Surgical Treatment for a Super-Giant Right Coronary Artery Aneurysm Induced by Kawasaki Disease

Abstract A 32-year-old man diagnosed with Kawasaki disease at the age of three years presented with coronary artery aneurysm (CAA). The aneurysm increased in size, and the patient was referred to our hospital for surgery. Preoperative computed tomography scan showed a super-giant right CAA and giant left CAAs; surgery was performed. The super-giant right CAA was resected, and the ostium of the right coronary artery was closed; then, coronary artery bypass grafting was performed. The left CAAs were not treated surgically because the risk of rupture was low. Here, we describe the successful surgical treatment of a right super-giant CAA.

Paracentral acute middle maculopathy in patient with atherosclerosis and angioplasty with stents in the coronary artery / Maculopatia média aguda paracentral em paciente com arterioesclerose e angioplastia com stent na artéria coronária

ABSTRACT Sophisticated imaging systems have helped to redefine the clinical presentation of acute macular neuroretinopathy and have markedly enhanced diagnostic sensitivity. The proposed mechanism of paracentral acute middle maculopathy is related to ischemia at the level of the superficial and deep retinal capillary plexi. This is a case report of a patient who developed an acute macular neuroretinopathy after an uneventful angioplasty with stents in the coronary artery.

RESUMO Sistemas de imagem sofisticados ajudaram a redefinir a apresentação clínica da neurorretinopatia macular aguda e têm sensibilidade diagnóstica marcadamente aumentada. A maculopatia média aguda paracentral tem sido relacionada à isquemia ao nível dos plexos capilares superficial e profundo da retina. Este é um relato de caso de paciente que desenvolveu uma neurorretinopatia macular aguda após uma cirurgia de angioplastia com stents da artéria coronária sem complicações.

Design and manufacture of a coronary stent INC-1 and initial tests in experimental animal model / Diseño y fabricación del stent coronario INC-1y pruebas iniciales en animales de experimentación

Abstract In this paper, we describe our coronary stent (INC-1) design and development, the way that we found the specific characteristics needed for our device including biophysics aspects, design, finite element testing, manufacturing, and mechanic trials, we submitted and animal models experiences. The stent platform was cobalt-chromium L605 (Co-Cr), with struts thickness of 80 μm, balloon expandable. We placed the coronary stent INC-1 on a rabbit and dog models so we can evaluate efficacy and security of the device in relationship to its biomechanical properties including navigation capacity, traceability, symmetric expansion, and safety, as well as endothelial attachment, thrombogenicity, and lack of involvement of secondary branches in these models. We succeeded in efficacy and safety of the device after fluoroscopy-guided implant proving excellent capacity of release system, traceability, fluoroscopic visualization, symmetric expansion, and complete endothelial attach. Furthermore, we obtained a good post-implant balloon withdrawal, functional integrity, and no vascular complications. We observed adequate clinical evolution 3 weeks after the stent implantation.

Resumen En esta publicación se describen el diseño y el desarrollo de un stent coronario (INC-1), la forma en que se determinaron las características biofísicas deseadas, el diseño y las pruebas computacionales por elemento finito, su fabricación, así como las pruebas mecánicas a las que se sometió el prototipo y por último las primeras experiencias en modelos animales. La plataforma del stent desarrollado fue de cobalto y cromo L605 (Co-Cr), con struts de 80 μm de grosor, expandido por balón. La colocación del stent coronario INC-1 se realizó en un modelo de conejo y uno canino con el objetivo de evaluar el éxito técnico y de seguridad del stent en relación con las propiedades biomecánicas (capacidad de navegación, maniobrabilidad, expansión simétrica del stent) y de seguridad (fijación a la pared vascular y ausencia de compromiso de ramas secundarias y formación de trombos en el momento de la colocación del stent en el modelo animal). Se obtuvo éxito técnico y de seguridad del stent después del implante guiado por fluoroscopia, lo que demostró adecuada capacidad del sistema liberador, excelente maniobrabilidad, adecuada visualización fluoroscópica, expansión simétrica y fijación completa a la pared vascular, capacidad para retirar el balón desinflado después del implante, e integridad funcional y sin complicaciones vasculares. La evolución clínica fue favorable a tres semanas del seguimiento planeado.

