Mitral valve repair. Quadrangular resection of the posterior leaflet in patients with myxomatous degeneration

OBJECTIVE - To analyze the immediate and late results of mitral valve repair with quadrangular resection of the posterior leaflet without the use of a prosthetic ring annuloplasty. METHODS - Using this technique, 118 patients with mitral valve prolapse who underwent mitral repair from January '84 through December '96 were studied. Age ranged from 30 to 86 (mean = 59.1±11.8) years and 62.7% were males. An associated surgery was performed in 22% of the patients, and coronary artery bypass graft was the most frequently performed surgery (15 patients - 12.7%). In 20 (16.9%) patients other associated techniques of mitral valve repair were used and shortening of elongated chordae tendineae was the most frequent one (6 patients). RESULTS - Immediate mortality was 0.9% (one patient). Long-term rates for thromboembolism, endocarditis, re-operation and death in the late postoperative period were 0.4%, 0.4%, 1.7% and 2.2% patients/year, respectively. The actuarial curve of survival was 83.8±8.6% over 12 years; survival free from re-operation was 91.8±4.3%, free from endocarditis was 99.2±0.8% and free from thromboembolism was 99.2±0.8%. In the late postoperative period, 93.8% of the patients were in functional class 1 (NYHA), with a complete follow-up in 89.7% of the patients. CONCLUSION - Patients with mitral valve prolapse who undergo mitral valve repair using this technique have a satisfactory prognosis over 12 years.

Chylothorax after myocardial revascularization with the left internal thoracic artery

A 38-year-old male underwent coronary artery bypass grafting (CABG). A saphenous vein graft was attached to the left marginal branch. The left internal thoracic artery was anastomosed to the left anterior descending artery (LAD). The early recovery was uneventful and the patient was discharged on the 5th postoperative day. After three months, he came back to the hospital complaining of weight loss, weakness, and dyspnea on mild exertion. Chest X-rays showed left pleural effusion. On physical examination, a decreased vesicular murmur was detected. After six days, the diagnosis of chylothorax was made after a milky fluid was detected in the plural cavity and total pulmonary expansion did not occur. On the next day, both anterior and posterior pleural drainage were performed by videothoracoscopy, and prolonged parenteral nutrition (PPN) was instituted for ten days. After seven days the patient was put on a low-fat diet for 8 days. The fluid accumulation ceased, the drains were removed and the patient was discharged with normal pulmonary expansion.

Primary coronary angioplasty and stent implantation in acute myocardial infarction. Comparative analysis of the in-hospital results in the CENIC/SBHCI registry

OBJECTIVE: Comparative analysis of the in-hospital results after primary implantation of stents or coronary balloon angioplasty in patients with acute myocardial infarction (MI). METHODS: CENIC (National Center of Cardiovascular Interventions) gathered data on 3,924 patients undergoing coronary angioplasty (in the primary form, without the previous use of thrombolytic agents) in the first 24 hours after a MI, during the period of 1996-1998. From these 3,924 patients, 1,337 (34%) underwent stent implantation. We analyzed the success of the procedure and the occurrence of adverse cardiac events. RESULTS: In patients undergoing stent implantation there were more males (77% vs 69%, p=0.001), previous by pass surgery (6.3% vs. 4.5%, p=0.01), anterior MI and stent implantation in left descending artery (55% vs. 48% vs. p=0.009), and saphenous vein bypass grafts (3.3% vs. 1.9%). the procedure was more succesful in the group of stents (97% vs. 84%, p=0.001) and reinfarction rate (2.5 vs. 4%, p=0.002). The need for emergency revascularization was similar (1% vs. 1.1%, NS). Total in-hospital mortality was lower in stent group (3.4% vs. 7. 2%, p=0.0001) and this effect was in patients Killip class III/V (19.5% vs. 32.5%, p= 0.002) because there was no difference in patients class I/II (1.7% vs. 2.8%, p=0.9). CONCLUSION: Primary stent implantation in acute myocardial infarction showed better early results than balloon angioplasty alome.

