematosus

It is reported a ruptured descending thoracic aortic aneurysm in a 25-year-old systemic lupus erythematosus woman who underwent 19 years steroid therapy. She was treated with 2 endovascular stent-grafts, discharged from hospital 13 days after the procedure in good health. Three months later she returned with hemorrhagic shock due to high digestive hemorrhage secondary to an aortic-esophageal fistula. She underwent to an open emergency surgery, and died during the post-operative period.

Fibroelastoma papilífero: experiência de uma instituição

Primary intracardiac tumors are rare, with prevalence between 0.0017% and 0.19% from non-selected autopsy studies. Approximately 75% are benign and almost half of them are myxomas. The remaining tumors are divided among rabdomyomas, lipomas and fibroelastomas. Myxomas are the most common intracardiac tumors in adult age and rabdomyomas the most common among pediatric population. Papillary fibroelastoma (PFE) is a relative rare benign heart tumor, corresponding to approximately 8% of intracardiac tumors. They most commonly manifested in cardiac valves1. In the past, they either consisted of necropsy findings or were found in surgical procedures at random. In vivo diagnosis was sporadic2. With the improvement of echocardiography techniques, PFE has been more frequently diagnosed. They are usually described as a movable, pedunculate, well-delimited mass and with predilection for valve endocardium. Therapeutic proposal, when they are pedunculate, is surgical resection, preventing cerebral, pulmonary, coronary or peripheral embolic phenomena1,3. Five cases diagnosed in our institution, in the period from August 1995 to June 2004, will be presented