Coronary involvement in behçet's disease: what are its risks and prognosis? (rare cases and literature review)

Abstract Objective: In our clinic, we aimed to investigate the effect of preoperative risk factors and postoperative complications on reoperation and mortality in cases with Behçet's disease which presents very rare coronary artery involvement. Methods: Thirteen patients with Behçet's Disease who had undergone coronary artery bypass grafting in our center between 2003 and 2015 were analyzed. We evaluated the clinical and laboratory findings, complications and mortality rates of our patients in light of the literature. Results: The mean age was 38.5 (30-55; 3 women). The mean time from onset of Behçet's disease to coronary artery disease was 4,7 (3-11) years. Fifty-four percent of the patients were asymptomatic. Coronary artery disease of these was exposed while peripheral vascular surgery was planned due to complications of Behçet's disease. Symptomatic patients presented angina pectoris (31%), acute coronary syndrome (8%) and arrhythmia (8%). In coronary pathology of patients, distal type obstruction (31%), aneurysm and pseudoaneurysm (31%), proximal segment thrombus (15%), chronic type stenosis and occlusions (31%) were present. Early mortality (15%) was due to acute myocardial infarction while the late mortality (15%) was due to cerebral and gastrointestinal bleeding. Reoperation was due to bleeding in one case on the 1st postoperative day and due to acute pulmonary embolism in another case in the 3rdpostoperative year. Conclusion: In Behçet's disease, coronary artery bypass grafting is a procedure with high mortality, especially in the acute period. The on-pump surgery technique in these cases can be safely performed for multiple bypasses and in patients above 40 years old.

Modelo ex-vivo com coração bovino: proposta para treinamento de dissecção microscópica e de microanastomoses vasculares / Ex vivo model with bovine heart: a proposal for training microscopic dissection and vascularmicroanastomoses

RESUMO O treinamento é um processo que exige paciência e constante prática. A execução de procedimentos microscópicos está presente no dia a dia de diversas especialidades cirúrgicas, mas infelizmente modelos experimentais não são de fácil de acesso. Propomos um modelo com coração bovino usado por residentes e jovens cirurgiões no treinamento de dissecção microscópica e microanastomoses. É descrita a montagem deste modelo, que pode ser realizado de maneira individual e com material acessível aos departamentos cirúrgicos. Nossa experiência na elaboração das peças, assim como, dicas para o processo são descritas no texto. O modelo com miocardio bovino pode ser reproduzido em qualquer centro que disponha de bancadas e instrumental cirúrgico. Dentre as vantagens estão o baixo custo, rápido preparo e grande disponibilidade do tecido utilizado. Consideramos o projeto útil no treinamento de residentes cirúrgicos e jovens cirurgiões.

ABSTRACT Training is a process that requires patience and constant practice. The execution of microscopic procedures is present in the day-to-day of several surgical specialties, but unfortunately experimental models are not easy to access in our environment. We propose a bovine heart model used by residents and young surgeons in the training of microscopic dissection and microanastomoses. It is described the assembly of this model, which can be performed individually and with accessible material to the surgical departments. Our experience in the preparation of the pieces, as well as tips for the process, are described in the text. The bovine myocardial model can be reproduced in any center with benches and surgical instruments. Low cost, fast preparation, and wide availability of the used tissue are among the advantages of this model. We consider the project useful in the training of surgical residents and young surgeons.

