Roberto Gomes de Carvalho

Cirurgia cardíaca no idoso

BACKGROUND: Because of the increase in the life expectancy of the Brazilian population, elderly patients are being increasingly referred to cardiac surgery. MATERIAL AND METHODS: Seventy-five patients, 70 years of age or older, who underwent cardiac surgery in the HC-UFPR, between 1995 and 1999 were studied. The purpose of this study was to analyze early and long-term results. Ages from 70 to 88 years, with 34 females (46.7%) and 41 males (53.3%). Symptoms included angina (81.3%), dyspnea (42.6%) and syncope (16%). There was 57.3% of patients in NYHA class I, 17.3% in class II, 18.6% in class III and 6.6% in class IV. The main risk factors listed were high blood pressure (61.3%), smoke (48%), diabetes mellitus (28%) and 9.3% had already had cardiac operations. Surgical procedures included 50 coronary artery bypass grafts - CABG (66.6%), 9 aortic valve replacements (12%), 5 aortic operations (6.6%), 4 CABG + valve replacement (5.2%) and other procedures (7%). The main postoperative complications were cardiovascular - ventricular arrhythmias (22.6%), supraventricular arrhythmias (21.3%), low cardiac output (16%) - infections (16%) and pulmonary problems (9.3%). The median stay in the ICU was 5 days. RESULTS: Sixty-five (78.4%) survivors had complete follow-up. The mean follow-up time was 20.7 months and long-term survival was 92%. Only one of the late deaths was cardiac related. CONCLUSION: Although this subgroup is associated with chronic diseases compromising other organs, advances in cardiac surgery and intensive care have made possible an intervention with safety and low morbidity and mortality.

Índice de risco de mortalidade por endocardite infecciosa: um modelo logístico multivariado

Objective: This study aimed at identifying predictive variables for in-hospital mortality, calculating the probability of death and creating a risk index for death by infective endocarditis by comparing two methods using a Receiver Operating Characteristic (ROC) curve. Methods: A retrospective study was conducted of 186 consecutive cases of confirmed infective endocarditis divided into two groups: discharged (137) and in-hospital death (49). Based on the odds ratios obtained by multivariate analysis, the probability of death was calculated and a mortality risk index created. Results: Factors predictive of higher mortality (multivariate analysis) and the risk index, with their respective weights were: age ≥ 40 years (OR = 4.16; 95%CI [1.63-10.80] - 4 points), class IV heart failure or cardiovascular shock (OR = 4.93; 95%CI [1.86-13.05] - 5 points), uncontrolled sepsis (OR = 5.97; 95%CI [1.95-18.35] - 6 points), conduction disorder (OR = 5.07; 95%CI [1.6715.35] - 5 points), arrhythmia (OR = 8.17; 95%CI [2.60-25.71] - 8 points), valve with extensive damage or abscess or prosthesis (OR = 4.77; 95%CI [1.44-15.76] - 5 points) and large and mobile vegetation (OR = 4.36; 95%CI [1.55-12.90] - 4 points). Patients with scores between 0 and 10 had a mortality of 5.26% and scores over 20 of 78.9%. Conclusions: The higher the score, the higher the mortality rate. The mortality risk index may be used to estimate mortality in Infective Endocarditis.

Simpatectomia torácica ao nível de 4ª e 5ª costelas para o tratamento de hiper-hidrose axilar

