Rodrigo Milani

Double skeletonized internal thoracic artery vs. double conventional internal thoracic artery in diabetic patients submitted to OPCAB

OBJECTIVE To evaluate the influence of the technique used in the dissection of thoracic arteries in the evolution of diabetic patients submitted to OPCAB. METHODS Seventy diabetic patients submitted to OPCAB using bilateral thoracic arteries were evaluated. In Group A, thoracic arteries were dissected as a pedicle, while in Group B they were skeletonized. RESULTS The mean age of patients in Group A was 52.14 +/- 7.35 years old versus 55.71 +/- 8.1 years for Group B (p=0.057). In Group A, six patients (17.1%) were insulin dependent against nine (25.7%) in Group B (p = 0.561). The EUROSCORE was 3.97 +/- 2.49 for Group A opposed to 4.14 +/- 3.06 for Group B (p = 0.879). The number of distal anastomoses in Group A was 3 +/- 0.77 versus 3.03 +/- 0.89 in Group B (p = 0.981). Three patients (8.57%) from Group A presented with mediastinitis. Insulin dependence was the only significant risk factor (p=0.008) for mediastinitis. In this group the use of skeletonized internal thoracic arteries significantly decreased the incidence of mediastinitis (p = 0.044). CONCLUSION The incidence of mediastinitis was lower in the group for which mammary arteries were dissected using skeletonization. Among insulin-dependent diabetics, 50% of the patients from the group in which the pedicled internal thoracic artery was utilized presented with mediastinitis; the utilization of skeletonized internal thoracic arteries significantly decreases the incidence of mediastinitis.

Revascularização total do miocárdio sem circulação extracorpórea: cinco anos de experiência

OBJECTIVE: To evaluate the immediate postoperative results of off-pump myocardium revascularization surgery by analyzing complications and mortality. METHOD: A total of 1440 patients were submitted to off-pump myocardium revascularization. The surgical technique is consisted in proximal occlusion of the approached artery, the application of the LIMA graft in the posterior pericardial deflection and stabilization of the target artery with a suction stabilizer. The distal anastomoses were performed first. RESULTS: Among the patients evaluated, 924 were male and 516 were female,with a mean age of 63.12 ± 8.76 years. The ejection fraction was normal in 749 patients, 740 (51.4%) patients had suffered previous myocardial infarction and 687 (47.6%) patients were in functional class III or IV. The mean EuroSCORE was 4.93 ± 3.32. The mean number of dial anastomoses was 3.12 ± 1.23 per patient. A total of 1173 (81.5%) patients remained less than 12 hours on mechanical ventilation and among them, 888 (61.7%) remained for less than six hours. The stay in the ICU was of one night for 330 (22.8%) patients, for two nights for 930 (64.6%) patients and 182 (12.4%) patients remained three or more nights. In regards to complications, three (0.2%) patients presented with renal insufficiency, six (0.4%) patients suffered stroke, 19 (1.3%) patients were reoperated for bleeding, 19 (1.3%) patients had mediastinitis, 18 (1.25%) patients suffered severe myocardial infarction and 212 (14.7%) presented atrial fibrillation. There were 50 (3.5%) deaths, 29 (2.5%) of them being among the 1148 operated electively, nine (4.7%) among 190 patients submitted to coronary re-operation and 12 (11.7%) among 102 patients undergoing emergency operations. CONCLUSION: With the evolution of biomedical technological, all the vessels of the heart are now approached. These data suggest that the operation for myocardial revascularization is safe and efficient. It can be applied to all patients who need coronary surgery, with low rates of complication and mortality.

Myocardial Revascularization without Extracorporeal Circulation in Patients Over 75 Years of Age. Analysis of Immediate Results

Results Arterial hypertension was present in 174 (90%), dyslipidemia in 115 (59%), smoking in 89 (46%), and diabetes in 57 (29%). Ninety-six (49.7%) patients had had a previous myocardial infarction, 53 of whom (27.4%) had experienced an acute ischemic event in a period < 30 days after surgery. Critical obstructive lesions in 3 or more coronary vessels were present in 156 (80.95%) patients, while 30 (15%) patients had an important obstruction of the left main coronary artery, and 30 (15%) patients had an ejection fraction < 30%. The score obtained according to the EUROSCORE ranged from 3 to 18, with an expected mortality rate for the group of 7.54±2.69%. The total number of distal anastomoses was 639. Seven (3.62%) patients died, 3 due to bronchopneumonia, 1 due to mediastinitis, 1 due to metabolic causes, 1 due to cardiogenic shock, and another died suddenly after refixation of a sternal dehiscence. Reoperation due to bleeding, orotracheal reintubation, and prolonged mechanical ventilation were factors associated with an increase in mortality.

Tratamento cirúrgico sem circulação extracorpórea de arteriopatia relacionada com arterite de Takayasu envolvendo aorta e vasos da base

We report the cases of 2 female patients with Takayasus arteritis referred to our service with lesions affecting the descending thoracic aorta and great vessels. One of the patients had a critical obstructive lesion in the left coronary ostium. Both patients underwent surgery without extracorporeal circulation, with full heparinization and autotransfusion.