Acute myocardial infarction in progressively elderly patients. A comparative analysis of immediate results in patients who underwent primary percutaneous coronary intervention

OBJECTIVE: Analysis of the in-hospital results, in progressively elderly patients who undergo primary percutaneous coronary intervention (PCI) in the first 24 hours of AMI. METHODS: The patients were divided into three different age groups (60/69, 70/79, and > or = 80 years) and were treated from 7/95 until 12/99. The primary success rate and the occurrence of major clinical events were analyzed at the end of the in-hospital phase. Coronary stent implantation and abciximab use were employed at the intervencionist discretion. RESULTS: We analyzed 201 patients with age ranging from 60 to 93 years, who underwent primary PCI. Patients with ages above 70 were more often female (p=.015). Those with ages above 80 were treated later with PCI (p=.054), and all of them presented with total occlusion of the infarct-related artery. Coronary stents were implanted in 30% of the patients. Procedural success was lower in > or = 80 year old patients (p=.022), and the death rate was higher in > or = 70 years olds (p=.019). Reinfarction and coronary bypass surgery were uncommon events. A trend occurred toward a higher combined incidence of major in-hospital events according to increased age (p=.064). CONCLUSION: Elderly patients ( > or = 70 years) presented with adverse clinical and angiographic profiles and patients > or = 80 years of age obtained reduced TIMI 3 flow success rates after primary PTCA, and those > or = 70 years had a higher death rate.

Calcified aneurysms in coronary arteries of a 48-year-old patient

This is a case report of a 48-year-old female patient with a compatible history of Kawasaki disease during childhood, who was admitted to the emergency coronary unit with unstable angina pectoris. Coronary angiography identified two coronary aneurysms, one causing right coronary occlusion and the other causing severe obstruction of the left anterior descending coronary artery. Coronary artery bypass surgery was indicated.

Transradial approach for coronary interventions

OBJECTIVE: To assess the feasibility and safety of coronary interventions performed through the radial artery. METHODS: We studied 103 patients with ages from 38 to 86 years (57±8.7), 90 (87%) males, and: radial pulse with a good amplitude, presence of ulnar pulse, a good collateral flow through the palmar arch assessed with the Allen's test. RESULTS: The vascular approach was obtained in 97 (94%) patients, 88 (91%) treated electively and 9 (9%) during acute myocardial infarction, for primary angioplasty; 56 (64%) unstable angina; 22 (25%) stable angina; 10 (11%) were asymptomatic, 6 referred for recanalization of chronic occlusion and 4 silent ischemia in the first week after acute myocardial infarction. We approached 107 arteries: anterior descending artery, 49 (46%); right coronary artery, 27 (25%); circumflex artery, 25 (23%); diagonal artery, 6 (6%); and 2 saphenous vein bypass grafts. We treated 129 lesions: 80 (62%) B2 type; 23 (18%) B1 type; 17 (13%) C type; and 9 (7%). A type. There were 70 stents , and 59 balloon angioplasties performed. Thirty-two (33%) patients used GP IIb/IIIa inhibitors. The mean duration of the elective procedure was 42.3±12.8 min. Success, correct stent deployment and residual lesion <20%, was reached in 100% of the lesions treated with stent implantation; arterial dilation with residual lesion <50% was obtained in 96% of the lesions treated with transluminal coronary angioplasty (TCA). Complications, were: 1 (1.0%) non-Q-wave acute myocardial infarction; 2 (2%) hematomas in the forearm; and 2 losses of radial pulse. CONCLUSION: Radial artery aproach is practical and safe for percutaneous coronary interventions there was a low incidence of complications.

The use of primary stenting or balloon percutaneous transluminal coronary angioplasty for the treatment of acutely occluded saphenous vein grafts. Results from the Brazilian National Registry - CENIC