Síndrome coronariana aguda em indivíduos com revascularização cirúrgicaou percutânea prévia / Acute coronary syndrome in individuals with previous surgical or percutaneous revascularization

Aproximadamente 30% dos pacientes que se apresentam com quadro de síndrome coronariana aguda têm revascularização prévia do miocárdio. Os eventos coronarianos subsequentes à revascularização do miocárdio podem ocorrer por progressão da doença aterosclerótica no leito coronário nativo, evento relacionado ao stent (reestenose, trombose ou neoaterosclerose) ou evento relacionado à cirurgia de revascularização domiocárdio (degeneração ou oclusão de enxertos cirúrgicos). Esses pacientes que necessitamde um novo procedimento de revascularização têm perfil de alto risco, geralmente associado a doença renal crônica, diabetes mellitus, doença arterial periférica, além deelevada carga aterosclerótica no leito coronariano nativo, degeneração de enxertos de veia safena e reestenose de stents. Este cenário faz com que o segundo procedimento de revascularização tenha maior risco e maior complexidade. Neste artigo discutiremos as características clínicas e as possibilidades terapêuticas de pacientes com SCA e revascularização percutânea ou cirúrgica prévias.

Around 30% of patients who present acute coronary syndrome have undergone previous myocardial revascularization. Coronary events following myocardial revascularization can occur due to progression of atherosclerotic disease in the native coronary bed, an event related to the stent (restenosis, thrombosis or neoatherosclerosis) or to the myocardial revascularization surgery (degeneration or occlusion of surgical grafts). These patients who need a new revascularization procedure have a high-risk profile, generally associated with chronic kidney disease, diabetes mellitus, and peripheral arterial disease, as well as a high atherosclerotic burden in the native coronary bed, degeneration of grafts of the saphenous vein, and restenosis of stents. This scenario confers a higher risk and greater complexity on the second revascularization procedure. In this article, we discuss the clinical characteristics and therapeutic possibilities of patients with ACS and previous percutaneous or surgical revascularization.

Angioplastia primária de artéria circunflexa anômala após cirurgia de troca valvar mitral / Primary percutaneous coronary intervention of anomalous circumflex artery after mitral valve replacement

A origem anômala da artéria coronária circunflexa do seio de Valsalva direito é a anomalia coronariana mais frequente. Relata-se o caso de uma paciente com artéria circunflexa anômala originada da artéria coronária direita, submetida a cirurgia de troca valvar mitral, evoluindo com choque cardiogênico e oclusão aguda da artéria circunflexa. Foi necessária intervenção coronariana percutânea de emergência e implante de stent não farmacológico. A paciente evoluiu com melhora clínica, sem novas complicações cardíacas...

Anomalous origin of the circumflex coronary artery from the right sinus of Valsalva is the most frequent coronary anomaly. We report the case of a patient with anomalous circumflex artery originating from the right coronary artery, who underwent mitral valve replacement surgery evolving with cardiogenic shock and acute occlusion of the circumflex artery. Emergency percutaneous coronary intervention and bare-metal stent implantation were required. The patient improved clinically without any further cardiaccomplications...

Aterectomia rotacional multiarterial em lesão de tronco de coronária esquerda seguida de implante de stents / Multivessel rotational atherectomy in left main coronary artery lesion followed by stent implantation

Paciente com 82 anos, portadora de múltiplas comorbidades, com angina do peito apesar de terapia medicamentosa otimizada. Submetida à coronariografia, que evidenciou doença triarterial com envolvimento do tronco da coronária esquerda e intensa calcificação das artérias coronárias. A cirurgia de revascularização miocárdica foi contraindicada, sendo encaminhada para intervenção coronária percutânea, realizada em dois tempos, com intervalo de 15 meses. Primeiramente, a coronária esquerda foi abordada, realizando-se aterectomia rotacional no tronco da coronária esquerda, artérias descendente anterior e circunflexa, com implante de cinco stents farmacológicos com sucesso. Posteriormente, a coronária direita foi tratada com aterectomia rotacional e implante de quatro stents farmacológicos, também com sucesso

A 82-year-old patient with multiple comorbidities and angina, in spite of optimal drug therapy, was submitted to coronary angiography, which showed three-vessel disease with left main coronary artery involvement and severe coronary artery calcification. Coronary artery bypass grafting surgery was contraindicated and the patient was referred for percutaneous coronary intervention, which was carried out in two stages, with a 15-month interval between them. Firstly, the left coronary artery was treated and rotational atherectomy was performed in the left main coronary artery, left anterior descending and left circumflex arteries, with successful implantation of five drug-eluting stents. Subsequently, the right coronary artery was treated with rotational atherectomy, and four drug-eluting stents were also successfully implanted

