Roberto Rocha e Silva

CABG late angiographic grafting patency analysis in patients with recurrent symptoms.

OBJECTIVE Left internal thoracic artery (LITA) grafting has become the gold standard in coronary artery bypass graft procedure (CABG). In order to optimize the use of LITA or other grats, sequential anastomosis has been used. There is no consensus on equivalence of results between isolated and sequential grafts. The aim of this study is to compare the patency of isolated versus sequential grafts. METHODS From January 2000 to August 2007, a retrospective patency analysis of the grafts used in 88 symptomatic patients who underwent CABG procedure in our Service was performed through cinecoronariography. Statistical analysis was performed through Students t test. Each distal anastomosis was considered an independent graft. RESULTS The mean postoperative period was of 53 +/- 138 months and mean age was 64 +/- 11 years. LITA isolated grafts presented patency rate significantly higher than the sequential grafts, respectively 92% (46/50) and 77% (30/39) P = 0.02. However, in injured coronary arteries of >or= 70%, isolated LITA patency rate was similar to sequential grafts, (95%; 37/39) and (93%; 26/28) respectively; P = 0.37. Mean radial artery patency rate was similar to isolated 71% (5/7) and sequential 90% (19/21) grafts; P = 0.10. Saphenous vein patency rates were similar for isolated 72% (31/43) and sequential 81% (73/90) grafts; P = 0.12. There was no difference between radial artery and saphenous vein patency rates. CONCLUSION In symptomatic patients, isolated LITA patency is superior than sequential LITA. However, in coronary injuries of >or= 70%, the isolated and sequential patency rates are similar. Sequential grafts from radial artery and saphenous vein are similar to their respective isolated grafts.

Aortic Valve Replacement: Treatment by Sternotomy versus Minimally Invasive Approach

Objective To compare the results of aortic valve replacement with access by sternotomy or minimally invasive approach. Methods Retrospective analysis of medical records of 37 patients undergoing aortic valve replacement by sternotomy or minimally invasive approach, with emphasis on the comparison of time of cardiopulmonary bypass and aortic clamping, volume of surgical bleeding, time of mechanical ventilation, need for blood transfusion, incidence of atrial fibrillation, length of stay in intensive care unit, time of hospital discharge, short-term mortality and presence of surgical wound infection. Results Sternotomy was used in 22 patients and minimally invasive surgery in 15 patients. The minimally invasive approach had significantly higher time values of cardiopulmonary bypass (114.3±23.9 versus 86.7±19.8min.; P=0.003), aortic clamping (87.4±19.2 versus 61.4±12.9 min.; P<0.001) and mechanical ventilation (287.3±138.9 versus 153.9±118.6 min.; P=0.003). No difference was found in outcomes surgical bleeding volume, need for blood transfusion, incidence of atrial fibrillation, length of stay in intensive care unit and time of hospital discharge. No cases of short-term mortality or surgical wound infection were documented. Conclusion The less invasive approach presented with longer times of cardiopulmonary bypass, aortic clamping and mechanical ventilation than sternotomy, however without prejudice to the length of stay in intensive care unit, time of hospital discharge and morbidity.

Radial artery harvesting technique without hemostatic clips and clinical experience

OBJECTIVE The various techniques of radial artery (RA) harvesting produce similar results. These techniques use electrocautery, ultrasonic scalpel, or sharp scissors in different combinations, but usually associated with the use of hemostatic clips. We describe a RA harvesting technique with the combination of sharp scissors and electrocautery without the use of hemostatic clips. METHODS We describe a retrospective study of 107 patients ranging from 28 and 78 years of age (mean +/- SD; 53.3 +/- 8 yrs). Bleeding, re-operation, infarct, and death were analyzed. RESULTS No bleeding was imputable to the RA and no re-operations were required. There were three (2.8%) infarcts possibly related to the RA anastomosis territory. Mortality was 0.9%, but unrelated to cardiac complications. CONCLUSION RA electrocautery harvesting without hemostatic clips presented no bleeding and was an inexpensive procedure, requiring no investments in additional equipment.

