Coronary artery bypass grafting in octogenarians: long-term results.

INTRODUCTION: As surgical revascularization is becoming more frequent in octogenarians, we reviewed our data to analyze the impact of coronary artery bypass grafting on short- and long-term morbidity and mortality. METHODS: We performed a retrospective study of 101 consecutive patients aged 80 years or older, who underwent coronary artery bypass in a single cardiac center between January 2002 and December 2007. The patients were divided into two groups: off-pump (64.4%) and on-pump (35.6%), depending on whether the surgery was performed with cardiopulmonary bypass. Early results and those up to 6 years after surgery were assessed. RESULTS: Baseline characteristics were similar between the groups and follow-up was 90% complete. There were no significant differences between groups in mean age (off-pump = 82.7 +/- 18 years vs. on-pump = 82.2 +/- 2.2 years; p = NS) or in logistic EuroSCORE (off-pump = 11.2 +/- 12.3 vs. on-pump = 8.5 +/- 5.1; p = NS). However, the off-pump group had less complete revascularization (off-pump = 43.1% vs. on-pump = 83.3%, p = 0.0001) and shorter mean hospital stay (off-pump = 9.3 +/- 5.4 days vs. on-pump = 11.5 +/- 7.3 days; p = 0.09). Both groups showed low hospital mortality (off-pump = 1.5% vs. on-pump = 2.8%, p = NS). At 6-year follow-up, off-pump surgery patients had the same late prognosis (total survival: off-pump = 80% vs. on-pump = 77.4%, p = NS; cardiovascular mortality: off-pump = 15% vs. on-pump = 16.1%, p = NS). CONCLUSION: In octogenarians coronary artery bypass grafting had excellent results. The off-pump technique, even though it can mean less complete revascularization, leads to shorter hospital stay and has the same 6-year results as in patients operated under cardiopulmonary bypass.

[Extra-anatomic aortic bypass for repair of aortic arch diseases in adults]. / A derivação extra-anatómica no tratamento cirúrgico, em adultos, de doenças do arco e istmo aórticos.

Surgical management of aortic arch diseases in the adult are challenging. Use of extra-anatomic conduits are a well established form of treatment. We report a retrospective study of four patients operated on in our institution between 2000 and 2006, using this technique. Two patients had a median sternotomy, one a left thoracotomy and one a right thoracotomy. There were no perioperative mortality and all patients were alive and doing well after a mean follow-up of 19 months. In this subset of patients, surgical treatment should be individualized. In our experience, extra-anatomic bypass is a valuable, effective and safe surgical option.

[Morbidity and mortality after heart transplanation]. / Morbilidade e mortalidade após transplantação cardíaca.

AIM: To evaluate the morbidity and mortality after heart transplantation in the patients treated at Santa Cruz Hospital. METHODS: Between February 1986 and December 2000, 113 patients underwent orthotopic heart transplantation at Santa Cruz Hospital. Actuarial survival rates at 12 months, 5 and 10 years after surgery were calculated (Kaplan-Meier analysis). We identified the causes of death and evaluated their relation with time after transplantation. Quality of life after surgery was assessed by functional status and employment status. Main causes of morbidity were identified: infection, rejection, tumors, allograft vasculopathy and side effects of chronic immunosuppression. RESULTS: Eighty-one patients (71.7%) were discharged alive after transplantation. In this group, actuarial survival was 82.2% at 12 months, 64.6% at 5 years and 45.3% at 10 years. Maximal survival was 14.7 years. In the immediate postoperative period, the main causes of mortality were procedure-related ou primary cardiac complications. Infection was the most common cause of death in the first 3 months after transplantation. Allograft vasculopathy was the main cause of death in the group of patients surviving the first year. Malignancy was another cause of late mortality. Clinically relevant non-fatal infections occurred in 35.4% of our patients. Overall, 108 mild rejection episodes were diagnosed in 55 patients, 82 moderate rejection episodes in 52 patients and 9 severe rejections in 8 patients. Eleven non-fatal tumors were detected in 10 patients. In the group of patients who have underwent at least one coronary arteriography, 34.6% present allograft vasculopathy. Clinically relevant complications of chronic immunosuppression were: hypertension in 50% patients; dyslipidemia in 31%; osteoporosis in 19.5%; diabetes mellitus in 15%; end-stage renal failure in 3.5%. CONCLUSION: Cardiac transplantation is a valid treatment for end-stage heart failure. Most patients surviving long-term are in good physical status and their quality of life is comparable to that of the general population.

