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AimsThe integration of smartwatches into postoperative cardiac care transforms patient monitoring, systematically tracking vital signs and delivering real-time data to a centralized platform. This study focuses on developing a platform for seamless integration, assessing reliability, and evaluating the impact on post-cardiac surgery. The goal is to establish a robust foundation for understanding the efficacy and dependability of smartwatch-based telemonitoring, enhancing care for this population.Methods and resultsA total of 108 cardiac surgery patients were divided into telemonitoring (TLM) and control (CTL) groups. The TLM group utilized smartwatches for continuous monitoring of vital parameters (SpO2, HR, BP, ECG) over 30 ± 3 days. Statistical analyses (Pearson, Intraclass Correlation, Bland-Altman, Tost Test) were employed to compare smartwatch measurements with traditional methods. Significant correlations and concordance were observed, particularly in HR and BP measurements. Challenges were noted in SpO2 measurement. The ECG algorithm exhibited substantial agreement with cardiologists (Kappa: 0.794; p > 0.001), highlighting its reliability. The telemonitoring platform played a crucial role in early detection of clinical changes, including prompt Emergency Department (ED) visits, contributing significantly to preventing outcomes that could lead to mortality, such as asymptomatic Atrioventricular block. Positive patient responses affirmed technological efficacy, especially in identifying cardiac arrhythmias like atrial fibrillation.ConclusionThe integration of smartwatches into remote telemonitoring for postoperative cardiac care demonstrates substantial potential, improving monitoring and early complication detection, thereby enhancing patient outcomes. The FAPO-X Study (Assisted Digital Telemonitoring with Wearables in Patients After Cardiovascular Surgery; NCT05966857) underscores the promising role of telemonitoring in postoperative cardiac care.

ABSTRACT Introduction: The aims of this study were to determine the incidence of severe and moderate primary graft dysfunction (PGD) in our center, to identify, retrospectively, donors’ and recipients’ risk factors for PGD development, and to evaluate the impact of PGD within 30 days after heart transplantation. Methods: Donors’ and recipients’ medical records of 64 consecutive adult cardiac transplantations performed between January 2016 and June 2017 were reviewed. The International Society for Heart and Lung Transplantation (ISHLT) criteria were used to diagnose moderate and severe PGD. Associations of risk factors for combined moderate/severe PGD were assessed with appropriate statistical analyses. Results: Sixty-four patients underwent heart transplantation in this period. Twelve recipients (18.7%) developed severe or moderate PGD. Development of PGD was associated with previous donor cardiopulmonary resuscitation and a history of prior heart surgery in the recipient (P=0.01 and P=0.02, respectively). The 30-day in hospital mortality was similar in both PGD and non-PGD patients. Conclusion: The use of the ISHLT criteria for PGD is important to identify potential risk factor. The development of PGD did not affect short-term survival in our study. More studies should be done to better understand the pathophysiology of PGD.

ABSTRACT Introduction: Deep sternal wound infections (DSWI) are so serious and costly that hospital services continue to strive to control and prevent these outcomes. Microcosting is the more accurate approach in economic healthcare evaluation, but there are no studies in this field applying this method to compare DSWI after isolated coronary artery bypass grafting (CABG). This study aims to evaluate the incremental risk-adjusted costs of DSWI on isolated CABG. Methods: This is a retrospective, single-center observational cohort study with a propensity score matching for infected and non-infected patients to compare incremental risk-adjusted costs between groups. Data to homogeneity sample was obtained from a multicentric database, REPLICCAR II, and additional sources of information about costs were achieved with the electronic hospital system (Si3). Inflation variation and dollar quotation in the study period were corrected using the General Market Price Index. Groups were compared using analysis of variance, and multiple linear regression was performed to evaluate the cost drivers related to the event. Results: As expected, infections were costly; deep infection increased the costs by 152% and mediastinitis by 188%. Groups differed among hospital stay, exams, medications, and multidisciplinary labor, and hospital stay costs were the most critical cost driver. Conclusion: In summary, our results demonstrate the incremental costs of a detailed microcosting evaluation of infections on CABG patients in São Paulo, Brazil. Hospital stay was an important cost driver identified, demonstrating the importance of evaluating patients’ characteristics and managing risks for a faster, safer, and more effective discharge.

Abstract Introduction: The Technical Performance Score (TPS) was developed and subsequently refined at the Boston Children's Hospital. Our objective was to translate and validate its application in a developing country. Methods: The score was translated into the Portuguese language and approved by the TPS authors. Subsequently, we studied 1,030 surgeries from June 2018 to October 2020. TPS could not be assigned in 58 surgeries, and these were excluded. Surgical risk score was evaluated using Risk Adjustment in Congenital Heart Surgery (or RACHS-1). The impact of TPS on outcomes was studied using multivariable linear and logistic regression adjusting for important perioperative covariates. Results: Median age and weight were 2.2 (interquartile range [IQR] = 0.5-13) years and 10.8 (IQR = 5.6-40) kilograms, respectively. In-hospital mortality was 6.58% (n=64), and postoperative complications occurred in 19.7% (n=192) of the cases. TPS was categorized as 1 in 359 cases (37%), 2 in 464 (47.7%), and 3 in 149 (15.3%). Multivariable analysis identified TPS class 3 as a predictor of longer hospital stay (coefficient: 6.6; standard error: 2.2; P=0.003), higher number of complications (odds ratio [OR]: 1.84; 95% confidence interval [CI]: 1.1-3; P=0.01), and higher mortality (OR: 3.2; 95% CI: 1.4-7; P=0.004). Conclusion: TPS translated into the Portuguese language was validated and showed to be able to predict higher mortality, complication rate, and prolonged postoperative hospital stay in a high-volume Latin-American congenital heart surgery program. TPS is generalizable and can be used as an outcome assessment tool in resource diverse settings.

Abstract Introduction: Elevated neutrophil-lymphocyte ratio (NLR) has been associated with poorer outcomes in cyanotic patients undergoing single ventricle palliation. Little is known about this biomarker on patients with tetralogy of Fallot (TOF), the most common cyanotic congenital heart disease. Our objective is to study the impact of preoperative NLR on outcomes of TOF patients undergoing total repair. Methods: This retrospective study included 116 consecutive patients between January 2014 and December 2018. Preoperative NLR was measured from the last complete blood count test before the surgery. Using the cutoff value of 0.80, according to the receiver-operating characteristic (ROC) curve, the sample was divided into two groups (NLR < 0.80 and ≥ 0.80). The primary endpoint was hospital length of stay (LOS). Results: ROC curves showed that higher preoperative NLR was associated with longer hospital LOS, with an area under the curve of 0.801±0.040 (95% confidence interval 0.722 - 0.879; P

Abstract This study presents the method used for chest reconstruction and treatment of mediastinitis following cardiac surgery at the Heart Institute of the University of São Paulo Medical School. After infection control with antibiotic therapy associated with aggressive surgical debridement and negative pressure wound therapy, chest reconstruction is performed using flaps. The advantages and disadvantages of negative pressure wound therapy are discussed, as well as options for flap-based chest reconstruction according to the characteristics of the patient and sternum. Further studies are needed to provide evidence to support the decisions when facing this great challenge.

Abstract Introduction: To support the development of practices and guidelines that might help to reduce adverse events related to human factors, we aimed to study the response and perception by members of a cardiovascular surgery team of various error-driven or adverse features that might arise in the operating room (OR). Methods: A previously validated Disruptions in Surgery Index (DiSI) questionnaire was completed by individuals working together in a cardiovascular surgical unit. Results were submitted to reliability analysis by calculating the Cronbach’s alpha coefficient. Non-parametric Kruskal-Wallis test and Dunn’s post-test were performed to estimate differences in perceptions of adverse events or outcomes between the groups (surgeons, nurses, anesthesiologists, and technicians). P

Abstract Introduction: The coronavirus disease 2019 (COVID-19) has negatively impacted healthcare services worldwide. We hypothesized that the pandemic would affect our case mix and mortality. Our objective was to study this impact. Methods: We retrospectively studied all patients who underwent congenital heart surgeries from March 21st to August 21st in 2019 and 2020 using the institutional electronic database. We compared demographic data, preoperative and postoperative length of stay (LOS), risk stratification using Risk Adjustment for Congenital Heart Surgery (RACHS) classification and outcomes in both periods. Results: We observed a 66.7% decrease in our surgical volume (285 × 95 patients). Patients operated in the pre-pandemic period were older (911.3 [174.8 - 5953.8] days-old) compared to the pandemic period (275 days-old; P

