RCAAP Repository

Abstract OBJECTIVE: Risk assessment for operative mortality is mandatory for all cardiac operations. For some operation types such as aortic valve repair, EuroSCORE II overestimates the mortality rate and a new scoring system (German AV score) has been developed for a more accurate assessment of operative risk. In this study, we aimed to validate German Aortic Valve Score in our clinic in patients undergoing isolated aortic valve replacement. METHODS: A total of 35 patients who underwent isolated open aortic valve replacement between 2010 and 2013 were included. Patients with concomitant procedures and transcatheter aortic valve implantation were excluded. Patients' data were collected and analyzed retrospectively. Patients' risk scores EuroSCORE II were calculated online according to criteria described by EuroSCORE taskforce, Aortic Valve Scores were also calculated. RESULTS: The mean age of patients was 61.14±13.25 years (range 29-80 years). The number of female patients was 14 (40%) and body mass index of 25 (71.43%) patients was in range of 22-35. Mean German Aortic Valve Score was 1.05±0.96 (min: 0 max: 4.98) and mean EuroSCORE was 2.30±2.60 (min: 0.62, max: 2.30). The Aortic Valve Score scale showed better discriminative capacity (AUC 0.647, 95% CI 0.439-0.854). The goodness of fit was x2HL=16.63; P=0.436). EuroSCORE II scale had shown less discriminative capacity (AUC 0.397, 95% CI 0.200-0.597). The goodness of fit was good for both scales. The goodness of fit was x2HL=30.10; P=0.610. CONCLUSION: In conclusion, German AV score applies to our population with high predictive accuracy and goodness of fit.

Abstract INTRODUCTION: Elevated hemoglobin A1c levels in patients with diabetes mellitus have been known as a risk factor for acute kidney injury after coronary artery bypass grafting. However, the relationship between hemoglobin A1c levels in non-diabetics and acute kidney injury is under debate. We aimed to investigate the association of preoperative hemoglobin A1c levels with acute kidney injury in non-diabetic patients undergoing isolated coronary artery bypass grafting. METHODS: 202 non-diabetic patients with normal renal function (serum creatinine <1.4 mg/dl) who underwent isolated coronary bypass were analyzed. Hemoglobin A1c level was measured at the baseline examination. Patients were separated into two groups according to preoperative Hemoglobin A1c level. Group 1 consisted of patients with preoperative HbA1c levels of < 5.6% and Group 2 consisted of patients with preoperative HbA1c levels of ≥ 5.6%. Acute kidney injury diagnosis was made by comparing baseline and postoperative serum creatinine to determine the presence of predefined significant change based on the Kidney Disease Improving Global Outcomes (KDIGO) definition. RESULTS: Acute kidney injury occurred in 19 (10.5%) patients after surgery. The incidence of acute kidney injury was 3.6% in Group 1 and 16.7% in Group 2. Elevated baseline hemoglobin A1c level was found to be associated with acute kidney injury (P=0.0001). None of the patients became hemodialysis dependent. The cut off value for acute kidney injury in our group of patients was 5.75%. CONCLUSION: Our findings suggest that, in non-diabetics, elevated preoperative hemoglobin A1c level may be associated with acute kidney injury in patients undergoing coronary artery bypass grafting. Prospective randomized studies in larger groups are needed to confirm these results.

Abstract OBJECTIVE: Myocardial protection is the most important in cardiac surgery. We compared our modified single-dose long-acting lignocaine-based blood cardioplegia with short-acting St Thomas 1 blood cardioplegia in patients undergoing single valve replacement. METHODS: A total of 110 patients who underwent single (aortic or mitral) valve replacement surgery were enrolled. Patients were divided in two groups based on the cardioplegia solution used. In group 1 (56 patients), long-acting lignocaine based-blood cardioplegia solution was administered as a single dose while in group 2 (54 patients), standard St Thomas IB (short-acting blood-based cardioplegia solution) was administered and repeated every 20 minutes. All the patients were compared for preoperative baseline parameters, intraoperative and all the postoperative parameters. RESULTS: We did not find any statistically significant difference in preoperative baseline parameters. Cardiopulmonary bypass time were 73.8±16.5 and 76.4±16.9 minutes (P=0.43) and cross clamp time were 58.9±10.3 and 66.3±11.2 minutes (P=0.23) in group 1 and group 2, respectively. Mean of maximum inotrope score was 6.3±2.52 and 6.1±2.13 (P=0.65) in group 1 and group 2, respectively. We also did not find any statistically significant difference in creatine-phosphokinase-MB (CPK-MB), Troponin-I levels, lactate level and cardiac functions postoperatively. CONCLUSION: This study proves the safety and efficacy of long-acting lignocaine-based single-dose blood cardioplegia compared to the standard short-acting multi-dose blood cardioplegia in patients requiring the single valve replacement. Further studies need to be undertaken to establish this non-inferiority in situations of complex cardiac procedures especially in compromised patients.