[Atrial fibrillation surgery using intraoperative radiofrequency]. / Cirurgia da fibrilhação auricular utilizando radiofrequência intra-operatória.

Radiofrequency ablation is successful in most supraventricular tachyarrhythmias and the first results in percutaneous applications in atrial fibrillation have been published. At present, all the surgical techniques for the treatment of atrial fibrillation use extensive atrial incisions. A case report is presented of a 67 year old woman with chronic atrial fibrillation and rheumatic mitral and tricuspid valve disease. At surgery, pulmonary vein isolation was performed using a continuous linear ablation around the pulmonary veins, instead of using extensive atrial incisions. Concommitantly, a mitral valve replacement and tricuspid valve annuloplasty were performed. Five months after surgery, the patient remains with a stable sinus rhythm surgery and in functional class I (NYHA).

[Angina pectoris: the possibilities for surgical treatment. Recent progress]. / Angina de peito: possibilidades do tratamento cirúrgico. Progressos recentes.

After reviewing the history of coronary surgery the author describes the different grafts used in coronary artery bypass grafting and its results. They vary with coronary anatomy, left ventricle function, age, arterial hypertension, diabetes, etc. The rationale of the different surgical approaches are discussed, emphasizing the advantages of a close medical-surgical cooperation.

[Clinical and echocardiographic assessment of surgical replacement of the aortic valve with lung autograft: results after 2 years]. / Avaliacão clínca e ecocardiográfica da cirurgia de substituicão da válvula aórtica com auto-enxerto pulmonar: resultados aos 2 anos.

OBJECTIVE: The goal of this study was to evaluate the clinical and echocardiographic results of a cohort of patients subjected to aortic valve replacement with pulmonary autograft (Ross procedure). DESIGN: We studied prospectively with clinical and echocardiographic evaluation all patients subjected to this type of aortic valve surgery, before operation, intraoperatively, before hospital discharge and at the end of this study in September 1994 and we analysed the evolution of the results during the follow-up period. PATIENTS: 22 consecutive patients 12 men and 10 women mean age 48 +/- 14 years subjected to Ross operation between April 1992 and June 1994. METHODS: Patients were studied with transesophageal echocardiography intraoperatively and transthoracic echocardiography. Two-dimensional and M-mode evaluation, continuous and pulsed wave Doppler and color coded Doppler were performed, with assessment of the morphology and Doppler profile of both the autograft and the homograft in pulmonary position. RESULTS: No early or late mortality was registered, and apart two patients who were reoperated, all patients were asymptomatic in the last medical visit. There was no incidence of thromboembolic events even though no anticoagulation has been used. Aortic regurgitation was present in 14 patients, grade 1 in 11 patients and grade 2 in three. In the last echocardiogram performed the analysis of aortic flow, demonstrated absence of significant transvalvular gradient (maximal aortic gradient of 5.6 +/- 0.4 mmHg and mean aortic gradient of 1.8 +/- 0.08 mmHg). Pulmonary regurgitation was absent in nine patients, and present in 13, considered trivial in all cases. CONCLUSIONS: These data suggest that this type of surgery has a low operative risk, with absence of thromboembolic complications and excellent clinical and echocardiographic results.

[Anomalous insertion of mitral papillary muscles in obstructive hypertrophic myocardiopathy. Report of 2 cases]. / Insercão anómala de músculos papilares mitrais na miocardiopatia hipertrófica obstrutiva. A propósito de dois casos.