Abstract Introduction: The coronavirus disease 2019 (COVID-19) pandemic brought an unprecedented lack of control of what was to come. The intent of this document is to provide a balance of how much was ceased to be done for patients with aortic disease, to assess the mortality of these patients, and to show what happened to those who became COVID-19 positive during their hospitalization. Methods: From April 1st to July 31st 2020, the worst period of the pandemic in São Paulo, Brazil, the Institute’s aortic surgical patients operated on were evaluated and those were compared with patients operated during the same period in 2019. Results: In 2019, 88 surgeries were performed; most of them were elective (66 [75%]), 10 were urgent, and 12 were emergency surgeries. In 2020, during the COVID-19 pandemic, we operated on only 31 patients, being 74.2% non-elective surgeries (P

Abstract Introduction: Anemia and blood transfusion are risk factors for morbidity/mortality in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The objective of this study is to analyze the association of blood transfusion with morbidity/mortality in patients undergoing coronary artery bypass grafting (CABG) under CPB in the state of São Paulo, Brazil. Methods: This is a retrospective analysis using the State of São Paulo Registry of Cardiovascular Surgery from November 2013 to August 2014. Blood transfusion was only considered during surgery or within six hours after surgery. Anemia was defined as hematocrit ≤ 37.5%. Patients < 18 years old were excluded. The sample was divided in four groups - Group I (851, no anemia), Group II (200, anemia without blood transfusion), Group III (181, no anemia and transfusion), and Group IV (258, anemia and transfusion). Results: A total of 1,490 patients were included; 639 (42.9%) were anemic and 439 (29.5%) underwent blood transfusion. Group II showed lower composite morbidity (odds ratio [OR] −0.05; confidence interval [CI] −0.27-0.17; P=0.81) than Group III (OR 0.41; CI 0.23-0.59; P=0.018) or Group IV (OR 0.54; CI 0.31-0.77; P=0.016). Group III was at greater risk of mortality (OR 0.73; CI 0.43-1.03; P=0.02) than Group II, which was exposed only to anemia (OR −0.13; CI −0.55-0.29; P=0.75), or Group IV (OR 0.29; CI −0.13-0.71; P=0.539). Conclusion: Anemia in patients undergoing CABG with CPB is bad, but blood transfusion can be worse, increasing at least 50% the risk for mortality and/or morbidity.

Abstract Introduction: The presence of mild to moderate pericardial effusion after cardiac surgery is common and oral medical therapy is usually able to treat it. Larger effusions are less frequent and surgical intervention is usually necessary. However, there are some rare cases of large effusions that are recurrent even after intervention and become challenging to treat. Methods: We describe the case of a patient submitted to coronary artery bypass grafting (CABG) without any intraoperative complications, who was regularly discharged from the hospital. She was referred to our emergency department twice after surgery with large pericardial effusion that was drained. Even after those two interventions and with adequate oral medication, the large effusion recurred. Results: During follow-up, the patient had her symptoms resolved, with no need for further hospital admission. Her echocardiograms after the last intervention showed no pericardial effusion. The present surgical technique demonstrated to be easy to perform, thus it should be considered as a treatment option for these rare cases of large and repetitive effusions, which do not respond to the traditional methods. Conclusions: In challenging cases of recurrent and large pericardial effusions, the pericardial-peritoneal window is an alternative surgical technique that brings clinical improvement and diminishes the risk of cardiac tamponade.

Abstract Since Barnard’s first heterotopic heart transplant in 1974, Copeland’s method has been the greatest contribution to heterotopic transplants but has the drawback of donor’s right ventricular atrophy. This new method proposes a modification in the anastomosis of the superior vena cava aiming to pre-serve donor’s right ventricular function by decompressing the pulmonary territory and reducing the pulmonary arterial pressure, as a biological ventricular assist device. Finally, a second intervention is proposed, where a “twist” is performed to place the donor’s heart in an orthotopic position after re-moval of the native heart. A pioneering research on this method received approval from the ethics committee of the Heart Institute of São Paulo. We believe that this method has the potential to im-prove quality of life in a selected group of patients.

Abstract Since the beginning of the coronavirus disease (COVID-19) pandemic, in March 2020, the number of people infected with COVID-19 worldwide increases continuously. Brazil is being followed with great concern in the international media, as it can, very soon, be the epicenter of the pandemic. Initial surgical data suggest that patients who acquire COVID-19 in the perioperative period are prone to a higher morbidity and mortality, however, evidence in cardiac surgery is still scarce. This article aims to aggregate to the growing evidence suggesting that perioperative infection with severe acute respiratory syndrome coronavirus 2 contributes to a more morbid evolution of the case.

Abstract Introduction: The objective of this study was to evaluate whether a surgery with the use of valved conduit is capable of leading to better immediate and late results than those obtained by the valve-sparing aortic root reconstruction technique. Methods: Between January 2002 and June 2016, 448 patients underwent aortic root reconstruction. These were divided into three groups according to the technique used: 319 (71.2%) patients received mechanical valved conduits, 49 (10.9%) received biological valved conduits, and 80 (17.9%) underwent the valve-sparing aortic root reconstruction technique. The results were examined by univariate and multivariate analyses of Cox proportional hazards models with multiple logistic regression. Results: The hospital mortality rate was 7.5%. The mortality rates were 8.2%, 12%, and 2.5% in the mechanical valved conduit, biological valved conduit, and aortic valve-sparing groups, respectively, with no significant difference between groups (P=0.1). Thromboembolic complications and reoperation-free survival were also similar (P=0.169 and P=0.688). However, valve-sparing aortic root replacement was superior in terms of long-term survival (P 70 years (P

Abstract Objective: To analyze the impact of vacuum-assisted venous drainage (VAVD) on arterial pump flow in a simulated pediatric cardiopulmonary bypass circuit utilizing a centrifugal pump (CP) with an external arterial filter. Methods: The simulation circuit consisted of a Quadrox-I Pediatric oxygenator, a Rotaflow CP (Maquet Cardiopulmonary AG, Rastatt, Germany), and a custom pediatric tubing set primed with Lactated Ringer's solution and packed red blood cells. Venous line pressure, reservoir pressure, and arterial flow were measured with VAVD turned off to record baseline values. Four other conditions were tested with progressively higher vacuum pressures (-20, -40, -60, and -80 mmHg) applied to the baseline cardiotomy pressure. An arterial filter was placed into the circuit and arterial flow was measured with the purge line in both open and closed positions. These trials were repeated at set arterial flow rates of 1500, 2000, and 2500 mL/min. Results: The use of progressively higher vacuum caused a reduction in effective arterial flow from 1490±0.00 to 590±0.00, from 2020±0.01 to 1220±0.00, and from 2490±0.0 to 1830±0.01 mL/min. Effective forward flow decreased with increased levels of VAVD. Conclusion: The use of VAVD reduces arterial flow when a CP is used as the main arterial pump. The reduction in the forward arterial flow increases as the vacuum level increases. The loss of forward flow is further reduced when the arterial filter purge line is kept in the recommended open position. An independent flow probe is essential to monitor pump flow during cardiopulmonary bypass.

Abstract We present an unusual case of a 67-year-old woman with an incidental finding of a cardiac mass on a chest computed tomography. Coronary angiotomography confirmed the diagnosis of right coronary artery aneurysm, with 5.7×5.7 cm. The patient underwent aneurysm resection and coronary bypass surgery, with subsequent histologic study suggestive of arteritis sequelae. Giant coronary artery aneurysms have a high risk of complications and aneurysm exclusion must be beneficial. This is a rare condition that can also be part of a systemic inflammatory disease.

Abstract Quadricuspid aortic valve (QAV) is a rare cardiac malformation. Many cases are incidentally diagnosed in aortic surgeries or autopsies and it usually appears as an isolated anomaly. The most widely classification used is the one by Hurwitz and Roberts[1], which divides 7 alphabetical subtypes based on the cusps size. The aim of this report is to describe three different anatomic presentations of this rare aortic valve anomaly.

Cardiopulmonary bypass causes an inflammatory response and consumption of coagulation factors, increasing the risk of bleeding and neurological and renal complications. Its use during lung transplantation may be due to pulmonary hypertension or associated cardiac defects or just for better exposure of the pulmonary hilum. We describe a simple technique, or open pericardium retraction, to improve hilar exposure by lifting the heart by upward retraction of the pericardial sac. This technique permits lung transplantation without cardiopulmonary bypass when bypass use is recommended only for better exposure.