OBJETIVO: Descrever os resultados clinicos e o grau de satisfacao de pacientes submetidos a simpatectomia toracica ao nivel de 4a e 5a costelas (R4-R5) para o tratamento da hiper-hidrose axilar. METODOS: Foram incluidos 118 pacientes com diagnostico de hiper-hidrose axilar e submetidos a simpatectomia toracica ao nivel de R4-R5, realizada por um unico cirurgiao, no Hospital de Clinicas da Universidade Federal do Parana, Curitiba (PR), entre marco de 2003 e dezembro de 2007. Dados relativos a resolucao da sudorese axilar, ao grau de satisfacao com o resultado da cirurgia e ao efeito compensatorio no pos-operatorio precoce (7 dias) e tardio (1 ano) foram coletados. RESULTADOS: Dos 118 pacientes do estudo, 99 (83,9%) e 81 (68,6%) apresentaram resolucao total dos sintomas no pos-operatorio precoce e tardio, respectivamente. Houve efeito compensatorio em 49 pacientes (41,5%) no pos-operatorio precoce e em 77 (65,2%) no pos-operatorio tardio. Desses 77, 55 (71,4%) consideraram esses efeitos como leves. No pos-operatorio precoce, 110 pacientes (93,2%) estavam satisfeitos com os resultados da cirurgia, enquanto 104 pacientes (88,1%) mantinham-se satisfeitos no pos-operatorio tardio. CONCLUSOES: A simpatectomia ao nivel R4-R5 e eficaz na resolucao da hiper-hidrose axilar primaria. O grau de satisfacao dos pacientes com os resultados em longo prazo e alto. O efeito compensatorio leve e o principal efeito colateral relacionada a essa tecnica.

Plástica da valva mitral com emprego do anel de Gregori-Braile: análise de 66 pacientes

The complications of valvular prosthesis has led us to preserve the mitral valve. Objective: This paper analyses mitral reconstruction in 66 patients (pts.) where the ring of Gregori-Braile was used, in the period between October 1989 and October 1995. Casuistic and Methods: 45 (74.1%) were male and the mean age was 32.9 years. Rheumatic disease was present in 49 pts. and mitral insufficiency in 38 pts. (57.5%). The follow-up was 2.560 pts./mounth (mean 38.8 months) in 64 pts. (96.9%). The method used to evaluate the patients were as follows: clinical symptoms in FC (NYHAC), systolic mitral murmur and Doppler-echocardiographic study in the pre and post-operative period. The mitral techniques were: ring implantation, mobilization of leaflets and chordae tendinae and restriction of valve mobility. Shortening of the chordae was used in 44 pts. (66.6%). Associated procedures were: reduction of the LA (8 pts.), aortic valve replacement (3 pts.) and Cox procedure in 3 pts. One patient died (1.5%) in early PO from pulmonar thromboembolism. Results: The PO functional class improved. In the pre-op 41 pts. (62.1%) were in FC III and 23 pts. in FCIV (34.8%). In the PO, 53 pts (80.3%) were in FC I and 8 pts. (12.1%) in FC II. The mitral murmur was absent or + intensity in 92.4% in PO. The FC and murmur improved significantly (p < 0.001). The Doppler-echocardiographic study showed: mean left ventricular diastolic diameter was 5.96 cm in the pre-op and 5.33 cm in the PO (p < 0.001); mean LA dimension was 5.67 cm (pre-op) and 4.65 cm in the PO (p < 0.001); mean aortic diameter was 2.97 cm in the pre-op and 3.13 cm in PO (p < 0.01); the mean shortening was 35.38% in pre-op and 34.12% in PO (not significantly). The mean valve area was 1.7 cm2 in the pre-op period and 2.43 cm2 in PO (p < 0.003) and the mean gradient pressure in the pre-op and PO period was 11.10 mmHg and 5.58 mmHg (p < 0.003), respectively. In the late PO, 3 pts. died (4.5%). After 72 months, the survival was 95.5%, 96% free from reoperation and 98.4% free from thromboembolism. Conclusions: Mitral reconstruction is a safe procedure, the improvement in functional class was statistically significant, and the procedure should be done whenever possible to correct the mixed lesion and mitral insufficiency.

Artéria coronária direita de origem anômala: diagnóstico e tratamento

We report the case of a rare anomaly of the right coronary artery (RCA) arising from the left aortic sinus, having a single ostium with the left coronary artery, associated with documented episodes of inferior ischemia, in which surgical treatment with a right internal thoracic artery to RCA bypass graft and the corresponding ligation provided greater stability to the coronary blood flow and good clinical progress.

Fibroelastoma of the mitral valve as a cause of transient ischemic stroke

A 44-year-old woman had a transient ischemic stroke, fibroelastoma of the mitral valve being the source of the embolus. The patient evolved with neutropenia induced by ticlopidine after 10 days of treatment. We report the major clinical features, therapeutical options, and medicamentous toxicity resulting from the use of antiplatelet drugs.