Hypertrophic obstructive cardiomyopathy is a pathologic entity whose features are complex and diverse. Its surgical treatment generally requires myectomy. When the left ventricle outflow gradient is also due to mitral valve abnormalities, mitral valve replacement has been considered as the treatment of choice for the relief of the obstruction. We report two cases in which transesophageal echocardiography has allowed a good definition of this complex area of the heart and a better diagnosis and treatment of its components. Its use led to the diagnosis of abnormal papillary muscles inserted directly in the anterior leaflet of the mitral valve, with severe left ventricle outflow obstruction. Surgical treatment consisted of septal myectomy and excision of the muscles, thus preventing the need for mitral replacement. Systolic anterior motion of the mitral valve subsided and the outflow gradients became negligible. This new approach for the treatment of hypertrophic obstructive cardiomyopathy will be of benefit for patients in whom the anomalous insertion of the papillary muscles are recognized before surgery, thus preventing mitral valve replacement.

Innervation of human epicardial coronary veins: immunohistochemistry and vasomotility.

OBJECTIVE: The aim was to investigate the innervation and vasomotor responses to classical and putative transmitters of the coronary venous bed. METHODS: The innervation of human epicardial coronary veins was investigated using acetylcholinesterase histochemistry and immunofluorescence staining, together with antisera against the general neuronal marker protein gene product 9.5 (PGP 9.5), the catecholamine synthesising enzyme tyrosine hydroxylase, and neuropeptides [neuropeptide Y, vasoactive intestinal peptide (VIP), substance P, and calcitonin gene related peptide (CGRP)]. The vasomotor responses to noradrenaline, acetylcholine, neuropeptide Y, substance P, human alpha calcitonin gene related peptide (alpha CGRP), and VIP were tested on isolated circular human epicardial coronary vein segments. RESULTS: A network of nerve fibres was shown in the major epicardial coronary veins by means of an antiserum to PGP 9.5. The majority of the perivascular nerve fibres possessed neuropeptide Y and tyrosine hydroxylase immunoreactivity. Only a few nerve fibres displayed substance P, CGRP, and VIP immunoreactivity and acetylcholinesterase activity. Noradrenaline and acetylcholine induced powerful contractions of all the tested segments, whereas no contraction was induced by neuropeptide Y, alpha CGRP, substance P, or VIP. All segments precontracted with U46619 responded with potent relaxation to alpha CGRP, substance P, and VIP, whereas noradrenaline and acetylcholine only in low concentrations induced weak relaxation of a few of the segments. No relaxation was induced by neuropeptide Y. CONCLUSIONS: This is the first study to demonstrate comprehensively the perivascular innervation of human coronary veins and corresponding vasomotor effects, suggesting a role in regulation of the coronary venous circulation.

Peptidergic innervation of human epicardial coronary arteries.

The peptidergic innervation of proximal (internal diameter, > 0.8 mm) and distal (internal diameter, < 0.8 mm) regions of human epicardial coronary arteries was investigated by means of immunohistochemical, chromatographic, radioimmunological, and in vitro pharmacological techniques. The use of an antiserum to the general neuronal marker protein gene product 9.5 revealed that the proximal part of epicardial arteries possessed a relatively sparse supply of nerve fibers forming a loose network in the adventitia. The perivascular network increased in density as the vessels were followed distally. In both proximal and distal regions, the majority of nerve fibers possessed neuropeptide Y and tyrosine hydroxylase immunoreactivity. Calcitonin gene-related peptide (CGRP)- and substance P-immunoreactive nerve fibers were very sparse in the proximal region of the arteries and increased in number distally. Only a few scattered vasoactive intestinal peptide (VIP)-immunoreactive nerve fibers were detected in both arterial regions. The use of high-performance liquid chromatography and radioimmunoassay revealed that the immunoreactive material present in coronary artery extracts closely resembled synthetic peptides. An in vitro pharmacological method demonstrated that neuropeptide Y elicited no detectable response in either proximal or distal arterial segments. In contrast, CGRP, substance P, and VIP all produced a concentration-dependent relaxation of both arterial regions. CGRP and substance P were stronger and more potent than VIP. CGRP and substance P induced a more potent response in distal compared with proximal regions of the arteries. These results suggest that the peptidergic nerves supplying human large epicardial coronary arteries may be predominantly involved in mediating vasodilation.