BACKGROUND:Mortality prediction after cardiac procedures is an essential tool in clinical decision making. Although rheumatic cardiac disease remains a major cause of heart surgery in the world no previous study validated risk scores in a sample exclusively with this condition. OBJECTIVES:Develop a novel predictive model focused on mortality prediction among patients undergoing cardiac surgery secondary to rheumatic valve conditions. METHODS:We conducted prospective consecutive all-comers patients with rheumatic heart disease (RHD) referred for surgical treatment of valve disease between May 2010 and July of 2015. Risk scores for hospital mortality were calculated using the 2000 Bernstein-Parsonnet, EuroSCORE II, InsCor, AmblerSCORE, GuaragnaSCORE, and the New York SCORE. In addition, we developed the rheumatic heart valve surgery score (RheSCORE). RESULTS:A total of 2,919 RHD patients underwent heart valve surgery. After evaluating 13 different models, the top performing areas under the curve were achieved using Random Forest (0.982) and Neural Network (0.952). Most influential predictors across all models included left atrium size, high creatinine values, a tricuspid procedure, reoperation and pulmonary hypertension. Areas under the curve for previously developed scores were all below the performance for the RheSCORE model: 2000 Bernstein-Parsonnet (0.876), EuroSCORE II (0.857), InsCor (0.835), Ambler (0.831), Guaragna (0.816) and the New York score (0.834). A web application is presented where researchers and providers can calculate predicted mortality based on the RheSCORE. CONCLUSIONS:The RheSCORE model outperformed pre-existing scores in a sample of patients with rheumatic cardiac disease.

Abstract Background: Renal dysfunction is an independent predictor of morbidity and mortality in cardiac surgery. For a better assessment of renal function, calculation of creatinine clearance (CC) may be necessary. Objective: To objectively evaluate whether CC is a better risk predictor than serum creatinine (SC) in patients undergoing cardiac surgery. Methods: Analysis of 3,285 patients registered in a prospective, consecutive and mandatory manner in the Sao Paulo Registry of Cardiovascular Surgery (REPLICCAR) between November 2013 and January 2015. Values of SC, CC (Cockcroft-Gault) and EuroSCORE II were obtained. Association analysis of SC and CC with morbidity and mortality was performed by calibration and discrimination tests. Independent multivariate models with SC and CC were generated by multiple logistic regression to predict morbidity and mortality following cardiac surgery. Results: Despite the association between SC and mortality, it did not calibrate properly the risk groups. There was an association between CC and mortality with good calibration of risk groups. In mortality risk prediction, SC was uncalibrated with values > 1.35 mg /dL (p < 0.001). The ROC curve showed that CC is better than SC in predicting both morbidity and mortality risk. In the multivariate model without CC, SC was the only predictor of morbidity, whereas in the model without SC, CC was not only a mortality predictor, but also the only morbidity predictor. Conclusion: Compared with SC, CC is a better parameter of renal function in risk stratification of patients undergoing cardiac surgery.

Introdução: O modelo mais utilizado para predição de mortalidade em cirurgia cardíaca foi recentemente remodelado, mas dúvidas referentes à sua metodologia e desenvolvimento têm sido relatadas. Objetivo: O objetivo deste estudo foi avaliar o desempenho do EuroSCORE II na predição de mortalidade em pacientes submetidos a cirurgia de coronária e/ou valva na instituição. Métodos: Mil pacientes, operados consecutivamente de coronária e/ou valva, entre outubro de 2008 e julho de 2009, foram analisados. O desfecho de interesse foi mortalidade intra-hospitalar. A calibração foi realizada pela correlação entre mortalidade esperada e observada por meio do teste de Hosmer Lemeshow. A discriminação foi calculada pela área abaixo da curva ROC. O desempenho do EuroSCORE II foi comparado com os modelos EuroSCORE e InsCor (modelo local). Resultados: Na calibração, o teste de Hosmer Lemeshow foi inadequado para o EuroSCORE II (P=0,0003) e bom para os modelos EuroSCORE (P=0,593) e InsCor (P=0,184). No entanto, na discriminação, a área abaixo da curva ROC para o EuroSCORE II foi de 0,81 [IC 95% (0,76-0,85), P

INTRODUCTION: The descending branch of the lateral femoral circumflex artery is an option for coronary artery bypass grafting. OBJECTIVE: To evaluate the early patency and adaptation of lumen diameter using multidetector computed angiotomography. METHODS: Thirty-two patients were selected to undergo coronary artery bypass grafting using the descending branch of the lateral circumflex artery, the internal thoracic artery, and other grafts. Evaluations were carried out through high resolution computed tomography performed on the 7th and 90th postoperative day. Diameters of the descending branch of the lateral circumflex artery and the left internal thoracic artery were measured 3 cm before the distal anastomosis, in the middle portion, and 3 cm after the proximal anastomosis. Diameters were compared using paired t-test (P

FUNDAMENTO: Escores de risco apresentam dificuldades para obter o mesmo desempenho em diferentes populações. OBJETIVO: Criar um modelo simples e acurado para avaliação do risco nos pacientes operados de doença coronariana e/ou valvar no Instituto do Coração da Universidade de São Paulo (InCor-HCFMUSP). MÉTODOS: Entre 2007 e 2009, 3.000 pacientes foram operados consecutivamente de doença coronariana e/ou valvar no InCor-HCFMUSP. Desse registro, dados de 2/3 dos pacientes foram utilizados para desenvolvimento do modelo (técnica de bootstrap) e de 1/3 para validação interna do modelo. O desempenho do modelo (InsCor) foi comparado aos complexos 2000 Bernstein-Parsonnet (2000BP) e EuroSCORE (ES). RESULTADOS: Apenas 10 variáveis foram selecionadas: Idade > 70 anos; sexo feminino; cirurgia de revascularização coronariana + valva; infarto de miocárdio < 90 dias; reoperação; tratamento cirúrgico da valva aórtica; tratamento cirúrgico da valva tricúspide; creatinina < 2mg/dL; fração de ejeção < 30%; e eventos. O teste de Hosmer Lemeshow para o InsCor foi de 0,184, indicando uma excelente calibração. A área abaixo da curva ROC foi de 0,79 para o InsCor, 0,81 para o ES e 0,82 para o 2000BP, confirmando que os modelos são bons e similares na discriminação. CONCLUSÕES: O InsCor e o ES tiveram melhor desempenho que o 2000BP em todas as fases da validação; pórem o novo modelo, além de se identificar com os fatores de risco locais, é mais simples e objetivo para a predição de mortalidade nos pacientes operados de doença coronariana e/ou valvar no InCor-HCFMUSP.BACKGROUND: Risk scores show difficulties to attain the same performance in different populations. OBJECTIVE: To create a simple and accurate risk assessment model for patients submitted to surgery due to coronary and/or valvular disease at Instituto do Coração da Universidade de São Paulo (InCor-HCFMUSP). METHODS: Between 2007 and 2009, 3,000 patients were submitted to surgical procedure due to coronary artery and/or valvular disease at InCor-HCFMUSP. From this record, data of 2/3 of the patients were used for model development (bootstrap technique), and 1/3 for internal validation of the model. The performance of the model (InsCor) was compared to the 2000 Bernstein-Parsonnet (2000BP) and EuroSCORE (ES) complexes. RESULTS: Only 10 variables were selected: age > 70 years, female sex; coronary revascularization + valve, myocardial infarction < 90 days; reoperation; surgical treatment of aortic valve; surgical treatment of tricuspid valve; creatinine < 2mg/dL; ejection fraction < 30%, and events. The Hosmer Lemeshow test for the InsCor was 0.184, indicating excellent calibration. The area under the ROC curve was 0.79 for the InsCor, 0.81 for the ES and 0.82 for 2000BP, confirming that the models are good and have similar discrimination. CONCLUSIONS: The InsCor and ES performed better than 2000BP at all stages of validation, but the new model, in addition to showing identification with the local risk factors, is simpler and more objective for mortality prediction in patients undergoing surgery due to coronary and/or valvular disease at InCor-HCFMUSP.

OBJECTIVE: Experimental studies on lung preservation have always been performed using animal models. We present ex vivo lung perfusion as a new model for the study of lung preservation. Using human lungs instead of animal models may bring the results of experimental studies closer to what could be expected in clinical practice. METHOD: Brain-dead donors whose lungs had been declined by transplantation teams were used. The cases were randomized into two groups. In Group 1, Perfadex®was used for pulmonary preservation, and in Group 2, LPDnac, a solution manufactured in Brazil, was used. An ex vivo lung perfusion system was used, and the lungs were ventilated and perfused after 10 hours of cold ischemia. The extent of ischemic-reperfusion injury was measured using functional and histological parameters. RESULTS: After reperfusion, the mean oxygenation capacity was 405.3 mmHg in Group 1 and 406.0 mmHg in Group 2 (p = 0.98). The mean pulmonary vascular resistance values were 697.6 and 378.3 dyn·s·cm-5, respectively (p =0.035). The mean pulmonary compliance was 46.8 cm H20 in Group 1 and 49.3 ml/cm H20 in Group 2 (p =0.816). The mean wet/dry weight ratios were 2.06 and 2.02, respectively (p=0.87). The mean Lung Injury Scores for the biopsy performed after reperfusion were 4.37 and 4.37 in Groups 1 and 2, respectively (p = 1.0), and the apoptotic cell counts were 118.75/mm² and 137.50/mm², respectively (p=0.71). CONCLUSION: The locally produced preservation solution proved to be as good as Perfadex®. The clinical use of LPDnac may reduce costs in our centers. Therefore, it is important to develop new models to study lung preservation.