Influência da estimulação biatrial temporária externa na prevenção da fibrilação atrial no pós-operatório de revascularização miocárdica sem circulação extracorpórea

BACKGROUND: Atrial fibrillation is the most common complication after myocardial revascularization, and it increases morbidity/mortality. OBJECTIVE: The purpose of this prospective randomized study was to test the hypothesis that temporary biatrial pacing is effective in reducing the incidence of postoperative atrial fibrillation after myocardial revascularization. METHODS: Ninety-eight non-consecutive patients who had undergone off-pump myocardial revascularization received two temporary electrodes attached to the right and left atria, which were connected to either pair of atrial pacemaker electrodes, in addition to the leads implanted in the right ventricle. Two groups of patients were randomized (control: 49 patients with no biatrial pacing; therapeutic: 49 patients with biatrial pacing). The variables of interest were atrial fibrillation (present or absent) and length of hospital stay. RESULTS: The incidence of atrial fibrillation was 36.73% in the control group and 14.29% in the therapeutic group (p=0.0194). Length of hospital stay was 7.00 ± 2.82 days for patients with no atrial fibrillation (n=73) and 9.20 ± 2.87 days for patients with atrial fibrillation (n=25) (p=0.0001). Age was an important predictor of arrhythmia and ranged between 62.34 ± 9.00 years in the group with no atrial fibrillation and 67.20 ± 7.42 years in the group with atrial fibrillation (p=0.0170). CONCLUSION: Compared to controls, prophylactic temporary biatrial pacing is effective in preventing atrial fibrillation. Hospital stay was longer for patients who developed postoperative atrial fibrillation, and age was an important predictor for the development of arrhythmia.

Off-pump coronary artery bypass grafting with arterial grafts: analysis of 300 cases

Objective: The present study reviews our immediate results of off-pump coronary artery bypass grafting using only arterial grafts. Method: Between June 2000 and December 2004, 300 patients were submitted to off-pump myocardial revascularization using only arterial grafts. The left internal mammary artery was the first-choice graft, followed by the radial artery and the right mammary artery. Results: The ages of the patients ranged from 33 to 77 years, with 234 male and 66 female. In respect to risk factors for coronary disease, 77% had hypertension, 66% had a history of smoking, 53% had high levels of cholesterol and 21% had diabetes. Eighty-four patients (28%) had a history of myocardial infarction and 77 (25.6%) were using endovenous nitroglycerin in the preoperative period. The ejection fraction was less than 30% in 77 (25.6%) patients. A total of 189 patients had multi-vessel disease. The EuroSCORE ranged from 0 to 12 points with an expected mortality rate of 3.7%. The total numbers of distal anastomoses were 838, with a mean of 2.79 ± 0.97 anastomoses per patient. There were six deaths in this series, one caused by renal failure, one caused by metabolic disorders, two caused by mediastinitis, one caused by pneumonia and one caused by bleeding. Diabetes was the only factor associated with mortality. Conclusion: The use of arterial grafts in off-pump myocardial revascularization did not increase the immediate morbidity or mortality in this series. The results were similar to the results predicted by the EuroSCORE. The use of only arterial grafts in diabetic patients must be carefully evaluated.

Operação de Ross: a intervenção ideal para pacientes aórticos jovens?

Background: Aortic valve prosthesis with adequate hemodynamic performance should allow more complete left ventricular mass regression and return left ventricular function back to normal. This possibly affects long term prognosis after aortic valve replacement. Objective: Assessment of hemodynamic performance of the pulmonary autograft in the aortic position and the regression of left ventricular mass after the Ross procedure. Material and Methods: Between May/95 and Mar/96, 45 patients with mean age of 27.1 years were submitted to a Ross procedure. Doppler echocardiography and cardiac catheterization were performed on all patients before hospital discharge to analyze the hemodynamic performance of the auto and homografts employed, as well as to evaluate left ventricular mass and function. Fourteen patients with follow-up longer than six months were sumitted to dobutamine stress echocardiography to study hemodynamic performance of the auto and homografts at during exercise. Results: Hospital mortality was 6%. After a mean follow-up of 12.8 months (1-23), there was one late sudden death. No valve related event was noted during this period. Immediate and late hemodynamic performance of the pulmonary autografts were normal with average mean gradients of 1.8 ± 0.6 mmHg and average maximum instantaneous gradients of 2.9 ± 0.9 mmHg. Valvular insufficiency was almost null. Even during exercise, gradients did not increase significantly with average mean gradients of 4.3 ± 2.5 mmHg and average maximum gradients of 10.4 ± 6.1 mmHg. Homografts used for right ventricular reconstruction exhibited excellent immediate hemodynamic performance. However, at late follow-up an increase in flow velocities was noted with an average of mean gradients of 10 ± 7.1 mmHg at rest and 26 ± 13.3 mmHg at exercise. Left ventricular mass index dropped from 168 ± 46 g/m2 preoperatively to 115 ± 32 g/m2 six months after the operation. Left ventricular function was normal at rest and during exercise in the marjority of patients. Conclusions: Given the normal hemodynamic performance of the autografts, the important decrease in left ventricular mass and the normal left ventricular function late postoperatively, the Ross procedure is considered the operation of choice for young patients who need aortic valve replacement.