Bilateral carotid endarterectomy combined with myocardial revascularization during the same surgical act

The best surgical approach for the treatment of patients with severe cerebral artery disease and simultaneous serious coronary artery disease still remains controversial. In this report we present a case of a 72-year-old female patient admitted to the hospital with unstable angina. Triple coronary artery obstructive disease and severe bilateral carotid artery stenosis were diagnosed. A combined, simultaneous surgical procedure was performed. After total circulatory by-pass with a membrane oxygenator, the patients body temperature was lowered to 32 degrees C. During the cool-down period, three proximal anastomoses of segments of autologous saphenous veins were performed in the ascending aorta. Immediately afterwards, bilateral carotid endarterectomy was performed, followed by three distal anastomoses to coronary arteries. The patient showed a satisfactory post-operative outcome. It was concluded that the combination of moderate hypothermia, hemodilution with appropriate hemodynamic control, as used in this patient, was an effective method of cerebral protection. The simultaneous approach of carotid endarterectomy and coronary artery by-pass surgery should be seen as a safe option for the treatment of this type of patient.

The transplant of cardiac cells and myoblast skeletal cells in myocardial infarction

OBJETIVO:Comparar o resultado funcional e anatomo-patologico entre o transplante de celulas mioblasticas e cardiacas no infarto do miocardio. METODO: Realizado infarto da parede ântero-lateral do ventriculo esquerdo em 26 ratos Wistar, com ligadura da arteria coronaria esquerda. Apos cinco dias, os animais foram submetidos a ecocardiografia transtoracica para calculo dos volumes sistolico (VSFVE) e diastolico (VDFVE) finais e da fracao de ejecao do ventriculo esquerdo (FEVE). Os animais foram divididos em tres grupos: 1) controle (n=10), 2) celulas cardiacas adultas (n=8) e 3) celulas musculares esqueleticas adultas (n=8). Sete dias apos o infarto do miocardio, os animais foram reoperados por esternotomia mediana, sendo identificada a regiao de fibrose no ventriculo esquerdo e nela, injetado 0.15ml de meio de cultura no grupo I, 8.5x106/0.15ml de celulas cardiacas heterologas no grupo II e 8.5x106/0.15ml de celulas musculares esqueleticas heterologas no grupo III. Todos os animais receberam ciclosporina (15mg/kg/dia). Apos dois meses do transplante, realizou-se nova ecocardiografia avaliando os mesmos parâmetros. RESULTADOS: Apos dois meses do transplante celular, o grupo I apresentou um decrescimo da FEVE (48.18% vs. 33.25% p=0.0003), sendo que houve um acrescimo dos VSFVE e VDFVE (0.308ml vs. 0.536ml p=0.026 e 0.597ml vs. 0.776ml p=0.054, respectivamente). No grupo II houve uma estabilizacao da FEVE (42.48% vs. 41.31% p=0.4968, respectivamente) e um discreto aumento do VDFVE (0.602ml vs. 0.771ml p=0.0711). O VSFVE variou de 0.358ml a 0.450ml p=0.0400. O grupo III apresentou um acrescimo da FEVE, VDFVE e VSFVE (40% vs. 47.35% p=0.0142, 0.643ml vs. 0.931ml p=0.0026 e 0.388ml vs. 0.491ml p=0.0557 (sem significância), respectivamente. O GIII apresentou um maior valor, considerado estatisticamente significativo, da fracao de ejecao do ventriculo esquerdo, em comparacao ao GI e ao GII (47.35% + 6.89% vs. 41.31% + 8.46% vs. 33.25% + 12.41% p=0.0200, respectivamente). Identificou-se uma diferenca estatisticamente significativa da fracao de ejecao do ventriculo esquerdo entre o GIII e o GI, apos dois meses do transplante (47.35% + 6.891% vs. 33.25% + 12.41% p=0.0213, respectivamente). Identificou-se uma diferenca da fracao de ejecao, apos dois meses, entre o GIII e o GII, todavia nao foi considerada estatisticamente significativa (47.35% + 6.891% vs. 41.31% + 8.46% p= 0.481, respectivamente). Tambem se identificou uma diferenca deste mesmo parâmetro entre o GII e o GI, mas sem ser significativa (41.31% + 8.461% vs. 33.25% + 12.41% p=0.245, respectivamente). CONCLUSAO: As celulas mioblasticas mantiveram suas caracteristicas morfologicas apos o transplante no infarto do miocardio. Os fibroblastos foram as celulas encontradas em maior quantidade, durante o processo de cultura celular no grupo das celulas cardiacas. Apos dois meses do transplante das celulas, houve uma melhora significativa da FEVE do grupo III em comparacao ao grupo I, uma preservacao da contratilidade ventricular no grupo III e uma estabilizacao da fracao de ejecao do grupo II.