Este artigo tem por objetivo discutir aspectos relacionados ao conceito de qualidade de vida em Saúde. Este artigo apresenta também informações relacionadas aos instrumentos de qualidade de vida.This article aims to discuss aspects concerning Healthrelated to quality of life concepts. This paper presents some piece of information regarding the quality of life instruments.

FUNDAMENTO: A cirurgia cardiovascular vem passando por transformações em decorrência do avanço das técnicas percutâneas, do tratamento clínico e da prevenção primária. OBJETIVO: Avaliar a incidência e a mortalidade de operações cardiovasculares realizadas no Instituto do Coração (InCor-HCFMUSP). MÉTODOS: A PARtir do banco de dados do Instituto do Coração, foram analisadas as operações cardiovasculares realizadas entre 1984 e 2007, considerando-se a tendência dos principais procedimentos e as taxas de mortalidade. RESULTADOS: Em 24 anos, foram realizadas 71.305 operações cardiovasculares, com uma média anual de 2.971 procedimentos. O número de cirurgias de revascularização miocárdica, que na década de 1980 tinha uma média de 856/ano, atualmente está por volta de 1.106/ano. Os procedimentos das valvas cardíacas passaram de 400 para 597 operações/ano, com um crescimento de 36,7% em relação à década de 1990. As correções das cardiopatias congênitas também tiveram um aumento expressivo de 50,8% em relação à última década. A mortalidade global média, que no início era de 7,5%, atualmente é de 7,0%, sendo de 4,9% entre os procedimentos eletivos. Nas cirurgias de revascularização miocárdica, a mortalidade média atual é de 4,8% e entre as operações valvares é de 8,5%. Nas correções das cardiopatias congênitas corresponde a 5,3%. CONCLUSÃO: A cirurgia cardiovascular continua em ascensão. A revascularização miocárdica ainda é a operação mais realizada. Entretanto, o perfil dos procedimentos vem se alterando com o maior crescimento da abordagem sobre as valvas cardíacas e das cardiopatias congênitas. As taxas de mortalidade são superiores quando comparadas aos índices internacionais, refletindo a alta complexidade apresentada em um serviço terciário e de referência nacional.FUNDAMENTO: La cirugía cardiovascular ha estado pasando por transformaciones como consecuencia del avance de las técnicas percutáneas, del tratamiento clínico y de la prevención primaria. OBJETIVO: Evaluar la incidencia y la mortalidad de operaciones cardiovasculares realizadas en el Instituto do Coração (InCor-HCFMUSP). MÉTODOS: A partir del banco de datos del Instituto do Coração, se analizaron las operaciones cardiovasculares realizadas entre el 1984 y el 2007, y se consideró como la tendencia de los principales procedimientos las tasas de mortalidad. RESULTADOS: En 24 años, se llevaron a cabo 71.305 operaciones cardiovasculares, con un promedio anual de 2.971 procedimientos. El número de cirugía de revascularización miocárdica, que en la década de 1980 tenía un promedio de 856/año, actualmente está por volta de 1.106/año. Los procedimientos de las válvulas cardiacas pasaron de 400 para 597 operaciones/año, con un crecimiento de un 36,7% en relación con la década del 1990. Las correcciones de las cardiopatías congénitas también tuvieron un aumento expresivo de un 50,8% con relación a la última década. La mortalidad global promedio, que en el inicio era de un 7,5%, actualmente es del 7%, con un 4,9% entre los procedimientos electivos. En las cirugías de revascularización miocárdica, la mortalidad promedio actual es de un 4,8% y entre las operaciones valvulares es de un 8,5%. En las correcciones de las cardiopatías congénitas corresponde a un 5,3%. CONCLUSIÓN: La cirugía cardiovascular sigue en ascensión. La revascularización miocárdica todavía es la operación más realizada. Sin embargo, el perfil de los procedimientos se viene alterando con el mayor crecimiento del abordaje sobre las válvulas cardiacas y de las cardiopatías congénitas. Las tasas de mortalidad son superiores cuando comparadas a los índices internacionales, reflejando la alta complejidad presentada en un servicio terciario y de referencia nacional.BACKGROUND: Cardiovascular surgery has been undergoing transformations due to the advancement of percutaneous techniques, clinical treatment and primary prevention. OBJECTIVE: Evaluation of incidence and mortality of heart surgeries performed at the Instituto do Coração (InCor-HCFMUSP). METHODS: Using database from the Instituto do Coração, analysis was carried out on cardiovascular surgeries performed between 1984 and 2007, taking into consideration trends of main procedures and of mortality rates. RESULTS: In 24 years, 71,305 heart surgeries were performed, with an annual average of 2971 procedures. The number of coronary artery bypass graft surgeries, which in the 1980s had an average of 856/year, is currently around 1.106/year. Heart valve procedures increased from 400 to 597 surgeries per year, growing 36.7%, when compared to the 1990s. Repair of congenital heart disease also had a significant increase of 50.8% in relation to the last decade. Global mortality average rate, which at baseline was 7.5%, is currently at 7.0% and 4.9% among elective procedures. In coronary artery bypass graft surgery, current average mortality rate is 4.8% and 8.5% in valve surgery. Repair of congenital heart disease accounts for 5.3%. CONCLUSION: Cardiovascular surgery continues increasing. The coronary artery bypass graft is still the most commonly performed surgery. However, profile of procedures has been undergoing changes with the largest increase of approach to cardiac valves and congenital heart disease. Mortality rates are higher when compared to international rates, reflecting the high complexity presented in tertiary service of national reference.

OBJECTIVE: The purpose of this study was to compare spirometry data between patients who underwent single-lung or double-lung transplantation the first year after transplantation. INTRODUCTION: Lung transplantation, which was initially described as an experimental method in 1963, has become a therapeutic option for patients with advanced pulmonary diseases due to improvements in organ conservation, surgical technique, immunosuppressive therapy and treatment of post-operative infections. METHODS: We retrospectively reviewed the records of the 39 patients who received lung transplantation in our institution between August 2003 and August 2006. Twenty-nine patients survived one year post-transplantation, and all of them were followed. RESULTS: The increase in lung function in the double-lung transplant group was more substantial than that of the single-lung transplant group, exhibiting a statistical difference from the 1st month in both the forced expiratory volume in one second (FEV1) and the forced vital capacity (FVC) in comparison to the pre-transplant values (p

Em cães, a comprovação da real viabilidade da pneumonectomia direita, bem como, o estudo das complicações resultantes deste procedimento cirúrgico, tornam-se importantes diante da pequena quantidade de estudos na literatura específicos sobre pneumonectomia nesta espécie. O objetivo deste trabalho foi realizar um estudo experimental para avaliar a viabilidade da pneumonectomia direita em cães, através da avaliação paramétrica, hemogasométrica e radiográfica Foram utilizados 10 cães adultos, sadios, machos e fêmeas sem raça definida, pesando entre 13 e 32 kg. Todos os cães foram submetidos à intubação seletiva e toracotomia direita no 5º espaço intercostal, onde foi realizada a pneumonectomia. Foi realizado estudo temporal aos 7, 30 e 60 dias de pós-operatório, onde foi feito avaliação radiográfica, bem como, avaliação paramétrica e hemogasométrica (antes da indução anestésica, 1 hora após extubação, 48 horas, 7, 30 e 60 dias após o procedimento cirúrgico), con,siderados importantes para avaliar as possíveis complicações relacionadas com a técnica anestésica, cirúrgica, assim como, as complicações resultantes deste procedimento cirúrgico. Os resultados encontrados foram analisados estatisticamente. Apesar das alterações dos índices paramétricos e hemogasométricos, todos os cães apresentaram compensação das trocas gasosas após retirada de 57% do volume pulmonar. Na avaliação radiográfica, observamos que a expansão do pulmão remanescente causou deslocamento do coração e pulmão para hemitórax direito. Concluiu-se que a realização da pneumonectomia direita é plenamente viável no cão, permitindo evolução paramétrica, hemogasométrica e radiográfica satisfatória em todos os cães.In dogs, the evidence of viability of the right pneumonectomy, as well as the study of complications resulting from surgical procedure, are very important regarding the few specific studies made on the pneumonectomy in this animal species. The objective of this project was to carry out an experimental study to evaluate the viability of the right pneumonectomy in dogs through parametric, hemogasometric and radiographic evaluation. Ten adult healthy mongrel dogs, males and females, weighing 13-32 kg, were used. The dogs were submitted to selective intubation and right thoracotomy at the 5th intercostal space, where the pneumonectomy was performed. A radiografic evaluation was made on days 7, 30 and 60 after the surgery, as well as parametric and hemogasometric evaluations were done (before anesthetic induction, 1 hour after extubation, 48 hours and on days 7, 30 and 60 after the surgical procedure), considered important to evaluate possible complications due to the anesthetic and surgical techniques, as well as complications resulting from these procedures. The results were analyzed statistically. Besides the parametric and hemogasometric alterations, all dogs showed compensation for the gaseous exchanges after removing 57% of the pulmonary volume. Regarding the radiographic evaluation, it could be observed that the expansion of the remaining lung caused heart and lung displacement into the right hemithorax. It can be concluded that the right pneumonectomy is completely feasible in dogs, allowing a parametric, hemogasometric and radiographic satisfactory evaluation in all the animals.