Abstract INTRODUCTION: The mortality due to cardiogenic shock complicating acute myocardial infarction (AMI) is high even in patients with early revascularization. Infusion of low dose recombinant human brain natriuretic peptide (rhBNP) at the time of AMI is well tolerated and could improve cardiac function. OBJECTIVE: The objective of this study was to evaluate the hemodynamic effects of rhBNP in AMI patients revascularized by emergency percutaneous coronary intervention (PCI) who developed cardiogenic shock. METHODS: A total of 48 patients with acute ST segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock and whose hemodynamic status was improved following emergency PCI were enrolled. Patients were randomly assigned to rhBNP (n=25) and control (n=23) groups. In addition to standard therapy, study group individuals received rhBNP by continuous infusion at 0.005 µg kg−1 min−1 for 72 hours. RESULTS: Baseline characteristics, medications, and peak of cardiac troponin I (cTnI) were similar between both groups. rhBNP treatment resulted in consistently improved pulmonary capillary wedge pressure (PCWP) compared to the control group. Respectively, 7 and 9 patients died in experimental and control groups. No drug-related serious adverse events occurred in either group. CONCLUSION: When added to standard care in stable patients with cardiogenic shock complicating anterior STEMI, low dose rhBNP improves PCWP and is well tolerated.

Abstract INTRODUCTION: Enhanced respiratory muscle strength in patients with heart failure positively alters the clinical trajectory of heart failure. In an experimental model, respiratory muscle training in rats with heart failure has been shown to improve cardiopulmonary function through mechanisms yet to be entirely elucidated. OBJECTIVE: The present report aimed to evaluate the respiratory muscle training effects in diaphragm citrate synthase activity and hemodynamic function in rats with heart failure. METHODS: Wistar rats were divided into four experimental groups: sedentary sham (Sed-Sham, n=8), trained sham (RMT-Sham, n=8), sedentary heart failure (Sed-HF, n=7) and trained heart failure (RMT-HF, n=7). The animals were submitted to a RMT protocol performed 30 minutes a day, 5 days/week, for 6 weeks. RESULTS: In rats with heart failure, respiratory muscle training decreased pulmonary congestion and right ventricular hypertrophy. Deleterious alterations in left ventricular pressures, as well as left ventricular contractility and relaxation, were assuaged by respiratory muscle training in heart failure rats. Citrate synthase activity, which was significantly reduced in heart failure rats, was preserved by respiratory muscle training. Additionally, a negative correlation was found between citrate synthase and left ventricular end diastolic pressure and positive correlation was found between citrate synthase and left ventricular systolic pressure. CONCLUSION: Respiratory muscle training produces beneficial adaptations in the diaphragmatic musculature, which is linked to improvements in left ventricular hemodynamics and blood pressure in heart failure rats. The RMT-induced improvements in cardiac architecture and the oxidative capacity of the diaphragm may improve the clinical trajectory of patients with heart failure.