Operação de Senning com a utilização de tecidos do próprio paciente

O grande atrativo da Operacao de Senning como descrita originalmente e a utilizacao das paredes do proprio atrio do paciente para a realizacao dos tuneis venosos. A atrioseptostomia por balao, utilizada atualmente na grande maioria dos casos de transposicao das grandes arterias (TGA), cria grandes comunicacoes interatriais. Com isso, e necessario a utilizacao de enxertos biologicos ou sinteticos (Dacron, Teflon e pericardio bovino) na septacao do atrio esquerdo. Doze criancas consecutivas, com idades de 5 meses a 4 anos (media = 20 meses), foram submetidas a Operacao de Senning com a utilizacao de tecidos do proprio paciente. O diagnostico era de TGA em 9, TGA com comunicacao interventricular (CIV) em 1, TGA com estenose pulmonar valvar discreta em 1, TGA com justaposicao das auriculas em 1 caso e todas as criancas foram submetidas a atrioseptostomia com balao no periodo neonatal. Em 5 casos foi utilizada a auricula esquerda aberta e invertida para a septacao interatrial, 1 com inversao e, em 5, inversao com abertura da auricula esquerda e uso do proprio pericardio in situ para a realizacao do tunel das veias pulmonares, devido as reduzidas dimensoes do atrio direito (1 caso de justaposicao das auriculas). O tempo de internacao variou de 10 a 24 dias (media 15 dias), sendo que o periodo de pos-operatorio variou de 7 a 22 dias (media 12 dias). Nao houve obitos no periodo de internacao hospitalar. O seguimento no pos-operatorio foi de 8 a 34 meses (media 23 meses) e todos os pacientes apresentaram boa evolucao clinica. O ecocardiograma realizado no periodo de internacao e no seguimento pos-operatorio nao evidenciou sinais de obstrucao ao fluxo nos tuneis intracardiacos. O uso de tecidos do proprio paciente in situ, com potencial possibilidade de crescimento, resgata a vantagem principal da tecnica originalmente descrita por Senning.

Drenagem venosa assistida através da utilização controlada de vácuo no reservatório venoso do oxigenador

Nas operacoes minimamente invasivas o uso de cânula de menor calibre facilita a realizacao dos procedimentos cirurgicos, mas, por outro lado, a drenagem venosa pode ser prejudicada. O emprego de vacuo no reservatorio venoso do oxigenador e uma maneira simples e de baixo custo na correcao do problema. O objetivo deste trabalho e apresentar nossa experiencia com um dispositivo que permite alem da utilizacao do vacuo, a sua regulagem conforme a necessidade especifica do paciente e cânula empregada. Esse dispositivo consiste de uma valvula reguladora de vacuo, um filtro para a retencao de liquidos do ar aspirado e um manometro eletronico de pressao negativa. Os testes de bancada evidenciaram eficiencia e seguranca na aplicacao da pressao negativa no oxigenador ate 250 mmHg em temperaturas de ate 40oC. O estudo clinico consistiu, inicialmente, na aplicacao em 11 pacientes com esternotomia total. Posteriormente, foi utilizado em esternotomias parciais para tratamento da doenca isolada da valva aortica em 5 casos (L invertido) e 4 casos de atriosseptoplastia. Esse dispositivo permitiu a utilizacao de cânulas de diâmetros menores que as cânulas unicas convencionais, variando de 32 a 26 Fr, com a utilizacao de pressoes negativas de 62,40 ± 11,69 mmHg com drenagem venosa satisfatoria, sem evidencias indiretas de hemolise. O dispositivo por nos idealizado permitiu a drenagem venosa assistida com a utilizacao de vacuo de forma controlada, segura e eficiente.

The composite aortic wall graft technique: an option for a short coronary artery bypass graft

SUMMARY During coronary artery bypass graft (CABG) surgery, the saphenous vein is sutured through its proximal segment to the aorta. Intimal hyperplasia is one of the possible causes of graft occlusion. Notably, blood turbulence can induce wall shear stress that may also play an important role in this process. OBJECTIVE We propose a new technique for performing proximal anastomosis to avoid CABG failure. METHOD An 80 kg pig was subjected to open heart surgery. Four stitches were placed in the anterior ascending aorta, which formed a 2 cm by 4 cm patch. This patch was isolated through the application of a tangential clamp that was oriented parallel to the axis of the aorta. After releasing the patch, which was held to the aorta through its cranial end pedicle, the rims were sutured to each other creating a conduit with a length of 4 cm and an internal diameter of 4 mm. The rest of the aortotomy was closed by placing a direct suture between its rims. RESULT This novel technique created an “in situ” aortic wall graft that was 4 cm long and characterized as being of uniform 4 mm caliber.

Gait Speed improves EuroSCORE II prediction

Traditionally cardiac surgery risk scores have worse performance in elderly patients. Frailty evaluation may improve EuroSCORE II accuracy in predicting morbimortality