Analysis of transit time flow of the right internal thoracic artery anastomosed to the left anterior descending artery compared to the left internal thoracic artery

Introduction We evaluated with transit time flow the performance of the right and left thoracic arteries when used as a graft for the left anterior descending artery. Methods Fifty patients undergoing surgery for myocardial revascularization without cardiopulmonary bypass were divided into two groups. In group A patients received graft of right internal mammary artery to the anterior interventricular branch. In group B patients received graft of left internal mammary artery to the same branch. At the end of the operation the flow was assessed by measuring transit time. Results In group A, mean age was 60.6±9.49 years. The average height and weight of the group was 80.4±10.32 kg and 169.2±6.86 cm. The average number of grafts per patient in this group was 3.28±1.49. The mean flow and distal resistance obtained in right internal thoracic artery was 42.1±23.4 ml/min and 2.8±0.9 respectively. In group B, the mean age was 59.8±9.7 years. The average height and weight of this group was 77.7±14.22 kg and 166.0±8.2 cm. The average number of grafts per patient in this group was 3.08 ±0.82. The mean flow and distal resistance observed in this group was 34.2±19.1 ml/min and 2.0±0.7. There were no deaths in this series. Conclusion Right internal mammary artery presented a similar behavior to left internal mammary artery when anastomosed to the anterior interventricular branch of the left coronary artery. There was no statistical difference between the measured flow obtained between both arteries.

Minimally invasive redo mitral valve surgery without aortic crossclamp

INTRODUCTION Reoperations of the mitral valve have a higher rate of complications when compared with the first surgery. With the field of video-assisted techniques for the first surgery of mitral valve became routine, reoperation cases began to arouse interest for this less invasive procedures. OBJECTIVE To assess the results and the technical difficulties in 10 patients undergoing minimally invasive redo mitral valve surgery. METHOD Cardiopulmonary bypass was installed through a cannula placed in the femoral vessels and right internal jugular vein, conducted in 28 degrees of temperature in ventricular fibrillation. A right lateral thoracotomy with 5 to 6 cm in the third or fourth intercostal space was done, pericardium was displaced only at the point of atriotomy. The aorta was not clamped. RESULTS Ten patients with mean age of 56.9 ± 10.5 years, four were in atrial fibrilation rhythm and six in sinusal. Average time between first operation and reoperations was 11 ± 3.43 years. The mean EuroSCORE group was 8.3 ± 1.82. The mean ventricular fibrillation and cardiopulmonary bypass was respectively 70.9 ± 17.66 min and 109.4 ± 25.37 min. The average length of stay was 7.6 ± 1.5 days. There were no deaths in this series. CONCLUSION Mitral valve reoperation can be performed through less invasive techniques with good immediate results, low morbidity and mortality. However, this type of surgery requires a longer duration of cardiopulmonary bypass, especially in cases where the patient already has prosthesis. The presence of a minimal aortic insufficiency also makes this procedure technically more challenging.

Analysis of the immediate outcomes of a comparative randomized study between aorto-saphenous mechanical anastomosis versus conventional anastomosis

OBJECTIVE To evaluate the immediate results of mechanical aorto-saphenous anastomosis compared with conventional anastomosis. METHOD We evaluated 12 patients. The mean age ranged from 62.33 +/- 7.30 years. Of 12 patients submitted to surgery without extracorporeal circulation, 10 (83.3%) patients were male. Thirty-three proximal anastomoses were evaluated, 21 of them being performed through the conventional manner and 12 with the St. Jude Symmetry aortic connector. The time spent on anastomosis, and free flow and patency on the 4th day postoperative were analysed. RESULTS The mechanical anastomosis was successfully performed in all patients. Electrocardiographic alteration compatible with myocardial infarctation (MI) on the 2nd day postoperative was observed only in one patient. The patient was referred to angiographic restudy, becoming evident a conventional proximal anastomosis occlusion for the marginal branch. Three patients had atrial fibrillation. The average time spent to perform the mechanical anastomosis was 44.08 +/- 9.26 seconds against 3.86 +/- 0.61 minutes of the conventional anastomosis (p = 0.0022). The average blood free flow observed in the mechanical anastomosis was 302.75 +/- 82.76 mL/min versus 190.75 +/- 51.53 mL/min (p = 0.0022). In the angiographic restudy performed on the 4th postoperative day, it was detected the occlusin of three mechanical anastomosis. There was no new conventional anastomosis (p = 0.2500). CONCLUSION The present study showed a statistically significant superiority for mechanical anastomosis of the saphenous vein with the aorta when evaluated the blood free flow and the time to perform the anastomosis. In relation to the artery condition in the postoperative angiography, one cannot say there was statistically significant difference between the procedures studied.