Abstract INTRODUCTION: The biggest challenge faced in minimally invasive pediatric cardiac surgery is cannulation for cardiopulmonary bypass. Our technique and experience of cervical cannulation in infants and small children for repair of congenital cardiac defects is reported in this study. METHODS: From January 2013 to June 2015, 37 children (22 males) with mean age of 17.97±8.63 months and weight of 8.06±1.59 kg were operated on for congenital cardiac defects through right lateral thoracotomy. The most common diagnosis was ventricular septal defect (18 patients). In all patients, right common carotid artery, right internal jugular vein and inferior vena cava were cannulated for institution of cardiopulmonary bypass and aorta was cross clamped through right 2nd intercostal space. RESULTS: There were no deaths or any major complications related to cervical cannulation. Common carotid artery cannulation provided adequate arterial inflow while internal jugular vein with inferior vena cava provided adequate venous return in all patients. No patient required conversion to sternotomy or developed vascular, neurological or wound related complications. Three patients had residual lesions (small leak across ventricular septal defect patch-2, Grade II left atrio-ventricular valve regurgitation-1) and one patient had mild left ventricular dysfunction. At discharge, both common carotid artery and internal jugular vein were patent on color Doppler ultrasonography in all patients. In a mean follow-up period of 11.4±2.85 months, all patients were doing well. No patient had any wound related, neurological or vascular complication. No patient had residual leak across ventricular septal defect patch. CONCLUSION: Cervical cannulation of common carotid artery and internal jugular vein is a safe, reliable, efficient and quick method for institution of cardiopulmonary bypass in minimally invasive pediatric cardiac surgery.

Abstract INTRODUCTION: Left atrial ganglionated plexi ablation is an adjuvant technique used to increase the success rate of surgical ablation of atrial fibrillation. Ganglionated plexi ablation requires previous detection. We aimed to assess determinants of successful ganglionated plexi detection and to correlate range of ganglionated plexi ablation with risk of early atrial fibrillation recurrence. METHODS: The study involved 34 consecutive patients referred for surgical coronary revascularization with concomitant atrial fibrillation ablation. Ganglionated plexi detection was done by inducing vagal reflexes in the area of the pulmonary veins and left atrial fat pads. RESULTS: Detection of GP was successful in 85% of the patients. There was no difference in preoperative characteristics nor in atrial fibrillation type between patients in whom ganglionated plexi detection was successful and others. The number of detected ganglionated plexi correlated significantly only with preoperative resting heart rate. Significant negative correlation was found in patients with preoperative heart rate>75 beat/min in terms of total number of detected ganglionated plexi (P=0.04). Average number of detected ganglionated plexi was significantly higher in patients with in-hospital atrial fibrillation recurrence requiring electrical cardioversion (3.8±3) in comparison to rest of the study population (2±1.3; P=0.02). In patients in whom 4 or more ganglionated plexi were detected, significantly increased risk of in-hospital atrial fibrillation recurrence was observed (OR 15; 95% CI 1.5-164; P=0.003). CONCLUSION: Left atrial ganglionated plexi detection was unsuccessful in a considerable percentage of patients. Preoperative heart rate significantly influenced positive ganglionated plexi detection and number of ablated ganglia. Higher number of detected ganglionated plexi was related with early recurrence of atrial fibrillation.

Abstract The endothelium plays an important role in maintaining vascular homeostasis and regulating blood vessel function. Endothelial function is considered an independent predictor for risk of future cardiovascular events in cardiovascular and non-cardiovascular patients, as well as a predictor for postoperative complications in cardiovascular surgery patients. Brachial artery flow-mediated dilation by high-resolution ultrasound is widely used to evaluate endothelium-dependent vasodilation, which is mainly mediated by nitric oxide release. Physical exercise exerts beneficial effects on endothelial function and can be used in both primary and secondary prevention of cardiac and peripheral artery diseases, even in the postoperative period of cardiovascular surgery.

Abstract We present a patient with unstable angina candidate for coronary artery bypass grafting. Saphenous vein graft was used in obtuse marginal and left internal mammary artery to left anterior descending artery properly. After surgery, the patient experienced flaccid paralysis of lower limb and impaired sensation of touch and warmth of knee and below. A computed tomography angiogram of lower limbs and thoracolumbar magnetic resonance imaging showed no abnormality. Based on the symptom, clinical diagnosis of anterior spinal artery syndrome was considered. The artery of Adamkiewicz is an important supplier to the anterior spinal artery. Internal thoracic mammary artery, used in coronary artery bypass grafting, is suspected as a collateral supplier of the artery of Adamkiewicz and has been accused for cause of spinal infarction.

