Repositório RCAAP

Introduction: Most cardiomyocytes do not regenerate after myocardial infarction. Porcine small intestinal submucosa has been shown to be effective in tissue repair. Objective: To evaluate myocardial tissue regeneration and functional effects of SIS implantation in pigs after left ventriculotomy. Methods: Fifteen pigs were assigned to two groups: porcine small intestinal submucosa (SIS) (N=10) and control (N=5). The SIS group underwent a mini sternotomy, left ventriculotomy and placement of a SIS patch. The control group underwent a sham procedure. Echocardiography was performed before and 60 days after the surgical procedure. Histological analysis was performed with hematoxylin-eosin stain and markers for actin 1A4, anti sarcomeric actin, connexin43 and factor VIII. Results: Weight gain was similar in both groups. Echocardiography analysis revealed no difference between groups regarding end diastolic and systolic diameters and left ventricular ejection fraction, both pre (P=0.118, P=0.313, P=0.944) and post procedure (P=0.333, P=0.522, P=0.628). Both groups showed an increase in end diastolic (P<0,001 for both) and systolic diameter 60 days after surgery (P=0.005, SIS group and P=0.004, control group). New cardiomyocytes, blood vessels and inflammatory reactions were histologically identified in the SIS group. Conclusion: SIS implantation in pigs after left ventriculotomy was associated with angiomuscular regeneration and no damage in cardiac function.

Introduction: In spite of its importance as an experimental model, the information on the left coronary artery in pigs is sparse. Objective: To determine the morphologic features of the left coronary artery in pigs. Methods: We evaluated 158 pig hearts. The left coronary artery was perfused with synthetic resin after their ostia had been catheterized. Diameters and courses of the vascular beds were measured with an electronic caliper (Mitutoyo(r)). Results: The diameter of left coronary artery was 6.98 ± 1.56 mm and its length was 3.51±0.99 mm. It was found to end up by bifurcating itself into the anterior interventricular artery and the circumflex artery in 79% of the cases, and by trifurcating in 21% of the cases, with the presence of the diagonal artery. The anterior interventricular artery ended up at the apex in 79.7% of the cases, and the circumflex artery at the posterior aspect of the left ventricle in 64% of the case, this artery never reached the posterior interventricular sulcus. An anastomosis between the terminal branches of the anterior interventricular artery and the posterior interventricular artery was found in 7.6% of the specimens. The antero-superior branch of the anterior interventricular artery occurred in 89.9% of the hearts. A left marginal branch was observed in 87.9% of the cases with a diameter of 2.25±0.55 mm. Conclusion: Compared with humans, pigs have shorter left coronary artery trunks and branches; even the circumflex artery never reaches the posterior interventricular sulcus. Our findings are useful for the design of experimental hemodynamic and procedural models.

Introduction: The frequency of surgical procedures has increased steadily in recent decades, including the myocardial revascularization. Objectives: To demonstrate the importance of physiotherapy in the preoperative period of cardiac surgery in relation to the reduction of hospital stay, changes in lung volumes and respiratory muscle strength. Methods: We conducted a prospective study with patients undergoing myocardial revascularization, the Hospital das Clínicas da Universidade Estadual Paulista (UNESP)/Botucatu - SP. We evaluated 70 patients of both genders, aged between 40 and 75 years, subdivided into two groups: group I - 35 patients of both genders, who received a written protocol guidance, breathing exercises and respiratory muscle training in the preoperative period and group II - 35 patients of both genders, who received only orientation of the ward on the day of surgery. This study was approved by the Ethics Committee of UNESP / Botucatu - SP. Results: Maximal inspiratory pressure in third postoperative day and fifth postoperative day and significant difference between groups, being better for the intervention group. Expiratory pressure was significant in fifth postoperative day in the intervention group compared to controls. The difference of length of hospital stay in the postoperative was found between the groups with shorter hospital stay in the group receiving preoperative therapy. Conclusion: Physical therapy plays an important role in the preoperative period, so that individuals in the intervention group more readily restored the parameters evaluated before surgery, in addition, there was a decrease in the time of the postoperative hospital stay. Thus, it is thought the cost-effectiveness of a program of preoperative physiotherapy.