Moléstias de natureza infecciosa, traumática ou neoplásica acometem o pulmão dos cães, constituindo-se a pneumonectomia como possibilidade de tratamento para algumas dessas afecções. Assim, diante da escassez de dados encontrados na literatura, objetivou-se avaliar e comparar parâmetros hemogasométricos, pressão parcial de oxigênio (PaO2), de dióxido de carbono (PaCO2), concentração do íon hidrogênio (pH) e do íon bicarbonato [HCO3-] no sangue arterial de cães adultos, antes e após pneumonectomia esquerda. Foram estudados 18 cães, machos e fêmeas de idades variadas, pesando entre 15 e 20 kg, distribuídos aleatoriamente em dois grupos de 9 animais cada. No Grupo A, o coto brôn-quico esquerdo dos cães foi suturado manualmente com fio de polipropileno 5-0, e no Grupo B, o coto brônquico esquerdo foi suturado mecanicamente com grampeador cirúrgico. Os dados foram colhidos em 6 momentos: antes da administração da medicação pré-anestésica (T0), 1 hora após a extubação do animal (T1EXT), 48 horas após a intervenção cirúrgica (T48h), 17 (T7d), 15 (T15d) e 36 dias (T36d) após intervenção cirúrgica. Em seguida, foi realizada a análise estatística (teste de normalidade de Anderson-Darling, Wilcox e teste U de Man-Whitney). Os valores de PaO2 do Grupo A no T1EXT (67,00±11,31) mostraram-se significativamente inferiores em relação ao T0 (99,44±18,34), fato este que não ocorreu no Grupo B: T1EXT (87,00±8,35) em relação ao T0 (87,00±7,55). Não houve diferença do pH entre os momentos nos cães do grupo A, porém no grupo B observou-se uma diminuição em T1EXT (7,3644±0,0353) em relação ao T0 (7,4189±0,0136), sem que os animais tenham desenvolvido acidose. Apesar dessas alterações, concluiu-se que os cães submetidos à pneumonectomia esquerda (sutura manual ou mecânica do coto brônquico esquerdo) não apresentaram tendência a desenvolver desequilíbrio ácido-básico no período em que foram avaliados.It is well known that different diseases of infectious, traumatic or neoplasic origin can occur in the lungs of dogs, and pneumonectomy technique may be an option for the treatment of some of these diseases. The objective was to evaluate hemogasometric parameters, oxygen partial pressure (PaO2), carbon dioxide partial pressure (PaCO2), hydrogen ion concentration (pH) and bicarbonate ion concentration on the pre- and post-operative moments of the left pneumonectomy. Eighteen adult mongrel dogs, males and females, were randomly distributed into two groups with 9 dogs each. In Group A, the left bronchial stump of the dogs was sutured manually with polypropylene 5-0, and, in Group B, the left bronchial stump of the dogs was sutured mechanically with a surgical stapler. The data were collected at 6 moments: Before the pre-anesthetic administration (T0), one hour after the extubation (T1EXT), 48 hours after the surgery (T48h), 7 days after the surgery (T7d), 15 days after the surgery (T15d), and 36 days after the surgery (T36d). The results were statistically analyzed. PaO2 values of Group A on T1EXT (67.00±11.31) were significantly lower in relation to T0 (99.4±18.34), a fact that did not happen in Group B: T1EXT (87.00±8.35) in regard to T0 (87.00±7.55). There was no difference on pH values in dogs of Group A, but in Group B was observed a decrease on T1EXT (7.3644±0.0353) in relation to T0 (7.4189±0.0136), although the animals did not develop acidosis. It was concluded that dogs submitted to left pneumonectomy (sutured manually or sutured mechanically of left bronchial) did not show immediate and mediate acid-basic instability during the study.

BACKGROUND: Pectus excavatum (PEX) is a depression of the sternum in relation to the costal cartilages. Clinical and objective measures for classifying the defect are rare and difficult to apply. The present study aimed to create an anthropometric index (AI) for PEX as a method for diagnosis and for preoperative and postoperative assessment by comparing it to the Haller index (HI) and to the lower vertebral index (LVI). METHODS: From December 2001 to February 2004, 2 groups of patients were studied at our institution: a) 30 patients with normal configuration of the thoracic cage, upon physical examination; b) 20 patients with PEX. The latter underwent surgery according to the Ravitch technique modified by Robicsek, and they were evaluated in the postoperative period. All patients were assessed by means of the AI (clinical), HI (tomographic), and LVI (radiographic) measures at the level of deepest deformity in the case of the PEX patients, and in the distal third of the sternum in the normal patients. The patients who had undergone surgery were once again measured between the 60th and the 80th postoperative days. RESULTS: There was a high correlation between the AI and the HI (80% P < .001) and between the AI and the LVI (79% P < .001). The accuracy of the 3 indices was similar, in that the following cut points were established: AI = 0.12, HI = 3.10, and LVI = 0.25. Upon analyzing the preoperative results, we verified that for the 3 indices, over 75% of the patients with pectus excavatum were above the cut points and were confirmed as having the defect. In the postoperative results, the value of the indices found below the cut point was considered within the normal standard, and this occurred in 100% for the AI, in over 50% for the HI, and in 50% for the LVI. CONCLUSIONS: The AI allowed adequate measurement of the defect, maintaining a) a high correlation with the HI and the LVI and a high accuracy, similar to the already acknowledged and published indices and b) an efficient comparison between the preoperative measurement and the postoperative results.INTRODUÇÃO: O pectus excavatum (PEX) caracteriza-se por depressão do esterno em relação ao gradeado costal. Medidas clínicas e objetivas para classificar esse defeito são raras e de difícil aplicação. Este trabalho tem por objetivo criar um índice antropométrico para PEX (IA) como método diagnóstico e de avaliação pré e pós-operatória, comparando-o ao índice de Haller (IH) e ao índice vertebral inferior (IV). MÉTODOS: No período de dezembro de 2001 a fevereiro de 2004 foram estudados dois grupos de pacientes no Serviço de Cirurgia Torácica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP): a) 30 pacientes com a caixa torácica com configuração normal ao exame físico; b) 20 pacientes portadores de PEX. Estes últimos foram operados pela técnica de Ravitch modificada por Robicsek e pelo Serviço de Cirurgia Torácica do HC-FMUSP, sendo estudados no pós-operatório. Todos os pacientes foram avaliados a partir do IA (medidas clínicas), do IH (medidas tomográficas) e do IV (medidas radiográficas) no nível da maior deformidade (MD), no caso dos PEX e no terço distal do esterno (TD), nos normais. Os pacientes operados foram novamente medidos entre o 60º e o 80º dia do pós-operatório. RESULTADOS: Houve elevada correlação entre o IA e o IH (80% p< 0,001) e entre o IA e o IV (79% p< 0,001). A acurácia dos três índices foi similar, sendo que se estabeleceram os seguintes pontos de corte: IA= 0,12; IH= 3,10; e IV= 0,25. Ao ser analisado o pré-operatório, foi verificado para os três índices, que mais de 75% dos portadores de PEX encontravam-se acima dos pontos de corte e foram confirmados como portadores do defeito. No pós-operatório os valores dos índices encontrados abaixo do ponto de corte foram considerados dentro do padrão normal e isso ocorreu em 100% para o IA, em mais de 50% para o IH, e em 50% para o IV. CONCLUSÕES: O IA permitiu mensurar adequadamente o defeito, mantendo: a) alta correlação com o IH e o IV e elevada acurácia, semelhante à desses índices já consagrados; b) eficaz comparação entre o pré e pós-operatório.