Abstract Cardiac hydatid cyst is an uncommon but potentially fatal disease. In cystic Echinococcus humans are an accidental host. Liver and lungs are the most frequently involved organs. Herein a unique case of intramyocardial hydatid cyst of left ventricle along with pulmonary hydatid cyst in a 38-year-old lady is reported. Surgical removal of the cardiac hydatid cyst was done with the aid of cardiopulmonary bypass followed by removal of pulmonary hydatid cyst.

Abstract Objective: The study aimed to identify the factors affecting the prognosis of post myocardial infarction (MI) ventricular septal rupture (VSR) and to develop a protocol for its management. Methods: This was a single center, retrospective-prospective study (2009-2014), involving 55 patients with post MI VSR. The strengths of association between risk factors and prognosis were assessed using multivariate logistic regression analysis. The UNM Post MI VSR management and prognosis scoring systems (UPMS & UPPS) were developed. Results: Thirty-day mortality was 52.5% (35% in the last 3 years). Twenty-eight (70%) patients underwent concomitant coronary artery bypass grafting. Residual ventricular septal defect was found in 3 (7.5%) patients. The multivariate analysis showed low mean blood pressure with intra-aortic balloon pump (OR 11.43, P=0.001), higher EuroSCORE II (OR 7.47, P=0.006), higher Killip class (OR 27.95, P=0.00), and shorter intervals between MI and VSR (OR 7.90, P=0.005) as well as VSR and Surgery (OR 5.76, P=0.016) to be strong predictors of mortality. Concomitant coronary artery bypass grafting (P=0.17) and location (P=0.25) of VSR did not affect the outcome. Mean follow-up was 635.8±472.5 days and 17 out of 19 discharged patients were in NYHA class I-II. Conclusion: The UNM Post-MI VSR Scoring Systems (UPMS & UPPS) help in management and prognosis, respectively. They divide patients into 3 groups: 1) Immediate Surgery - Patients with scores of <25 require immediate surgery, preferably with extracorporeal membrane oxygenation support, and have poor prognosis; 2) Those with scores of 25-75 should be managed with "Optimal Delay" and they have intermediate outcomes; 3) Patients with scores of >75 can undergo Elective Repair and they are likely to have good outcomes.

Abstract Objective: To present the results of a new experimental device developed to facilitate the transapical access in endovascular treatment of structural heart diseases. It aims to reduce the risk of bleeding and complications in this type of access and demonstrate the device as a safe, fast and effective alternative. Methods: CorPoint is composed of three parts: introducer, base with coiled spring, and closing capsule. By rotating movements, the spring is introduced into the myocardium and progressively approaches the base to the surface of the heart. Guidewires and catheters are inserted through the hollow central part and, at the end of the procedure, the capsule is screwed over the base, therefore stopping any bleeding. Results: The device was implanted in 15 pigs, weighing 60 kg each, through an anterolateral thoracotomy, while catheters were introduced and guided by fluoroscopy. All animals had minimal bleeding; introducers with diameter up to 22 Fr were used and various catheters and guidewires were easily handled. After finishing the procedure, the closing capsule was attached and no bleeding was observed at the site. Conclusion: This new device has proved effective, fast and secure for the transapical access. This shows great potential for use, especially by ensuring an easier and direct access to the mitral and aortic valves; the shortest distance to be traveled by catheters; access to the ascending and descending aorta; decreased bleeding complications; decreased surgical time; and the possibility of allowing the technique to evolve and become totally percutaneous.