INTRODUÇÃO: O método mais comumente utilizado para a proteção miocárdica é o de administrar-se solução cardioplégica na circulação coronária. Entretanto, a proteção pode ser alcançada através da perfusão intermitente do sistema coronariano com sangue do próprio paciente, que é realizada por meio de múltiplas sequências de pinçamento e abertura do clamp aórtico ou por meio do pinçamento único e canulação acessória da raiz aórtica. Objetivo: Avaliar o desfecho clínico e a ocorrência de eventos neurológicos no período intra-hospitalar dos pacientes submetidos à cirurgia de revascularização do miocárdio com a técnica proposta aqui neste estudo. Métodos: Descreve-se uma técnica de proteção miocárdica no uso do pinçamento único de aorta que consiste na canulação acessória da raiz aórtica com sistema aperfeiçoado para perfusão coronária intermitente, foi realizado estudo observacional transversal prospectivo onde foram estudados 50 pacientes (idade média 58,5±7.19 anos) submetidos à cirurgia de revascularização do miocárdio sob a técnica proposta. Foram avaliadas variáveis clínicas e laboratoriais pré e pós-operatórias. Resultados: O nível médio de pico da CKMB pós-operatória foi de 51,64±27,10 U/L no segundo pós-operatório e da troponina I foi de 3,35±4,39 ng/ml no quarto pós-operatório, e estiveram dentro do limite da normalidade. Não foi observado nenhum óbito e um paciente evoluiu com alteração neurológica leve. A monitorização hemodinâmica não revelou alterações. Conclusão: A cirurgia de revascularização do miocárdio com a técnica aperfeiçoada de perfusão intermitente da raiz da aorta com pinçamento único mostrou-se como método seguro, possibilitando resultados clínicos satisfatórios nos pacientes estudados.

Introduction: The subclavian steal syndrome is characterized by the vertebral artery flow inversion, due to a stenotic lesion in the origin of the subclavian artery. The Coronary-subclavian Steal Syndrome is a variation of the Subclavian Steal Syndrome and is characterized by inversion of flow in the Internal Thracic artery that has been used as conduct in a myocardial revascularization. Its diagnosis must be suspected in patients with difference in pulse and arterial pressure in the upper limbs, that present with angina pectoris and that have done a myocardial revascularization. Its treatment must be a surgical bypass or a transluminal angioplasty. Objective: The objective is to show the left subclavian artery stenting as a safe and effective method to treat the coronary-subclavian steal syndrome. Methods: Historical prospective, non-randomized trial, through revision of the hospital records of the patients treated with the stenting of the left subclavian artery, from January 2006 to September 2012. Results: In the mentioned period, 4.291 miocardial revascularizations were performed with the use of the left mammary artery, and 16 patients were identified to have the Coronary-subclavian steal syndrome. All of them were submitted to endovascular treatment. The success rate was 100%; two patients experienced minor complications; none of them presented with major complications. Eleven of the 16 patients had ultrassonographic documentation of patent stent for at least one year; two patients lost follow up and other two died. Conclusion: The stenting of the left subclavian artery is a good option for the treatment of the Coronary-subclavian Steal Syndrome, with high level of technical and clinical success.

