Risk factors for stroke after coronary artery bypass grafting.

BACKGROUND: Stroke is a feared complication after coronary artery bypass grafting surgery (CABG), with an incidence between 1.3 and 4.3%. OBJECTIVE: To identify predictive factors for stroke after CABG in the modern era of cardiac surgery. METHODS: This is a case-control study of 65 pairs of patients, paired by sex, age (+ 3 years) and date of CABG (+ 3 months). The cases were patients submitted to elective CABG with extracorporeal circulation (ECC) that presented stroke (defined as clinical neurological deficit up to 24 hours post-operatively and confirmed by imaging assessment) and the controls were those individuals submitted to elective CABG with ECC, but without stroke. RESULTS: The univariate analysis demonstrated that the number of revascularized vessels was associated with the occurrence of stroke after the CABG (3 +/- 0.8 vs. 2.76 +/- 0.8, p = 0.01). The multivariate analysis by conditional logistic regression showed that systemic arterial hypertension (SAH) [OR: 6.1 (1.5 - 24), p = 0.009] and diabetes mellitus (DM) [OR: 3.1 (1.09 - 11), p= 0.03] were the determinants of the highest chance of stroke after CABG, whereas acute myocardial infarction (AMI) > 1 month, was the determinant of the lowest chance of stroke [OR: 0.1 (0.03 - 0.36), p = 0.003]. CONCLUSION: Hypertension and diabetes mellitus were identified as independent predictors of stroke within the first 24 postoperative hours after CABG. In patients with such risk factors, it is possible that the knowledge of the causal mechanisms of brain injury represents a strategy capable of decreasing the incidence of stroke after CABG.

Fatores de risco para acidente vascular encefálico após cirurgia de revascularização do miocárdio / Risk factors for stroke after coronary artery bypass grafting

FUNDAMENTO: O acidente vascular encefálico (AVE) é uma temida complicação após cirurgia de revascularização do miocárdio (CRM), com incidência entre 1,3 por cento e 4,3 por cento. OBJETIVO: Identificar fatores preditores de AVE após CRM, na era moderna da cirurgia cardíaca. MÉTODOS: Este é um estudo caso-controle de 65 pares de pacientes, no qual o pareamento foi realizado por sexo, idade (+ 3 anos) e data da CRM (+ 3 meses). Os casos são pacientes submetidos à CRM eletiva com circulação extracorpórea (CEC), que apresentaram AVE (definido como déficit clínico neurológico até 24 horas de pós-operatório e confirmado por exame de imagem), e os controles aqueles submetidos à CRM eletiva com CEC sem AVE. RESULTADOS: A análise univariada revelou que o número de vasos revascularizados foi associado com a ocorrência de AVE após a CRM (3 ± 0,8 vs. 2,76 ± 0,8, p = 0,01). Na análise multivariada por regressão logística condicional, a hipertensão arterial sistêmica [OR: 6,1 (1,5 - 24), p = 0,009] e o diabete melito [OR: 3,1 (1,09 - 11), p= 0,03] foram determinantes de maior chance de AVE após CRM, e o infarto agudo do miocárdio > 1 mês determinante de menor chance [OR: 0,1 (0,03 - 0,36), p = 0,003]. CONCLUSÃO: Hipertensão e diabete melito foram identificados como preditores independentes de AVE nas primeiras 24 horas de pós-operatório de CRM. Em pacientes com tais fatores de risco, é possível que o conhecimento dos mecanismos causadores da injúria cerebral represente uma estratégia capaz de diminuir a incidência de AVE após CRM.

BACKGROUND: Stroke is a feared complication after coronary artery bypass grafting surgery (CABG), with an incidence between 1.3 and 4.3 percent. OBJECTIVE: To identify predictive factors for stroke after CABG in the modern era of cardiac surgery. METHODS: This is a case-control study of 65 pairs of patients, paired by sex, age (+ 3 years) and date of CABG (+ 3 months). The cases were patients submitted to elective CABG with extracorporeal circulation (ECC) that presented stroke (defined as clinical neurological deficit up to 24 hours post-operatively and confirmed by imaging assessment) and the controls were those individuals submitted to elective CABG with ECC, but without stroke. RESULTS: The univariate analysis demonstrated that the number of revascularized vessels was associated with the occurrence of stroke after the CABG (3 ± 0.8 vs. 2.76 ± 0.8, p = 0.01). The multivariate analysis by conditional logistic regression showed that systemic arterial hypertension (SAH) [OR: 6.1 (1.5 - 24), p = 0.009] and diabete mellitus (DM) [OR: 3.1 (1.09 - 11), p= 0.03] were the determinants of the highest chance of stroke after CABG, whereas acute myocardial infarction (AMI) > 1 month, was the determinant of the lowest chance of stroke [OR: 0.1 (0.03 - 0.36), p = 0.003]. CONCLUSION: Hypertension and diabete mellitus were identified as independent predictors of stroke within the first 24 postoperative hours after CABG. In patients with such risk factors, it is possible that the knowledge of the causal mechanisms of brain injury represents a strategy capable of decreasing the incidence of stroke after CABG.