FUNDAMENTO: O Infarto Agudo do Miocárdio (IAM) é a principal causa isolada de óbito entre as doenças crônicas não transmissíveis no Brasil. O conhecimento das tendências de mortalidade é necessário para o planejamento de estratégias de prevenção. OBJETIVO: Avaliar a tendência de mortalidade por infarto do miocárdio no período de 1998 a 2009 na cidade de Curitiba (PR), sua distribuição por gênero, faixa etária e seu impacto na redução do número absoluto de mortes por essa doença nesse período. MÉTODOS: Dados demográficos foram obtidos do Instituto Brasileiro de Geografia e Estatística e dados de óbitos foram obtidos no Sistema de Informação de Mortalidade do Ministério da Saúde, considerando gênero, faixa etária e residência. A partir do ajuste de um modelo de Regressão de Poisson foram estimadas taxas de mortalidade e número de mortes esperadas que não foram observadas. RESULTADOS: Foi encontrada tendência de declínio significativa (p < 0,001) no período. A estimativa da redução média na taxa de óbito por IAM a cada ano foi de 3,8% (IC 95%: 3,2% - 4,5%). Não houve diferença significativa entre os gêneros (p = 0,238); entretanto, a evolução das taxas padronizadas específicas por idade diferiu significativamente entre as faixas etárias (p = 0,018). Estima-se que a redução anual de 3,8% na taxa de mortalidade tenha resultado em 2.168 mortes aquém do número esperado, considerando a taxa de mortalidade observada em 1998 e projetando esse número sobre o crescimento populacional ocorrido no período estudado. CONCLUSÃO: Embora permaneça como causa importante de óbito, a mortalidade por IAM apresentou queda significativa no período avaliado

Na última década, foram realizados vários estudos sobre alterações gastrointestinais associadas a insuficiência cardíaca crônica. Neste artigo, apresentamos revisão da literatura sobre a fisiopatologia e consequências clínicas das alterações patológicas digestivas de pacientes com insuficiência cardíaca. Anormalidades estruturais e funcionais do trato gastrointestinal, como edema da mucosa absortiva e hipercrescimento bacteriano intestinal, têm sido responsabilizadas por graves consequências clínicas. Entre essas, destacam-se caquexia cardíaca, ativação inflamatória sistêmica e anemia. Essas condições, isoladamente ou em combinação, podem levar a piora da disfunção ventricular preexistente. Embora atualmente não haja terapêutica específica direcionada às alterações gastrointestinais associadas a insuficiência cardíaca, o entendimento das anormalidades digestivas é fundamental para sua prevenção e manejo das consequências sistêmicas.

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Relatamos caso de perfusão dinâmica e quantitativa pela tomografia computadorizada de múltiplos detectores de dupla fonte de Raio X em um paciente de 44 anos, com diagnóstico prévio de doença coronariana. A tomografia demonstrou quantitativamente déficit de perfusão miocárdica nos territórios irrigados por artérias com estenoses significativas confirmadas pela angiotomografia e pela cineangiocoronariografia. A tomografia computadorizada com dupla fonte de Raio X permitiu a avaliação dinâmica perfusional e anatômica, em um único estudo, durante o controle evolutivo desse paciente.

O Fibroelastoma Papilífero é um tumor cardíaco benigno, encontrado principalmente nas válvulas. A maioria é assintomática, mas, quando presentes, são inespecíficos ou relacionados a fenômenos embólicos. Em geral, são diagnosticados em exames de imagem de rotina ou em cirurgias valvares e autópsias. Por sua raridade, há controvérsia sobre sua terapêutica. Descrevemos sete casos diagnosticados e tratados em nossa instituição entre 1989 a 2010, o que constitui a maior casuística nacional dessa patologia até o momento.

FUNDAMENTO: Pouco se sabe, em nosso meio, sobre diferenças regionais no tratamento da coronariopatia aguda. OBJETIVO: Analisar o comportamento regional relativamente à utilização de terapêuticas comprovadamente úteis na coronariopatia aguda. MÉTODOS: Foram selecionados aleatoriamente 71 hospitais, respeitando-se a proporcionalidade do país em relação à localização geográfica, entre outros critérios. Na população global, foi analisada regionalmente a utilização de AAS, clopidogrel, inibidor da ECA/bloqueador de AT1, betabloqueador e estatina, isoladamente e agrupados por escore individual que variou de 0 (nenhum medicamento utilizado) a 100 (todos utilizados). No infarto com supradesnivelamento de ST (IAMCSST) foram analisadas diferenças regionais sobre utilização de terapêuticas de recanalização (fibrinolíticos e angioplastia primária). RESULTADOS: No global da população, nas primeiras 24 horas de hospitalização, a média de escore na região Norte-Nordeste (70,5 ± 22,1) foi menor (p < 0,05) do que nas regiões Sudeste (77,7 ± 29,5), Centro-Oeste (82 ± 22,1) e Sul (82,4 ± 21). Por ocasião da alta, o escore da região Norte-Nordeste (61,4 ± 32,9) foi menor (p < 0,05) do que nas regiões Sudeste (69,2 ± 31,6), Centro-Oeste (65,3 ± 33,6), e Sul (73,7 ± 28,1); adicionalmente, o escore do Centro-Oeste foi menor (p < 0,05) do que o do Sul. No IAMCSST, o uso de terapêuticas de recanalização foi maior no Sudeste (75,4%, p = 0,001 em relação ao restante do país), e menor no Norte-Nordeste (52,5%, p < 0,001 em relação ao restante do país). CONCLUSÃO: O uso de terapêuticas comprovadamente úteis no tratamento da coronariopatia aguda está aquém do desejável no país, com importantes diferenças regionais.