Objetivo: Avaliar a evolução pôndero-estatural de crianças com cardiopatias congênitas submetidas a tratamento cirúrgico com intuito de determinar quando atingem o limiar de desenvolvimento normal e se há diferenças entre pacientes com padrão de desenvolvimento abaixo do patamar da normalidade no pré-operatório (z-score<-2 para o parâmetro analisado) em relação ao grupo total de cardiopatas. Métodos: Acompanhamento prospectivamente de 27 crianças submetidas à operação em cinco períodos: pré-operatório e em quatro subsequentes retornos ambulatoriais: 1º mês, 3º mês, 6º mês e 12º mês após a alta hospitalar. Os parâmetros antropométricos usados foram a média do z-score (Zm) do peso (ZmP/I), da altura (ZmA/I), prega cutânea subescapular (ZmPCS/I), perímetro braquial (ZmPB/I) e prega cutânea tricipital (ZmPCT/I). A avaliação da evolução dos parâmetros foi feita pela análise de variância e a comparação com a população geral normal pelo teste t não pareado, tanto no grupo total dos cardiopatas, quanto nos subgrupos com parâmetros pré-operatórios abaixo do patamar da normalidade (Zm<-2). Resultados: No grupo total não houve evolução significativa dos Zm de todos os parâmetros. O ZmP/I foi estatisticamente menor que da população normal até o 1º mês de seguimento (P=0,028); o ZmA/I, somente no pré operatório (P=0,044); o ZmPCS/I, no o 1º mês (P=0,015) e no 12º mês (P=0,038); o ZmPB/I e o ZmPCT/I sempre foram estatisticamente iguais ao da população geral. Nos pacientes com desenvolvimento abaixo do limiar da normalidade houve variação importante do ZmP/I (P=0,002), do ZmA/I (P=0,001) e do ZmPB/I (P=0,031) após a operação, sendo que o ZmP/I foi menor que da população normal até o 3º mês (P=0,015); o ZmA/I e o ZmPB/I, até o 1º mês (P=0,024 e P=0,039 respectivamente); o ZmPCS/I, até o 12º mês (P=0,005); o ZmPCT/I, somente no pré-operatório (P=0,011). Conclusão: A operação promoveu o retorno à normalidade para os cardiopatas em geral dentro de até três meses, porém para o grupo de pacientes abaixo do padrão normal de desenvolvimento o retorno ocorreu em até 12 meses.

O paradoxo do cálcio foi pela primeira vez citado em 1966 por Zimmerman et al. A partir daí, ganhou grande interesse por parte da comunidade científica internacional devido ao fato da ausência do íon cálcio produzir na célula muscular cardíaca dano semelhante à lesão de isquemia-reperfusão. Apesar de não serem conhecidos todos os mecanismos envolvidos no processo da lesão celular no paradoxo do cálcio, a conexão intercelular mantida somente pelo nexus parece ter papel chave na fragmentação celular. A adição de pequenas concentrações de cálcio, bloqueadores de canal de cálcio, hiponatremia ou hipotermia são importantes para evitar que haja lesão celular no momento da reperfusão com soluções com concentração fisiológica de cálcio.

Objective: Gather and describe general characteristics of different protocols of risk stratification for cardiac patients undergoing exercise. Methods: We conducted searches in LILACS, IBECS, MEDLINE, Cochrane Library, and SciELO electronic databases, using the following descriptors: Cardiovascular Disease, Rehabilitation Centers, Practice Guideline, Exercise and Risk Stratification in the past 20 years. Results: Were selected eight studies addressing methods of risk stratification in patients undergoing exercise. Conclusion: None of the methods described could cover every situation the patient can be subjected to; however, they are essential to exercise prescription.

Revisão sistemática sobre drenagem assistida a vácuo na circulação extracorpórea, demonstrando seus benefícios, desvantagens, por relatos de casos e evidências sobre seus efeitos na microcirculação. Realizou-se pesquisa sistemática, no período de 1997-2012, nas bases de dados do PubMed-Medline, Lilacs e SciELO. Termos: "circulação extracorpórea", "vácuo", "drenagem", "cirurgia cardíaca" e suas correspondentes traduções, em condições variadas. Dos 70 artigos selecionados, 26 foram incluídos na revisão. Embora a drenagem assistida a vácuo possua potencial significante de complicações e exija tecnologia e profissionalismo respectivo adequado, prevaleceu na literatura revisada o conceito de que a drenagem assistida a vácuo contribuiu na redução no índice de transfusões, hemodiluições, melhor campo operatório, não aumento de hemólise significativa, redução de complicações pós-cirúrgicas, uso de menor prime e uso de cânulas de menor calibre.