Extensa dissecção coronária espontânea com boa evolução clínica mantida sob tratamento conservador / Extensive spontaneous coronary dissection with favorable evolution maintained under conservative treatment

A dissecção coronária espontânea é uma entidade rara e, por conseguinte, de etiologia, fisiopatologia e tratamento ainda não estabelecidos. Acomete, em geral, mulheres jovens, sem os clássicos fatores de risco cardiovascular, comumente ao longo do ciclo gravídico-puerperal. Vários fatores influenciam na estratégia de tratamento, como quadro clínico, status hemodinâmico, topografia da dissecção, número de artérias afetadas e fluxo coronário distal. Como no caso relatado, em pacientes estáveis, com dissecções bem delimitadas e, sobremodo, quando o fluxo coronário é reestabelecido, pode-se optar por uma abordagem conservadora, em razão da alta incidência de resolução espontânea e da baixa incidência de eventos adversos a longo prazo

Spontaneous coronary dissection is a rare entity and, therefore, its etiology, pathophysiology, and treatment are not yet established. It affects mainly young women without the classic cardiovascular risk factors, commonly during the pregnancy-childbirth cycle. Several factors influence the treatment strategy, such as clinical presentation, hemodynamic status, topography, number of affected arteries, and distal coronary flow. As in the reported case, in stable patients with well-defined dissections and mainly when the coronary flow has been re-established, one can choose a conservative approach, due to the high incidence of spontaneous resolution and low incidence of long-term adverse events

Fatores predisponentes para revascularização angiográfica incompleta em pacientes com intervenção coronária percutânea de múltiplos vasos / Predisposing factors for incomplete angiographic revascularization in patients with multivessel percutaneous coronary intervention

A revascularização miocárdica anatômica completa está associada a um melhor controle dossintomas anginosos e a menores índices de eventos cardíacos maiores tardios. No entanto, em substancial número de pacientes tratados por meio de intervenção coronária percutânea (ICP), não logramos sua obtenção. Assim, nosso objetivo foi avaliar os fatores associados à revascularização miocárdica incompleta (RMI) em casos de ICP multiarterial. Métodos: Estudo de coorte envolvendo 1.049 pacientes revascularizados de forma prospectiva e consecutivapor meio de ICP com tratamento de dois ou mais vasos, entre 2012 e 2014, divididos em dois grupos: RMI(n = 324; 30,9%) e revascularização miocárdica completa (n = 725; 69,1%).Resultados: A RMI foi significativamente associada a faixa etária maior (66,5 anos vs. 64,1 anos; p = 0,003),hipertensão arterial (92,2% vs. 86,0%; p = 0,006), insuficiência renal crônica (36.4% vs. 26.0%; p < 0,001), síndrome coronariana aguda (26,3% vs. 21,0%; p = 0,05), revascularização cirúrgica prévia (16,1% vs. 7,1%;p = 0,001), lesões em enxertos venosos (3,4% vs. 1,0%; p < 0,001) e oclusões crônicas (3,3% vs. 1,4%; p =0,005), bem como a menor acesso a stents farmacológicos (57,8% vs. 64,8%; p = 0,002). Os resultados clínicos hospitalares não diferiram entre os grupos.Conclusões: A RMI ocorreu em cerca de um terço dos casos tratados, tendo sido observada associação significativa, com um perfil clínico de maior risco e com intervenções em lesões alvo comumente associadas com menor sucesso do procedimento. O grau de revascularização não gerou impacto nosresultados clínicos da fase hospitalar...