Hybrid management for hypoplastic left heart syndrome : an experience from Brazil.

Initial surgical reconstruction for hypoplastic left heart syndrome (HLHS) is associated with satisfactory outcomes only in a few referral centers. Moreover, there is a persistent high-risk period for sudden death while the patient waits for the next surgical procedure. The development of a less invasive approach, so-called "hybrid," postponing a major surgery outside the neonatal period, might reduce the immediate and late surgical burden on these patients. This is a retrospective study of a contemporary series of patients with HLHS seen in two separate institutions. Patients with HLHS or its variants who underwent a "hybrid" management were included in the study. Data are described as the mean and standard deviation or absolute numbers and percentage, as appropriate. From January 2004 to June 2006, 15 patients (10 male; 5 +/- 3.8 days old and 2.9 +/- 0.5 kg) were included in the study. Ten had both mitral and aortic atresia; the ascending aorta and atrial septal defect measured 2.5 +/- 1.4 and 4.9 +/- 1.2 mm, respectively. There were six hospital survivors after stage I (mortality rate 60%). During the interstage period, all but one patient needed additional procedures. One patient died of bacterial meningitis 4 months after stage I. Four patients were submitted to stage II operation at 6.6 +/- 0.5 months of age and one is waiting for the operation. All four required early reinterventions for pulmonary artery stenosis. Only one was discharged home and was not yet submitted to the third stage. The hybrid approach for HLHS was associated with poor results in this early experience from two independent institutions in a developing country. This might have been related to infrastructure and technical problems, as well as our own learning curve. Institutions working under the same conditions might face similar problems during their initial experience.

New transcatheter techniques for creation or enlargement of atrial septal defects in infants with complex congenital heart disease.

OBJECTIVES: To describe a series of 8 consecutive infants (5 with transposition of the great arteries [TGA] and 3 with hypoplastic left heart syndrome [HLHS]) who underwent nonconventional septostomy techniques. BACKGROUND: For some complex congenital heart defects, an unrestrictive atrial septal defect (ASD) is essential to achieve an adequate cardiac output and/or systemic saturation. In some scenarios, the use of conventional septostomy techniques may be technically difficult, hazardous, and/or ineffective. METHODS: Use of transhepatic approach, cutting balloons, and radiofrequency perforation with stenting of the atrial septum. RESULTS: The size of the ASD and the oxygen saturation increased in all patients with no major complications. In those with TGA, the ASDs were considered to be of good size at the arterial switch operation. Two of the 3 patients with hybrid palliation for HLHS have developed some degree of obstruction within the interatrial stent over 2-3 months. At surgery, the stents were found to be secured within the septum with one showing significant fibrous ingrowth after uneventful removal. The other had some nonobstructive ingrowth. CONCLUSIONS: Creation or enlargement of ASDs in infants using new nonconventional transcatheter techniques is feasible, safe, and effective, at least in the short-to-mid-term follow-up. Infants with TGA seem to benefit the most because the procedure results in satisfactory clinical stability for subsequent early surgical intervention. In infants with HLHS palliated by a hybrid approach, stent implantation to the atrial septum seems to buy enough time to bring them to the phase II safely despite progressive in-stent obstruction.

Infarto do miocárdio na endocardite infecciosa / Myocardial infarction in infective endocarditis

Two patients with chronic valvular heart disease and myocardial infarction were assisted at our hospital. Both of them were febrile and only one had petechiae associated with signs of valvular involvement led to suspicion of infective endocarditis. Although blood cultures were negative, echocardiographic, surgical and anatomopathologic findings were compatible with infective endocarditis. They required cardiac surgery during the acute phase of the infection because they presented progressive hemodynamic deterioration and no satisfactory response to antimicrobial regimen too. One patient died at late follow-up (two weeks after the hospital discharge) and the other survived, but with signs of cardiac failure (class II of NYHA) one year after the procedure