Objective: The aim of the present investigation was to determine whether the difference in inflammatory tissue reaction between the Riccinus communis (castor) polymer with calcium carbonate and the titanium implant is statistically significant. Methods: Thirty-two Cavia porcellus were allocated into four groups of eight animals each. We implanted the two types of materials in the retroperitoneal space of all the animals. They were euthanized at 7, 20, 30 and 40 days after surgery, and an histological study of the samples was conducted. Results: All implants showed characteristics of chronic inflammation regardless of the material and timepoint of evaluation. There was no statistically significant difference between Pm+CaCO3 and Ti with regard to the presence of granulation tissue, tissue congestion, histiocytes, lymphocytes, neutrophils, giant cells, and fibrosis (P> 0.05). Conclusion: The castor oil polymer plus calcium carbonate implant was not statistically different from the titanium implant regarding inflammatory tissue reaction.

Insertion of inferior vena cava filters has been well established in literature, reducing occurrence of pulmonary embolism after an episode of deep venous thrombosis in patients with contraindication to anticoagulation. There are a small number of complications related to procedure and embolization is rare. In this context, we described a case of intracardiac embolization associated with cardiac tamponade.

Introduction: Preoperatively elevated serum creatinine (SCr) is considered an independent risk factor for morbidity and mortality after cardiac surgery. The aim of this study was to apply the Kidney Disease Improving Global Outcomes classification for acute kidney injury in a population of patients with preoperatively elevated serum creatinine who underwent cardiac surgery (coronary artery bypass grafting or cardiac valve surgery) and to evaluate the acute worsening of renal function as a predictor of 30-day mortality. Methods: This was a single-center retrospective study that included patients from the Postoperative Cardiac Surgery Intensive Care Unit of the Hospital de Base, São José do Rio Preto Medical School. Demographics, type of surgery, laboratory data and pre, peri and postoperative data were obtained from a prospectively collected database. From January 2003 to June 2013, 2,878 patients underwent cardiac surgery, either coronary artery bypass grafting or cardiac valve surgery, at the Hospital de Base of São José do Rio Preto Medical School. Out of those, 918 showed elevated preoperative serum creatinine, with SCr > 1.30 mg/dL for men and > 1.00 mg/dL for women. Five hundred and forty nine patients (60%) undergoing coronary artery bypass grafting and 369 patients (40%) undergoing cardiac valve surgery. A Multivariate Cox Proportional Hazard Model (stepwise) was used to assess the relationship between AKI and mortality at 30 days. Results: Out of the 918 patients studied, 391 (43%) had postoperative AKI: 318 (35%) had Kidney Disease Improving Global Outcomes stage 1, 27 (2.9%) had Kidney Disease Improving Global Outcomes stage 2, and 46 (5.0%) had Kidney Disease Improving Global Outcomes stage 3. Patients in every stage of acute kidney injury showed progressive increase in EuroSCORE values, 30-day mortality ratescardiopulmonary bypass duration, and intensive care length of stay. Among patients classified as Kidney Disease Improving Global Outcomes stage 3, 76% required dialysis with a 30-day mortality of 66%. The Cox proportional hazards model showed that the hazard ratio for 30-day mortality was 4.8 for Kidney Disease Improving Global Outcomes stage 1 patients, 13.5 for Kidney Disease Improving Global Outcomes stage 2 patients, and 20.8 for Kidney Disease Improving Global Outcomes stage 3 patients (P<0.001 for all). Subgroup analyses (coronary artery bypass grafting and cardiac valve surgery) had similar results. Conclusion: In this population, acute kidney injury based on the Kidney Disease Improving Global Outcomes criteria was a powerful predictor of 30-day mortality in patients with elevated preoperative serum creatinine who underwent cardiac surgery (coronary artery bypass grafting or cardiac valve surgery).