FUNDAMENTO: A presença de nervos nas válvulas cardíacas foi demonstrada pela primeira vez há décadas e identificadas em subpopulações: simpáticas e parassimpáticas, e, portanto, é esperado que as válvulas sejam grandemente afetadas pelos nervos autônomos. Entretanto, poucos estudos têm se concentrado na regulação de válvulas cardíacas pelo sistema nervoso autônomo. OBJETIVO: Buscamos identificar o papel do sistema nervoso autônomo na regulação das propriedades mecânicas dos tecidos de válvulas mitrais porcinas. MÉTODOS: As propriedades mecânicas dos folhetos de válvulas mitrais porcinas foram avaliados em resposta à norepinefrina (NE) e acetilcolina (ACH), os principais neurotransmissores. Ao mesmo tempo, fentolamina (FENT), metoprolol (Metop), atropina (Atrop) e desnudamento endotelial foram adicionados ao sistema reativo. RESULTADOS: Sob condições fisiológicas, a rigidez não foi afetada pelo desnudamento endotelial (p &gt; 0,05). A NE significantemente aumentou a rigidez valvar por aumento de 10 vezes na concentração (10-6 vs 10-7, p < 0,05; 10-5 vs 10-6, p < 0,05). Essa resposta foi amenizada por FENT, Metop ou desnudamento endotelial (p < 0,05); entretanto, manteve-se aumentada de maneira significante quando comparada aos Controles (p < 0,05). A ACH causou uma diminuição na rigidez acompanhada por um aumento em sua concentração (alteração significante na rigidez por aumento de 10 vezes na concentração de ACH, 10-6 vs Controle, p < 0,05; 10-5 vs 10-6, p < 0,05), que foi revertida pelo desnudamento endotelial e Atrop (p &gt; 0,05 vs Controle). CONCLUSÃO: Esses achados ressaltam o papel do sistema nervoso autônomo na regulação das propriedades mecânicas das cúspides de válvula mitral porcina, o que reforça a importância do estado nervoso autônomo no funcionamento ideal da válvula.

MicroRNAs (miRNAs) são um grupo recém-descoberto de pequenos RNAs, não codificantes, que representam uma das áreas mais estimulantes da ciência médica moderna por modularem uma enorme e complexa rede regulatória da expressão dos genes.Recentemente, linhas de evidências sugerem que os miRNAs desempenham um papel crucial na patogênese da insuficiência cardíaca. Alguns miRNAs altamente expressos no coração como o miR-1, miR-133 e miR-208 estão fortemente associados ao desenvolvimento da hipertrofia cardíaca, enquanto o exato papel de miR-21 no sistema cardiovascular permanece controverso. Os níveis séricos de miRNAs circulantes como o miR-423-5p estão sendo avaliados como potenciais biomarcadores no diagnóstico e prognóstico da insuficiência cardíaca.Por outro lado, a manipulação dos níveis de miRNAs usando técnicas como os mimetizadores de miRNAs (miRmimics) e miRNAs antagônicos(antagomiRs) está tornando cada vez mais evidente o enorme potencial dos miRNAs como promissoras estratégias terapêutica sna insuficiência cardíaca.