PURPOSE: To assay the effects of cyclosporin A on mucus secretion from goblet cells and on mucociliary transport in situ in rats. METHODS: Twenty-one male Wistar rats were assigned to 3 groups: control (n = 5), saline (n = 8), and cyclosporin A (n = 8). After 30 days of drug therapy, the rats were killed, and the lungs were removed from the thoracic cavity. Mucus samples were collected, and the transport rate was evaluated in vitro using a bullfrog palate model. Mucociliary transport was timed in situ by direct view of particles trapped on the mucus moving across the respiratory tract. Finally, the amount of stored mucins in the goblet cells of the respiratory epithelium was measured. RESULTS: Drug dosage measurements showed that cyclosporine blood concentration at the moment the rats were killed was 1246.57 ± 563.88 ng/mL. The in vitro transport rate was significantly lower (P < .001) in the cyclosporin A-treated group. Also, the in-situ mucociliary transport rate was decreased in all cyclosporin A-treated animals when compared to the saline group (P = .02). Mucus quantity measurements showed a significant decrease on both acid (P = .01) and neutral (P = .02) mucus production from goblet cells in the animals submitted to cyclosporin A therapy. The correlation between the percentage of total mucus and in vitro transport rate was positive and significant (r = 0.706, P < .001), as was the correlation between the percentage of total mucus and the in situ mucociliary transport rate (r = 0.688, P = .001). CONCLUSION: This study shows that cyclosporin A plays an important role in the impairment of the mucociliary clearance in rats by reducing both acid and neutral mucus production from goblet cells and causing a decrease in the mucociliary transport velocity.OBJETIVO: Avaliar os efeitos da ciclosporina A sobre a produção de muco das células caliciformes e sobre o transporte mucociliar in situ de ratos. MÉTODOS: Vinte e um ratos machos Wistar foram distribuídos em três grupos: Controle (n=5), Salina (n=8) e Ciclosporina A (n=8). Após 30 dias de terapia, os ratos foram mortos e os pulmões removidos da cavidade torácica. Amostras de muco foram coletadas e a medida da transportabilidade in vitro foi realizada através de um modelo de palato de rã. A velocidade do transporte mucociliar foi medida através da observação direta do deslocamento de partículas aderidas ao muco do epitélio ciliado brônquico. Por fim, efetuamos a quantificação das mucinas estocadas nas células caliciformes do epitélio respiratório. RESULTADOS: O valor médio da concentração sangüínea da ciclosporina no momento do sacrifício dos ratos foi de 1.246,57 ± 563,88 ng/ml. A transportabilidade do muco in vitro foi estatisticamente menor (p < 0.001) no grupo tratado com ciclosporina. Da mesma forma, houve um decréscimo na velocidade de transporte mucociliar nos animais imunossuprimidos em relação aos que receberam o placebo (p = 0.02). Houve diminuição significativa na quantidade de muco ácido (p = 0,01) e neutro (p = 0,02) produzidos pelas células caliciformes nos animais tratados com ciclosporina. A correlação entre a porcentagem de muco e a transportabilidade in vitro foi positiva e significante (r = 0.706, p < 0.001), assim como entre a porcentagem do muco e o transporte mucociliar in situ (r = 0.688, p = 0.001). CONCLUSÃO: O presente estudo mostra que a ciclosporina A age no sistema mucociliar causando um sério prejuízo através da redução na produção de muco ácido e neutro pelas células caliciformes como também a diminuição da velocidade de transporte mucociliar in situ e a transportabilidade do muco in vitro.

INTRODUÇÃO: Alterações estruturais da circulação pulmonar traduzem processo de remodelação vascular e têm relação provável com variações locais de fluxo e isquemia. OBJETIVO: Definir as alterações histológicas na circulação pulmonar após obstrução experimental da artéria pulmonar. Correlacioná-las com os padrões de redistribuição sangüínea e remodelação vascular. MÉTODO: Foram submetidos à toracotomia esquerda 48 ratos Wistar, alocados aleatoriamente em dois grupos, com ligadura da artéria pulmonar e controle, e sacrificados com 1, 7, 30 e 60 dias. Nos pulmões retirados avaliou-se presença de sinais de injúria no parênquima e mensurou-se diâmetro externo e espessura da parede das arteríolas de bronquíolos terminais, respiratórios e alveolares. Diâmetro interno e porcentagem de espessura da parede foram calculados. RESULTADOS: Só ocorreu infarto, necrose e hemorragia no pulmão isquêmico. No não isquêmico houve aumento mantido dos diâmetros externo e interno das arteríolas, com redução inicial da espessura no 1º dia e valores semelhantes aos do grupo controle no 60º dia. No pulmão isquêmico houve redução transitória nos diâmetros externo e interno das arteríolas de bronquíolos terminais e respiratórios, com aumento, inicial e transitório, na sua espessura. As arteríolas alveolares apresentaram aumento do diâmetro externo e espessura da parede, com redução do diâmetro interno, mantida e progressiva. CONCLUSÃO: Este modelo reproduz arteriopatia distal em pacientes com tromboembolismo pulmonar crônico. A resposta vascular no pulmão não isquêmico é compatível com padrão de remodelação de hiperfluxo; a no pulmão isquêmico com hipofluxo e isquemia. Nas arteríolas de bronquíolos terminais e respiratórios a resposta foi transitória. Nas alveolares foi progressiva e mantida, pela provável ocorrência tardia de hiperfluxo local.BACKGROUND: Structural alterations to the pulmonary circulation characterize the vascular remodeling process and are likely correlated with local variations in flow and ischemia. OBJECTIVE: To define the histological alterations to the pulmonary circulation seen after experimentally-induced ischemia of the pulmonary artery and to correlate those alterations with known patterns of blood redistribution and vascular remodeling. METHOD: Wistar rats (n = 48) were randomized into two groups with ligation of the pulmonary artery and without (controls) and were sacrificed on post-ischemia days 1, 7, 30 and 60. Lungs were removed and inspected for signs of parenchymal injury. External diameters, as well as wall thicknesses in the pulmonary, alveolar and bronchial end arterioles, were measured. Internal diameter and wall thickness percentage were calculated. RESULTS: Infarction, necrosis and hemorrhage occurred only in ischemic lungs. In nonischemic lungs, there was a sustained increase in the internal and external arteriolar diameters, with an initial reduction in wall thickness on day 1, and day-60 values were similar to those seen in controls. In ischemic lungs, there was a transitory reduction in the internal and external diameters of the pulmonary and bronchial end arterioles, together with an initial, equally transitory, increase in their wall thickness. The alveolar arterioles presented sustained and progressive increases in external diameter and wall thickness, with concomitant reductions in internal diameter. CONCLUSION: This model mimics distal arterial disease in patients with chronic pulmonary thromboembolism. The vascular response in nonischemic lungs was consistent with a pattern of flow remodeling, whereas that seen in ischemic lungs was more consistent with flow and ischemia. In the pulmonary and bronchial end arterioles, the response was transitory, in contrast to the sustained and progressive response seen in the alveolar arterioles, which was probably caused by delayed local flow.

OBJECTIVE: To report on our initial clinical experience of the utilization of a mechanical anastomotic device (MAD) to perform saphenous vein graft to aorta anastomosis. METHOD: Between June 2002 and May 2003, 17 patients, including 13 male, with a mean age of 64.4 ± 9.4 years, were selected for coronary artery bypass grafting using MAD. A total of 49 anastomoses, 19 arterial and 30 vein grafts, were performed with a mean of 2.9 ± 0.5 anastomoses per patient. Eleven (36.7%) vein-graft anastomoses were performed with conventional sutures and 19 (63.3%) using MAD. The clinical evolution, enzymatic and electrocardiographic alterations as well as an angiographic study were analyzed in the postoperative period. RESULTS: Of the 17 patients, the mechanical device was used on 16 (94.1%). Six (37.5%) patients were operated on under cardiopulmonary bypass with a mean time of 102.9 ± 16.9 minutes. The postoperative evolution was satisfactory in all patients. No patient presented with enzymatic, myocardial infarction or other ischemic electrocardiographic alterations in the immediate postoperative period. Early postoperative angiography was performed in 9 (52.9%) patients. The anastomoses of the left internal thoracic artery to left anterior descending artery were patent in all cases. Of the 15 saphenous vein grafts studied, 11 (73.3%) were performed using MAD, 9 (81.8%) of which were patent. All the 4 conventionally sutured vein anastomoses were patent. No hospital deaths occurred. In the late follow-up, 88.2% of the patients were free of cardiac-related events. CONCLUSIONS: MAD for vein graft-to-aorta anastomosis proved to be feasible, but a wider analysis of the benefits of its utilization regarding operative time, aggression to the patient, patency of the grafts and final cost are necessary.