Complete anatomical myocardial revascularization is associated with better anginacontrol and lower rates of cardiac events. However, in a significant number of patients treated bypercutaneous coronary intervention (PCI), complete revascularization is not achieved. Thus, the aimof this study was to evaluate factors associated with incomplete myocardial revascularization (IMR) in multivessel PCI patients. Methods: This was a cohort study involving 1,049 prospectively and consecutively revascularized patients through PCI with treatment of two or more vessels, between 2012 and 2014, divided into two groups: IMR(n = 324; 30.9%) and complete myocardial revascularization (n = 725; 69.1%). Results: IMR was significantly associated with older age (66.5 years vs. 64.1 years; p = 0.003), arterial hypertension (92.2% vs. 86.0%; p = 0.006), chronic renal failure (36.4 % vs. 26.0%; p < 0.001), acute coronary syndrome (26.3% vs. 21.0%; p = 0.05), previous surgical revascularization (16.1% vs. 7.1 %; p = 0.001), saphenous venous graft lesions (3.4% vs. 1.0%, p < 0.001), and chronic occlusions (3.3% vs. 1.4%, p = 0.005), as well as lower access to drug-eluting stents (57.8% vs. 64.8%; p = 0.002). In-hospital clinical outcomes did not differ between the groups. Conclusions: IMR occurred in approximately one-third of treated cases, and a significant association was observed with a higher-risk clinical profile and with target lesion interventions commonly associated with lower procedure success. The degree of revascularization had no impact on in-hospital clinical outcomes...

Effects of conventional vs high-dose rocuronium on the QTc interval during anesthesia induction and intubation in patients undergoing coronary artery surgery: a randomized, double-blind, parallel trial

Myocardial ischemia, as well as the induction agents used in anesthesia, may cause corrected QT interval (QTc) prolongation. The objective of this randomized, double-blind trial was to determine the effects of high- vs conventional-dose bolus rocuronium on QTc duration and the incidence of dysrhythmias following anesthesia induction and intubation. Fifty patients about to undergo coronary artery surgery were randomly allocated to receive conventional-dose (0.6 mg/kg, group C, n=25) or high-dose (1.2 mg/kg, group H, n=25) rocuronium after induction with etomidate and fentanyl. QTc, heart rate, and mean arterial pressure were recorded before induction (T0), after induction (T1), after rocuronium (just before laryngoscopy; T2), 2 min after intubation (T3), and 5 min after intubation (T4). The occurrence of dysrhythmias was recorded. In both groups, QTc was significantly longer at T3 than at baseline [475 vs 429 ms in group C (P=0.001), and 459 vs 434 ms in group H (P=0.005)]. The incidence of dysrhythmias in group C (28%) and in group H (24%) was similar. The QTc after high-dose rocuronium was not significantly longer than after conventional-dose rocuronium in patients about to undergo coronary artery surgery who were induced with etomidate and fentanyl. In both groups, compared with baseline, QTc was most prolonged at 2 min after intubation, suggesting that QTc prolongation may be due to the nociceptive stimulus of intubation.

Intervenção coronária percutânea primária em paciente com artéria descendente anterior dupla / Primary percutaneous coronary intervention in patients with dual left anterior descending artery

A anatomia das artérias coronárias é bem conhecida, mas há grande variedade em sua origem e distribuição.A artéria descendente anterior dupla é definida como a presença de duas artérias descendentes anterioresdentro do sulco interventricular anterior, sendo classificada em quatro tipos. É uma variante anatômicabenigna que deve ser reconhecida, especialmente antes de procedimentos intervencionistas. Relatamoso caso de um paciente com artéria descendente anterior dupla tipo I, com apresentação clínica de infartoagudo do miocárdio com supradesnivelamento de segmento ST em parede anterior, encaminhado para arealização de intervenção coronária percutânea primária...

The anatomy of the coronary arteries is well known, but there is a wide variety in their origin and distribution. The dual left anterior descending artery is defined as the presence of two left anteriordescending arteries within the anterior interventricular sulcus and is classified into four types. It is a benign anatomical variant that should be recognized, especially before interventional procedures. We report a patient with type I dual left anterior descending artery, with acute anterior wall ST elevation myocardial infarction, referred for primary percutaneous coronary intervention...