[Anomalous origin of the left coronary from the pulmonary artery in adults: diagnosis with bidimensional, pulsed and color Doppler echocardiography]. / Origem anómala da coronária esquerda a partir da artéria pulmonar no adulto: diagnóstico por ecocardiografia bidimensional, Doppler pulsado e cor.

Anomalous origin of the left coronary artery (LCA) from the pulmonary trunk (PT) is an uncommon but frequently lethal congenital lesion of infancy. Clinically it may be difficult to distinguish from congestive cardiomyopathy, and the diagnosis is usually made by angiography. We describe the case of a 38 years old woman, in whom identification of this anomaly was achieved by 2D-Echo, pulsed Doppler and color flow mapping. She complained of fatigue, effort dyspnea and atypical chest pain. A II/VI systolic murmur at left sternal border was heard. There was cardiac enlargement on chest X-ray and ECG was suggestive of an old anterolateral myocardial infarction. The 2D-Echo study showed a dilated, poorly contracting left ventricle. A prominent right coronary ostium was recorded, but the LCA ostium could not be visualized. There was retrograde diastolic and systolic flow in proximal PT, where an anomalous vessel was seen in continuity with it by color flow mapping. Cardiac catheterization confirmed the diagnosis. The patient underwent successful reimplantation of the anomalous LCA, from the PT to the aorta. This case demonstrates usefulness of Echocardiography in the assessment of coronary artery anomalies.

[Effects of coronary surgery on silent ischemia]. / Influência da cirurgia coronária na isquémia silenciosa.

In order to assess the effects of coronary artery bypass surgery on silent myocardial ischemia, we studied a group of 39 consecutive patients, 38 male and 1 female with a mean age of 56 + 7 years, with stable chronic angina pectoris, by 48 hours-Holter monitoring and maximal treadmill exercise test before and after operation. The reduction of angina was 92% (p less than 0.0001) and of ischemia 57% (p less than 0.0001) after operation. Silent myocardial ischemia was detected in 21 patients (54%) before operation, 13 by Holter, 4 by exercise test and 4 by the two methods. After operation 13 patients (36%) continue to have silent ischemia depicted in 7 by Holter and in 7 by exercise test. No new patient developed silent ischemia after operation. The group of patients with silent ischemia preoperatively was not significantly different from the group without silent ischemia based on clinical and angiographic characteristics, results of surgery and exercise test parameters with exception of ST segment depression. In conclusion, silent myocardial ischemia may persist after successful coronary artery bypass surgery for the relief of angina pectoris, and should be monitored by serial Holter recordings and treated medically, if its prognosis and consequences proved to be similar to manifest symptomatic ischemia.

[Heart transplant]. / Transplantação cardíaca.

The author presents a short historical note on the evolution of heart transplantation. He comments on the problems related with patient selection, organ donation and harvesting, and clinical evolution after transplantation, based on his experience with 21 patients submitted to heart transplantation. They are divided in two groups. The first, includes 4 who were operated on while being on heart assisted devices and had a hospital mortality of 50% (14-86; CL 70%). The second comprises the other 17 patients who had a hospital mortality of 12% (14-86; CL 70%). On a average hospital stay of 45 days, 59% of the patients had complications, on a average of 2.4 events per patient. Infectious problems were the most frequent. He emphasis the need for a earlier surgical indication to prevent the height incidence of post operative complications. There were 1.6 rejection episodes per patient on an average follow up period of 11 months. Actuarial survival curve shows a 67% survival at 2 years.