OBJECTIVES: To evaluate the prognostic implications of myocardial creatine kinase and troponin I (cTn I) in blood samples from the coronary sinus of patients submitted to coronary artery bypass surgery both with and without ischemic preconditioning. METHODS: From October 1998 to May 1999, 35 patients with coronary artery disease who were submitted to coronary artery bypass surgery were studied. Samples containing creatine kinase and cTn I were obtained from the great cardiac vein during surgery at the onset of cardiopulmonary bypass, at the end of the first anastomosis, and at the end of cardiopulmonary bypass. In May 2002, 29 patients were evaluated in regards to the angina functional class, congestive heart failure, number of hospitalizations, myocardial infarction and death. There were 15 patients in the Preconditioned group and 14 in the Control group. Each group was subdivided into patients with and without cardiovascular symptoms. RESULTS: The Control and Preconditioned groups were not significantly different in relation to frequency of cardiovascular symptoms. There were progressive increases of the creatine kinase and cTn I levels at different Interval s of the study. The cTn I in the Preconditioned group was 1.21 ± 0.64 ng/mL and 3.19 ± 3.21 ng/mL in the Control group (pOBJETIVO: Avaliar a implicação prognóstica da dosagem da creatino-quinase miocárdica (CKMB) e Troponina I (cTn I) em amostras no seio coronariano, na evolução de pacientes submetidos a revascularização do miocárdio (RM), com e sem o pré-condicionamento isquêmico. MÉTODO: Entre outubro de 1998 e maio de 1999, 35 pacientes com insuficiência coronariana foram submetidos a RM foram estudados. No intra-operatório foram coletadas amostras do seio coronariano para dosagem de CKMB e cTn I. Os momentos de coleta foram: momento 1-no início da circulação extracorpórea (CEC), momento 2- após a primeira anastomose e momento 3- no final da CEC. Em maio de 2002, 29 pacientes foram avaliados quanto aos sintomas para classe funcional de angina e de insuficiência cardíaca congestiva, número de internações hospitalares, ocorrência de infarto agudo do miocárdio e morte. Os 29 pacientes estavam distribuídos em dois grupos: 15 no grupo pré-condicionamento e 14 no grupo controle. Cada grupo também foi subdividido em: pacientes com sintomas cardiovasculares e assintomáticos. RESULTADOS: Os grupos controle e pré-condicionado não apresentaram diferença estatística para a presença de sintomas cardiovasculares. Houve aumento progressivo nos valores de CKMB e cTn I nos diferentes momentos de coleta. A cTn I no grupo pré-condicionado foi de 1,21 +0,64 ng/ml e 3,19+ 3,21 ng/ml no grupo controle (p

OBJECTIVE: To assess, in a prospective way, the experience with video-assisted pericardioscopy obtained in patients with pericardial effusion of unclear etiology in the preoperative period. METHODS: From January 1998 to June 2000, 20 patients were operated upon with the aid of video-assisted pericardioscopy. On echocardiography, 17 of these patients had significant pericardial effusion, and 3 had moderate pericardial effusion. Video-assisted pericardioscopy was performed through a small incision of the Marfan type. RESULTS: The diagnosis of pericardial effusion was established as follows: idiopathic in 9 (45%) patients, neoplastic in 4 (20%), resulting from hypothyroidism in 3 (15%), tuberculous in 2 (10%), due to cholesterol in 1 (5%), and chylopericardial in 1 (5%). The biopsy was positive in 30% of the patients, and the etiology could not be defined in 45% of the patients. CONCLUSION: Video-assisted pericardioscopy proved to be a method with low morbidity and a high index of diagnostic positivity. A high percentage of pericardial effusions are caused by viral infections, which are not diagnosed through current methods, being, therefore, classified as idiopathic.

OBJETIVO: Determinar os fatores preditores de má evolução nos pacientes submetidos a revascularização do miocárdio (RM) na fase aguda do infarto do miocárdio (IAM). CASUÍSTICA E MÉTODOS: No período de março de 1998 a novembro de 1999, 49 pacientes foram submetidos a RM na fase aguda do IAM. Foram excluídos pacientes portadores de complicações mecânicas do IAM e submetidos a procedimentos associados a RM. Os pacientes foram divididos em: Grupo I - 29 casos que não apresentaram complicações decorrentes do IAM e Grupo II - 20 casos com uma ou mais complicações. As complicações consideradas foram: isquemia recorrente (18 pacientes), insuficiência cardíaca congestiva (11), choque cardiogênico (9), hipotensão (7), reinfarto (4), taquicardia ventricular sustentada (4) e fibrilação ventricular (3). Os grupos foram considerados comparáveis em relação às características pré-operatórias, exceto pela idade mais avançada no grupo II. No intuito de identificar os fatores determinantes de pior prognóstico pós-operatório, foram correlacionadas e analisadas as características dos pacientes e as complicações do IAM, estudados pelo teste de variância e análise multivariada. RESULTADOS: A mortalidade global foi de 6,12% (3 pacientes), sendo somente no grupo II. A análise multivariada identificou como fatores preditores de mortalidade hospitalar a hipotensão arterial (p=0,045), o choque cardiogênico (p=0,001) e a fibrilação ventricular (p=0,012). CONCLUSÕES: A RM na fase aguda do IAM é um procedimento seguro em pacientes sem complicações, sem mortalidade operatória. A presença de complicações pré-operatórias como choque cardiogênico, fibrilação ventricular e hipotensão são considerados fatores de mau prognóstico nesta condição.

Diretrizes tradicionalmente são desenvolvidas por médicos para aumentar a qualidade dos cuidados ao paciente, podendo fornecer aos seus usuários informação médica valiosa, aumentando a objetividade na decisão médica. Este artigo aborda aspectos determinantes de diretrizes de boa qualidade, sobretudo os métodos de elaboração, discutindo fatores envolvidos em sua aplicabilidade como custos implicações éticas e legais.Traditionally, guidelines are developed by physicians to improve quality of health care, to provide practitioners with valuable medical information and to improve objectivity in medical decision making. Determinant aspects of good guidelines, mainly, development methods, discussing, applicability factors such as costs, ethical and legal implications are approached in this article.

Objetivo: Este estudo testa a hipótese de que curtos períodos de isquemia podem aumentar a proteção obtida pelo pinçamento intermitente da aorta. Métodos: No grupo controle (18), a operação foi realizada com hipotermia sistêmica a 32 ºC com pinçamento intermitente da aorta e uso de circulação extracorpórea (CEC). No segundo grupo, denominado de pré-condicionamento (17), foram acrescidos dois pinçamentos de 3 minutos da aorta com intervalo de 2 minutos de reperfusão entre eles, previamente ao pinçamento intermitente da forma convencional. CK-MB, troponina I, adenosina e lactato foram obtidos do seio ocoronário no início da circulação extracorpórea (1), ao final da segunda anastomose (2) e ao final da CEC (3). Resultados: Os níveis de CK-MB e troponina I apresentaram uma leve tendência a aumentar ao final da CEC no grupo controle, enquanto os de adenosina e lactato não apresentaram diferença. Conclusão: Concluímos que o pré-condicionamento isquêmico não promoveu melhora significante na proteção miocárdica.

OBJETIVO: Avaliar a evolução hemodinâmica imediata na revascularização do miocárdio com pinçamento intermitente da aorta, acrescido ou não de um protocolo de pré-condicionamento. CASUÍSTICA E MÉTODOS: Trinta e cinco pacientes submetidos à revascularização do miocárdio foram randomizados em 2 grupos. No grupo controle (18), o procedimento foi realizado com pinçamento intermitente da aorta; no segundo grupo (17), denominado pré-condicionamento, foram acrescidos 2 pinçamentos curtos da aorta, previamente ao pinçamento intermitente convencional. Foram obtidos a pressão arterial média (PAm), a pressão capilar pulmonar (PCP), o índice cardíaco (IC) e o índice de trabalho sistólico do VE (ITSVE) antes da circulação extracorpórea (1); antes da sutura esternal (2); com 6h (3); 12h (4); 18h (5) e 24h de pós-operatório (6), além da fração de ejeção (FEVE) por ecocardiograma nos momentos 1 e 2. RESULTADOS: Não houve diferença estatística entre os grupos, havendo um aumento do IC e FEVE após a revascularização. Todos os pacientes tiveram boa evolução clínica. CONCLUSÃO: O comportamento hemodinâmico foi semelhante nos dois grupos de pacientes.