Efeitos da correção cirúrgica de estenose mitral sobre o ritmo cardíaco

Objetivo: Determinar a frequencia de reversao de fibrilacao atrial (FA) ao ritmo sinusal (SA) em pacientes com estenose mitral (EM) submetidos a tratamento cirurgico e identificar provaveis fatores favoraveis ou desfavoraveis a este evento. Casuistica e Metodos: Estudo de caso-controle, envolvendo 53 pacientes com EM, sem acometimento de outras valvas, submetidos a correcao cirurgica. A populacao estudada apresentou as seguintes caracteristicas: mulheres: 71,7%; idade media: 42,4 anos; classe funcional III: 67,9%; area mitral media: 0,92 cm2; atrio esquerdo medio: 56,0 mm; ritmo antes da operacao: SA: 51,0% e FA: 49,0%. Os pacientes foram divididos em dois grupos de acordo com o ritmo apresentado no periodo pos-operatorio tardio: grupo I, formado pelos pacientes que, apos a operacao, apresentavam ritmo SA e grupo II, constituido por aqueles que, no pos-operatorio, estavam em FA. Resultados: Dez (18,9%) pacientes (em relacao ao total; 38,5% em relacao aqueles com FA) apresentavam FA no periodo pre-operatorio e sofreram reversao para o ritmo SA no pos-operatorio e em 2 pacientes (3,8% em relacao ao total; 7,4% em relacao aqueles em ritmo SA) houve degeneracao do ritmo SA para FA. Houve diferenca estatisticamente significativa (p < 0,05) entre os dois grupos apenas em relacao a variavel idade (p = 0,0456). Conclusoes: A operacao de correcao de EM apresenta resultados insatisfatorios em relacao a reversao da FA para ritmo SA, sugerindo a necessidade de associacao de outro procedimento cirurgico para restaurar o ritmo normal. Varios estudos tentaram identificar os fatores predisponentes a permanencia e ao desenvolvimento de FA apos a operacao, porem foram obtidos resultados contraditorios. No presente estudo, a unica variavel que apresentou associacao com a FA foi a idade avancada.

Seguimento de 9 anos da bioprótese valvular cardíaca de pericárdio bovino IMC-Biomédica: estudo multicêntrico

A mitral pericardial bioprosthetic valve IMC-Biomedica was implanted in a consecutive series of 798 patients with mean age of 52 years, from December 1977 to November 1978. The 722 patients who survived operation were observed during a period of 9 years (mean 27036 months or 2253 years). Actuarial studies indicated an expected survived rate at 9 years of 66% for adult patients and 68% for younger patients. The probability of complications were the following: rupture 0.4; perivalvar leak 0.4%; thromboembolysm 2.7%; endocarditis 3.2%; calcification 4.4%. The actuarial freedom from calcification between 1977 to 1982 (Group I) was 94.0% to adults and 12.0% to younger patients. On the other hand, between 1982 to 1986 (Group II) the actuarial analysis of calcification showed that 99.0% adults and 92.0% younger patients were free from this complication. Hence we believe that our option for the pericardial bioprosthetic valve was appropriate because 96.0% patients were free of complications deaths with the valve; this means that in 9 years the bioprosthetic lethal potential was only 4.0%.