Introduction: Cardiac surgeons stress may impair their quality of life and professional practice. Objective: To assess perceived chronic stress and coping strategies among cardiac surgeons. Methods: Twenty-two cardiac surgeons answered two self-assessment questionnaires, the Trier Inventory for Chronic Stress and the German SGV for coping strategies. Results: Participants mean age was 40±14.1 years and 13 were male; eight were senior physicians and 14 were residents. Mean values for the Trier Inventory for Chronic Stress were within the normal range. Unexperienced physicians had significantly higher levels of dissatisfaction at work, lack of social recognition, and isolation (P<0.05). Coping strategies such as play down, distraction from situation, and substitutional satisfaction were also significantly more frequent among unexperienced surgeons. "Negative" stress-coping strategies occur more often in experienced than in younger colleagues (P=0.029). Female surgeons felt more exposed to overwork (P=0.04) and social stress (P=0.03). Conclusion: Cardiac surgeons show a tendency to high perception of chronic stress phenomena and vulnerability for negative coping strategies.

Objective: Aortic valve replacement with Braile bovine pericardial prosthesis has been routinely done at the Heart Institute of the Universidade de São Paulo Medical School since 2006. The objective of this study is to analyze the results of Braile Biomédica® aortic bioprosthesis in patients with aortic valve disease. Methods: We retrospectively evaluated 196 patients with aortic valve disease submitted to aortic valve replacement with Braile Biomédica® bovine pericardial prosthesis, between 2006 and 2010. Mean age was 59.41±16.34 years and 67.3% were male. Before surgery, 73.4% of patients were in NYHA functional class III or IV. Results: Hospital mortality was 8.16% (16 patients). Linearized rates of mortality, endocarditis, reintervention, and structural dysfunction were 1.065%, 0.91%, 0.68% and 0.075% patients/year, respectively. Actuarial survival was 90.59±2.56% in 88 months. Freedom from reintervention, endocarditis and structural dysfunction was respectively 91.38±2.79%, 89.84±2.92% and 98.57±0.72% in 88 months. Conclusion: The Braile Biomédica® pericardial aortic valve prosthesis demonstrated actuarial survival and durability similar to that described in the literature, but further follow up is required to assess the incidence of prosthetic valve endocarditis and structural dysfunction in the future.

Introduction: Cardiac transplantation remains the gold standard for end-stage cardiomyopathies and congenital heart defects in pediatric patients. Objective: This study aims to report on 20 years of experience since the first case and evaluate our results. Methods: We conducted a retrospective analysis of the database and outpatient follow-up. Between October 1992 and April 2012, 109 patients underwent 114 transplants. 51.8% of them being female. The age of patients ranged from 12 days to 21 years with a mean of 8.8±5.7 years and a median of 5.2 years. The underlying diagnosis was dilated cardiomyopathy in 61.5%, congenital heart disease in 26.6% and restrictive cardiomyopathy in 11.9%. All patients above 17 years old had congenital heart disease. Results: Survival rate at 30 days, 1, 5, 10, 15, and 20 years were 90.4%, 81.3%, 70.9%, 60.5%, 44.4% and 26.7%, respectively. Mean cold ischemic time was 187.9 minutes and it did not correlate with mortality (P>0.05). Infectious complications and rejection episodes were the most common complications (P<0.0001), occurring, respectively, in 66% and 57.4% of the survivors after 10 years. There was no incidence of graft vascular disease and lymphoproliferative disease at year one, but they affected, respectively, 7.4% and 11% of patients within 10 years. Conclusion: Twenty-year pediatric heart transplant results at our institution were quite satisfactory and complication rates were acceptable.

Objective: The objective of this paper is to present the results from Spiral Pump clinical trial after design modifications performed at its previous project. This pump applies axial end centrifugal hydraulic effects for blood pumping during cardiopulmonary bypass for patients under cardiac surgery. Methods: This study was performed in 52 patients (51% males), between 20 to 80 (67±14.4) years old weighing 53 to 102 (71.7±12.6) kg, mostly under myocardial revascularization surgery (34.6%) and valvular surgery (32.8%). Besides the routine evaluation of the data observed in these cases, we monitored pump rotational speed, blood flow, cardiopulmonary bypass duration, urine free hemoglobin for blood cell trauma analysis (+ to 4+), lactate desidrogenase (UI/L), fibrinogen level (mg/dL) and platelet count (nº/mm3). Results: Besides maintaining appropriate blood pressure and metabolic parameters it was also observed that the Free Hemoglobin levels remained normal, with a slight increase after 90 minutes of cardiopulmonary bypass. The Lactate Dehydrogenase showed an increase, with medians varying between 550-770 IU/L, whereas the decrease in Fibrinogen showed medians of 130-100 mg/dl. The number of platelets showed a slight decrease with the medians ranging from 240,000 to 200,000/mm3. No difficulty was observed during perfusion terminations, nor were there any immediate deaths, and all patients except one, were discharged in good condition. CONCLUSION: The Spiral Pump, as blood propeller during cardiopulmonary bypass, demonstrated to be reliable and safe, comprising in a good option as original and national product for this kind of application.