Resultados angiográficos e do seguimento clínico de 5 Anos após implante de stents farmacológicos com revestimento biodegradável em pacientes com alto risco de reestenose: análise de subgrupo do estudo randomizado PAINT / Angiographic and 5-year clinical follow-up after implantation of drug-eluting stents with biodegradable coating in patients at high risk of restenosis: the PAINT randomized trial

Introdução: Polímeros biodegradáveis foram desenvolvidos para reduzir a reação de hipersensibilidade associada aos polímeros duráveis dos stents farmacológicos de primeira geração, mantendo sua eficácia antiproliferativa e aumentado sua segurança. Avaliamos os resultados angiográficos de 9 meses e os resultados clínicos de longo prazo dos stents farmacológicos com polímeros biodegradáveis em pacientes com alto risco de reestenose. Métodos: Pacientes com diâmetro de referência ≤ 2,5 mm, extensão da lesão ≥ 15 mm, diabetes, ou uma combinação dessas características foram selecionados da população do estudo PAINT. Esses pacientes foram previamente randomizados e alocados para intervenção coronária percutânea recebendo os stents farmacológicos com polímeros biodegradáveis com sirolimus ou com paclitaxel ou stents metálicos, na razão 2:2:1. Resultados: Cento e setenta e oito pacientes foram tratados com stents farmacológicos com polímeros biodegradáveis (n = 142) ou stents metálicos (n = 36). No acompanhamento angiográfico de 9 meses, os primeiros mostraram menor perda tardia (0,40 ± 0,42 mm vs. 0,90 ± 0,47 mm; p < 0,01) e reestenose binária (7,4% vs. 25%; p < 0,01). No acompanhamento clínico de 5 anos, o grupo com stents farmacológicos com polímeros biodegradáveis mostrou menores taxas do desfecho combinado de morte cardíaca, infarto do miocárdio e revascularização do vaso-alvo (16,2% vs. 38,0%; p = 0,03), principalmente devido à redução da revascularização do vaso-alvo (9,9% vs. 36,1%; p < 0,01). Morte total, morte cardíaca e infarto do miocárdio não foram diferentes entre os grupos. A trombose do stent, provável ou definitiva, ocorreu em 2,8% vs. 0% (p = 0,30). Conclusões: Os stents farmacológicos com polímeros biodegradáveis eluidores de paclitaxel ou sirolimus foram eficazes na redução de reestenose angiográfica aos 9 meses e na necessidade de reintervenção por reestenose clínica em 5 anos, sem aumentar o risco de...

Background: Biodegradable polymers were developed to reduce the hypersensitivity reaction associated to durable polymers found with the first generation drug-eluting stents, while maintaining antiproliferative efficacy and increasing safety. This study evaluated the 9-month angiographic follow-up and long-term clinical outcomes of biodegradable polymer-coated drug-eluting stents compared with identical platform metallic stents in patients with high-risk for restenosis. Methods: Patients with a reference diameter ≤ 2.5 mm, lesion length ≥ 15 mm, diabetes, or a combination of these characteristics were selected from the population of the PAINT trial. These patients were previously randomized and allocated for percutaneous coronary intervention with either a sirolimus-eluting biodegradable polymer-coated stent, a paclitaxel-eluting biodegradable polymer-coated stent, or an identical metallic platform stent, at a ratio of 2:2:1. Results: One hundred and seventy-eight patients were treated with biodegradable polymer-coated drug-eluting stents (n = 142) or bare metal stents (n = 36). At the 9-month angiographic follow-up, biodegradable polymercoated drug-eluting stents had lower rates of late loss (0.40 ± 0.42 mm vs. 0.90 ± 0.47 mm; p < 0.01) and binary restenosis (7.4% vs. 25%; p <0.01). In the 5-year clinical follow-up, the group with biodegradable polymer-coated drug-eluting stents had lower rates of the composite endpoint of cardiac death, myocardial infarction, and target vessel revascularization (16.2% vs. 38.0%; p = 0.03), especially due to the reduction of target vessel revascularization (9.9% vs. 36.1%; (p 0.01). Total death, cardiac death and myocardial infarction were not different among groups. 0% (p = 0.30). Conclusions: Paclitaxel or sirolimus-eluting biodegradable polymer-coated stents were effective in reducing angiographic restenosis at 9 months and the need of reintervention for clinical restenosis in 5...