O grande atrativo da Operação de Senning como descrita originalmente é a utilização das paredes do próprio átrio do paciente para a realização dos túneis venosos. A atrioseptostomia por balão, utilizada atualmente na grande maioria dos casos de transposição das grandes artérias (TGA), cria grandes comunicações interatriais. Com isso, é necessário a utilização de enxertos biológicos ou sintéticos (Dacron, Teflon e pericárdio bovino) na septação do átrio esquerdo. Doze crianças consecutivas, com idades de 5 meses a 4 anos (média = 20 meses), foram submetidas à Operação de Senning com a utilização de tecidos do próprio paciente. O diagnóstico era de TGA em 9, TGA com comunicação interventricular (CIV) em 1, TGA com estenose pulmonar valvar discreta em 1, TGA com justaposição das aurículas em 1 caso e todas as crianças foram submetidas à atrioseptostomia com balão no período neonatal. Em 5 casos foi utilizada a aurícula esquerda aberta e invertida para a septação interatrial, 1 com inversão e, em 5, inversão com abertura da aurícula esquerda e uso do próprio pericárdio in situ para a realização do túnel das veias pulmonares, devido às reduzidas dimensões do átrio direito (1 caso de justaposição das aurículas). O tempo de internação variou de 10 a 24 dias (média 15 dias), sendo que o período de pós-operatório variou de 7 a 22 dias (média 12 dias). Não houve óbitos no período de internação hospitalar. O seguimento no pós-operatório foi de 8 a 34 meses (média 23 meses) e todos os pacientes apresentaram boa evolução clínica. O ecocardiograma realizado no período de internação e no seguimento pós-operatório não evidenciou sinais de obstrução ao fluxo nos túneis intracardíacos. O uso de tecidos do próprio paciente in situ, com potencial possibilidade de crescimento, resgata a vantagem principal da técnica originalmente descrita por Senning.

Nas operações minimamente invasivas o uso de cânula de menor calibre facilita a realização dos procedimentos cirúrgicos, mas, por outro lado, a drenagem venosa pode ser prejudicada. O emprego de vácuo no reservatório venoso do oxigenador é uma maneira simples e de baixo custo na correção do problema. O objetivo deste trabalho é apresentar nossa experiência com um dispositivo que permite além da utilização do vácuo, a sua regulagem conforme a necessidade específica do paciente e cânula empregada. Esse dispositivo consiste de uma válvula reguladora de vácuo, um filtro para a retenção de líquidos do ar aspirado e um manômetro eletrônico de pressão negativa. Os testes de bancada evidenciaram eficiência e segurança na aplicação da pressão negativa no oxigenador até 250 mmHg em temperaturas de até 40oC. O estudo clínico consistiu, inicialmente, na aplicação em 11 pacientes com esternotomia total. Posteriormente, foi utilizado em esternotomias parciais para tratamento da doença isolada da valva aórtica em 5 casos (L invertido) e 4 casos de atriosseptoplastia. Esse dispositivo permitiu a utilização de cânulas de diâmetros menores que as cânulas únicas convencionais, variando de 32 a 26 Fr, com a utilização de pressões negativas de 62,40 ± 11,69 mmHg com drenagem venosa satisfatória, sem evidências indiretas de hemólise. O dispositivo por nós idealizado permitiu a drenagem venosa assistida com a utilização de vácuo de forma controlada, segura e eficiente.

Visando um melhor resultado estético pode-se optar por técnicas minimamente invasivas na correção cirúrgica das cardiopatias congênitas. Entre os acessos utilizados realizamos a esternotomia parcial em 20 pacientes pediátricos para correção de comunicação interatrial (CIA). Após análise deste grupo de pacientes concluímos tratar-se de técnica cirúrgica segura, de fácil execução e com ótimo resultado estético. Não ocorreram complicações específicas relacionadas ao acesso cirúrgico.A better cosmetic effect may result from minimally invasive techniques available for the surgical correction of congenital cardiopathies. Amongst the possible accesses for the correction of an interatrial communication, we selected a partial sternotomy which we performed in 20 pediatric patients. When analyzed, this group of patients demonstrated that this approach is a safe and easy one, and that the cosmetic result is very satisfactory. No complications specifically related to the surgical access were observed.

Com o advento de novas técnicas cirúrgicas para o tratamento das arritmias cardíacas, em especial da fibrilação atrial, como a cirurgia de Cox, o conhecimento das características e do trajeto das artérias coronárias atriais assumiu grande importância. O objetivo deste trabalho é o estudo desta circulação e a definição dos padrões de irrigação atrial. Para tanto, utilizamos 30 corações a fresco de indivíduos sem cardiopatia prévia, cujas artérias coronárias e ramos foram visibilizados através de injeção de resina vinílica corada com tinta laca preta, seguida de cuidadosa dissecção. Após avaliação macroscópica das peças, não foram encontrados padrões de irrigação uniforme dos átrios. Porém, a artéria do nó sinoatrial (ANSA), quando analisada isoladamente, revelou não apenas padrões de origem, como também padrões de trajeto. Foram descritos 7 padrões de origem e trajeto da ANSA, considerando-se pontos de referências da estrutura anatômica dos átrios. Os padrões descritos, diferente dos encontrados por outros autores, são de fácil interpretação e de aplicabilidade direta em técnicas cirúrgicas que abordam os átrios.Since the appearance of new surgical techniques such as Cox surgery employed for the treatment of cardiac arrhythmia, especially for atrial fibrillation, the knowledge of coronary artery characteristics and courses has been of increasing importance. The aim of this study was the analysis of this circulation and definition of atrial irrigation patterns. Hence, the coronary arteries of 30 normal human hearts were injected with colored resin and carefully dissected. After macroscopic evaluation of the hearts, no atrial irrigation patterns were found. However, when only the sinus atrial node was analyzed, it showed origin patterns as well as course patterns. Seven origin and route patterns of this artery are described, considering the anatomical structure of the atria as reference points. The described patterns, differently from others found in the literature, are easy to understand and apply in surgical techniques which deal with the atria.

A surgical experimental investigation is being carried out in an attempt to provide a viable alternative to the current approaches to cardiac resection of the left ventricular myocardium in cases of cardiomyopathies with dilated ventricle. The experiments are based upon the presence of anatomicosurgical segments in the dog's heart similar to those existing in the atria and ventricles of humans. So far three mongrel dogs (weight 15 kg) were submitted to cardiac catheterism to evaluate the anatomy of the coronary arteries and their branches, the function and cavity of the left ventricle (LV). A lateral thoracotomy on the left side was performed to expose the heart. Cardiopulmonary bypass (CPB) of each animal was established through the right atrium and the femoral artery (4 mg/kg Heparin, at 32°C, intermittent aorta cross-clamping). The left marginal artery and veins were ligated, causing an area of acute myocardial infarction, showing well-defined sharp limits. Such an area was then resected and the left ventricle was reconstructed. The animals were weaned from CPB, one dog having remained in a stable condition during a 7-day period of observation. The second was sacrificed after 4-day period of observation and the third dog died four hours after CPB owing to an excessive reduction of the LV chamber related to an anatomical variation. Pre and post operation transthoracic echocardiograms were obtained after undergoing cardiac catheterism. The echocardiogram revealed discrete mitral insufficiency, reduction of the diameter of the left ventricle with approximation of the papillary muscles, a dysfunction and an impressive reduction of the cavity of the left ventricle. Peri-sutural areas of infarction were not observed. The orientation given by the anatomicosurgical segmentation of the coronary circulation is an important alternative to the present surgical treatment of cardiomyopathies with dilated ventricle.Uma investigação experimental cirúrgica está sendo realizada, numa tentativa de fornecer uma alternativa viável às atuais abordagens para ressecção cardíaca do ventrículo esquerdo em casos de cardiomiopatias com dilatação ventricular. Os experimentos são baseados na presença de segmentos anatomocirúrgicos em corações de cães, similares aos existentes nos átrios e ventrículos humanos. Três cães (peso 15kg) foram submetidos a cateterismo cardíaco, para avaliar a anatomia das artérias coronárias e de seus ramos, a função e cavidade do ventrículo esquerdo (VE). Toracotomia lateral esquerda foi realizada para expôr o coração. Circulação extracorpórea (CEC) de cada animal foi estabelecida através do átrio direito e da artéria femoral (4 mg/kg Heparina, 32°C, clampeamento intermitente da aorta). Artéria e veias marginais esquerdas foram ligadas, causando uma área de infarto agudo do miocárdio, exibindo limites de corte bem definidos. Desta forma, uma área foi ressecada e o ventrículo esquerdo foi reconstruído. Os animais foram desconectados da CEC. Um cão permaneceu em condição estável durante um período de 7 dias de observação. O segundo foi sacrificado após 4 dias de observação e o terceiro cão morreu 4 horas após CEC, devido a uma redução excessiva da câmara do VE relacionada a uma variação anatômica. Os ecocardiogramas transtorácicos pré e pós-operatórios foram obtidos após cateterismo cardíaco. O ecocardiograma revelou insuficiência mitral discreta, redução do diâmetro do ventrículo esquerdo com aproximação dos músculos papilares, uma disfunção e uma redução significativa da cavidade do ventrículo esquerdo. Áreas peri-suturais de infarto não foram observadas. A orientação dada pela segmentação anatomocirúrgica da circulação coronariana é uma alternativa importante ao tratamento cirúrgico atual de cardiomiopatias com ventrículo dilatado.