Introduction: A feature of dilated cardiomyopathy is the deformation of ventricular cavity, which contributes to systolic dysfunction. Few studies have evaluated this deformation bearing in mind ventricular regions and segments of the ventricle, which could reveal important details of the remodeling process, supporting a better understanding of its role in functional impairment and the development of new therapeutic strategies. Objective: To evaluate if, in basal, equatorial and apical regions, increased internal transverse perimeter of left ventricle in idiopathic dilated cardiomyopathy occurs proportionally between the septal and non-septal segment. Methods: We performed an anatomical study with 28 adult hearts from human cadavers. One group consisted of 18 hearts with idiopathic dilated cardiomyopathy and another group with 10 normal hearts. After lamination and left ventricle digital image capture, in three different regions (base, equator and apex), the transversal internal perimeter of left ventricle was divided into two segments: septal and not septal. These segments were measured by proper software. It was established an index of proportionality between these segments, called septal and non-septal segment index. Then we determined whether this index was the same in both groups. Results: Among patients with normal hearts and idiopathic dilated cardiomyopathy, the index of proportionality between the two segments (septal and non-septal) showed no significant difference in the three regions analyzed. The comparison results of the indices NSS/SS among normal and enlarged hearts were respectively: in base 1.99 versus 1.86 (P=0.46), in equator 2.22 versus 2.18 (P=0.79) and in apex 2.96 versus 3.56 (P=0.11). Conclusion: In the idiopathic dilated cardiomyopathy, the transversal dilatation of left ventricular internal perimeter occurs proportionally between the segments corresponding to the septum and free wall at the basal, equatorial and apical regions of this chamber.

Objective: Evaluate the addition of long-distance heart procurement on a heart transplant program and the status of heart transplant recipients waiting list. Methods: Between September 2006 and October 2012, 72 patients were listed as heart transplant recipients. Heart transplant was performed in 41 (57%), death on the waiting list occurred in 26 (36%) and heart recovery occurred in 5 (7%). Initially, all transplants were performed with local donors. Long-distance, interstate heart procurement initiated in February 2011. Thirty (73%) transplants were performed with local donors and 11 (27%) with long-distance donors (mean distance=792 km±397). Results: Patients submitted to interstate heart procurement had greater ischemic times (212 min ± 32 versus 90 min±18; P<0.0001). Primary graft dysfunction (distance 9.1% versus local 26.7%; P=0.23) and 1 month and 12 months actuarial survival (distance 90.1% and 90.1% versus local 90% and 86.2%; P=0.65 log rank) were similar among groups. There were marked incremental transplant center volume (64.4% versus 40.7%, P=0.05) with a tendency on less waiting list times (median 1.5 month versus 2.4 months, P=0.18). There was a tendency on reduced waiting list mortality (28.9% versus 48.2%, P=0.09). Conclusion: Incorporation of long-distance heart procurement, despite being associated with longer ischemic times, does not increase morbidity and mortality rates after heart transplant. It enhances viable donor pool, and it may reduce waiting list recipient mortality as well as waiting time.

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Relatamos caso de lactente jovem com desconforto respiratório precoce e hipertensão pulmonar, diagnosticado como variante de pulmão em ferradura, e revisamos literatura a cerca desta rara malformação pulmonar e suas repercussões cardíacas e hemodinâmicas.