Autologous Transplantation of Bone Marrow Adult Stem Cells for the Treatment of Idiopathic Dilated Cardiomyopathy / Transplante Autólogo de Células-Tronco Adultas para Tratamento da Cardiomiopatia Dilatada Idiopática

Background: Morbimortality in patients with dilated idiopathic cardiomyopathy is high, even under optimal medical treatment. Autologous infusion of bone marrow adult stem cells has shown promising preliminary results in these patients. Objective: Determine the effectiveness of autologous transplantation of bone marrow adult stem cells on systolic and diastolic left ventricular function, and on the degree of mitral regurgitation in patients with dilated idiopathic cardiomyopathy in functional classes NYHA II and III. Methods: We administered 4,54 x 108 ± 0,89 x 108 bone marrow adult stem cells into the coronary arteries of 24 patients with dilated idiopathic cardiomyopathy in functional classes NYHA II and III. Changes in functional class, systolic and diastolic left ventricular function and degree of mitral regurgitation were assessed after 3 months, 6 months and 1 year. Results: During follow-up, six patients (25%) improved functional class and eight (33.3%) kept stable. Left ventricular ejection fraction improved 8.9%, 9.7% e 13.6%, after 3, 6 and 12 months (p = 0.024; 0.017 and 0.018), respectively. There were no significant changes neither in diastolic left ventricular function nor in mitral regurgitation degree. A combined cardiac resynchronization and implantable cardioversion defibrillation was implanted in two patients (8.3%). Four patients (16.6%) had sudden death and four patients died due to terminal cardiac failure. Average survival of these eight patients was 2.6 years. Conclusion: Intracoronary infusion of bone marrow adult stem cells was associated with an improvement or stabilization of functional class and an improvement in left ventricular ejection fraction, suggesting the efficacy of this intervention. There were no significant changes neither in left ventricular diastolic function nor in the degree of mitral regurgitation. .

Fundamento: Pacientes portadores de cardiomiopatia dilatada idiopática apresentam alta morbimortalidade, mesmo em tratamento clínico otimizado. A infusão autóloga de células-tronco adultas da medula óssea mostrou resultados clínicos preliminares promissores nesses pacientes. Objetivo: Determinar a eficácia do transplante autólogo de células-tronco adultas da medula óssea sobre as funções sistólica e diastólica, e o grau de insuficiência mitral em pacientes portadores de cardiomiopatia dilatada idiopática em classes funcionais NYHA II e III. Métodos: Infundiram-se 4,54 x 108 ± 0,89 x 108 células-tronco adultas da medula óssea nas artérias coronárias de 24 pacientes com cardiomiopatia dilatada idiopática em classes funcionais NYHA II e III. Após 3 meses, 6 meses e 1 ano, avaliaram-se as mudanças de classe funcional, das funções ventricular esquerda sistólica e diastólica, e do grau da insuficiência mitral. Resultados: No seguimento, seis (25%) pacientes melhoraram sua classe funcional e oito (33,3%) mantiveram sua classe funcional inicial. A fração de ejeção ventricular esquerda aumentou 8,9%, 9,7% e 13,6%, após 3 e 6 meses e 1 ano (p = 0,024; p = 0,017 e p = 0,018), respectivamente. A função diastólica ventricular esquerda e o grau de insuficiência mitral não demonstraram mudanças significativas. Dois pacientes (8,3%) receberam cardioversor e ressincronizador implantável. Ocorreram quatro (16,6%) mortes súbitas e quatro (16,6%) mortes por insuficiência cardíaca terminal. A sobrevida média desses oitos pacientes foi de 2,6 anos. Conclusão: A infusão intracoronariana de células-tronco adultas da medula óssea em pacientes com cardiomiopatia dilatada idiopática promoveu melhora ...

Comparison of two surgical techniques for creating an acute myocardial infarct in rats / Comparação de duas técnicas cirúrgicas para criar um infarto agudo do miocárdio em ratos

Objective: To perform a comparative assessment of two surgical techniques that are used creating an acute myocardial infarc by occluding the left anterior descending coronary artery in order to generate rats with a left ventricular ejection fraction of less than 40%. Methods: The study was completely randomized and comprised 89 halothane-anaesthetised rats, which were divided into three groups. The control group (SHAM) comprised fourteen rats, whose left anterior descending coronary artery was not occluded. Group 1 (G1): comprised by 35 endotracheally intubated and mechanically ventilated rats, whose left anterior descending coronary artery was occluded. Group 2 (G2): comprised 40 rats being manually ventilated using a nasal respirator whose left anterior descending coronary artery was occluded. Other differences between the two techniques include the method of performing the thoracotomy and removing the pericardium in order to expose the heart, and the use of different methods and suture types for closing the thorax. Seven days after surgery, the cardiac function of all surviving rats was determined by echocardiography. Results: No rats SHAM group had progressed to death or had left ventricular ejection fraction less than 40%. Nine of the 16 surviving G1 rats (56.3%) and six of the 20 surviving G2 rats (30%) had a left ventricular ejection fraction of less than 40%. Conclusion: The results indicate a tendency of the technique used in G1 to be better than in G2. This improvement is probably due to the greater duration of the open thorax, which reduces the pressure over time from the surgeon, allowing occlusion of left anterior descending coronary artery with higher accuracy. .

Objetivo: Realizar uma avaliação comparativa de duas técnicas cirúrgicas que são usadas para criar um infarto agudo do miocárdio pela oclusão da artéria coronária descendente anterior esquerda, a fim de gerar ratos com uma fração de ejeção ventricular esquerda inferior a 40%. Métodos: O estudo foi completamente randomizado e composto por 89 ratos anestesiados com halotano, que foram divididos dentro de três grupos. O grupo controle (SHAM) composto por 14 ratos, cuja artéria coronária descendente anterior esquerda não foi ocluída. Grupo 1 (G1): composto por 35 ratos intubados endotraquealmente e ventilados mecanicamente, cuja artéria coronária descendente anterior esquerda foi ocluída. Grupo 2 (G2): constituído por 40 ratos sendo ventilados manualmente utilizando um respirador nasal, cuja artéria coronária descendente anterior esquerda foi ocluída. Outras diferenças entre as duas técnicas incluem o método de realizar a toracotomia e remover o pericárdio, a fim de expor o coração, e o uso de diferentes métodos e tipos de sutura para fechar o tórax. Sete dias após a cirurgia, a função cardíaca de todos os ratos sobreviventes foi determinada por ecocardiografia. Resultados: Nenhum rato do grupo SHAM foi a óbito ou teve fração de ejeção ventricular esquerda menor que 40%. Nove dos 16 ratos sobreviventes do G1 (56,3%) e seis dos 20 ratos sobreviventes do G2 (30%) tiveram uma fração de ejeção ventricular esquerda inferior a 40%. Conclusão: Os resultados indicam uma tendência da técnica utilizada no G1 ser melhor do que a do G2. Esta melhora deve-se provavelmente à maior duração do tórax aberto, o que reduz a pressão de tempo sobre o cirurgião, permitindo uma oclusão da artéria coronária descendente anterior esquerda com maior acurácia. .

How to perform a coronary artery anastomosis in complete endoscopic fashion with robotic assistance / Como realizar anastomose coronariana totalmente endoscópica com assistência robótica

Current technology in robotic surgery allows us to perform myocardial revascularization procedures in a totally endoscopic fashion. We will describe the technique of choice for left internal mammary artery to left anterior descendent artery anastomosis with the use of cardiopulmonary bypass machine. The method is efficient and there is long term follow-up showing similar patency of the graft when compared to conventional methods (when performed through sternotomy).

A tecnologia atual em cirurgia robótica permite realizar-se procedimento de revascularização do miocárdio de modo totalmente endoscópico. Descreveremos aqui a técnica de escolha para anastomose de artéria mamaria interna esquerda em artéria coronariana descendente anterior com uso de circulação extracorpórea. O método e eficaz e já existe acompanhamento a longo prazo mostrando patência do enxerto semelhante ao método convencional por esternotomia.