OBJECTIVE: We conducted a comparative analysis of the in-hospital outcomes of patients who underwent primary percutaneous transluminal angioplasty (PTCA) or stent implantation because of an acute myocardial infarction (AMI) related to an acute vein graft occlusion. METHODS: Since 1991 the Brazilian Society of Hemodynamic and Interventional Cardiology has maintained a large database (CENIC). From these, we selected all consecutive patients, who underwent primary PTCA or stenting in the first 24 hours of AMI, with the target vessel being an occluded vein graft. Immediate results and major coronary events occurring up until hospital discharge were analyzed. RESULTS: During this period, 5,932 patients underwent primary PTCA or stenting; 158 (3%) of the procedures were performed because of an acute vein graft occlusion. Stenting was performed in 74 (47%) patients. Patients treated with stents had a higher success rate and lower mean residual stenosis compared with those who underwent primary balloon PTCA. The incidence of reinfarction and death were similar for stenting and balloon PTCA. CONCLUSION: Primary percutaneous treatment of AMI related to acute vein graft occlusion is still an uncommon practice. Primary stenting improved luminal diameter and offered higher rates of success; however, this strategy did not reduce the in-hospital reinfarction and death rate, compared with that occurring with PTCA treatment.

Mechanical versus biological aortic valve implants in the elderly. A comparison of early and mid-term results

OBJECTIVE: Our aim was to compare, in a non randomized study, the surgical outcome in elderly patients with mechanical (Group 1; n=83) and bioprosthetic valve implants (Group 2; n=136). METHODS: During a three year period, 219 patients >75 years underwent Aortic Valve Replacement. The groups matched according to age, sex, comorbidity, valve pathology and concomitant Coronary Artery Bypass Surgery. Follow-up was a total of 469 patient-years (mean follow-up 2.1 years, maximum 4,4 years). RESULTS: Operative mortality was zero and the overall early mortality was 2.3 % (within 30 days). Actuarial survival was 87.5 ± 4.0% and 66.1 ± 7.7% (NS) at 4 years in Group 1 and Group 2, respectively. Freedom from valve-related death was 88.9 ± 3.8% in Group 1 and 69.9±7.9% (NS) in Group 2 at 4 years. CONCLUSION: Aortic Valve Replacement in the elderly (>75 years) is a safe procedure even in cases where concomitant coronary artery revascularization is performed. Only a few anticoagulant-related complications were reported and this may indicate that selected groups of elderly patients with significant life expectancy may benefit from mechanical implants .

Primary coronary angioplasty in 9,434 patients during acute myocardial infarction: predictors of major in- hospital adverse events from 1996 to 2000 in Brazil

OBJECTIVE: To verify the results after the performance of primary coronary angioplasty in Brazil in the last 4 years. METHODS: During the first 24 hours of acute myocardial infarction onset, 9,434 (12.2%) patients underwent primary PTCA. We analyzed the success and occurrence of major in-hospital events, comparing them over the 4-year period. RESULTS: Primary PTCA use increased compared with that of all percutaneous interventions (1996=10.6% vs. 2000=13.1%; p<0.001). Coronary stent implantation increased (1996=20% vs. 2000=71.9%; p<0.001). Success was greater (1998=89.5% vs. 1999=92.5%; p<0.001). Reinfarction decreased (1998=3.9% vs. 99=2.4% vs. 2000=1.5%; p<0.001) as did emergency bypass surgery (1996=0.5% vs. 2000=0.2%; p=0.01). In-hospital deaths remained unchanged (1996=5.7% vs. 2000=5.1%, p=0.53). Balloon PTCA was one of the independent predictors of a higher rate of unsuccessful procedures (odds ratio 12.01 [CI=95%] 1.58-22.94), and stent implantation of lower mortality rates (odds ratio 4.62 [CI=95%] 3.19-6.08). CONCLUSION: The success rate has become progressively higher with a significant reduction in reinfarction and urgent bypass surgery, but in-hospital death remains nearly unchanged. Coronary stenting was a predictor of a lower death rate, and balloon PTCA was associated with greater procedural failure.

Predictive factors of in-hospital mortality and of severe perioperative complications in myocardial revascularization surgery

OBJECTIVE: To investigate preoperative predictive factors of severe perioperative intercurrent events and in-hospital mortality in coronary artery bypass graft (CABG) surgery and to develop specific models of risk prediction for these events, mainly those that can undergo changes in the preoperative period. METHODS: We prospectively studied 453 patients who had undergone CABG. Factors independently associated with the events of interest were determined with multiple logistic regression and Cox proportional hazards regression model. RESULTS: The mortality rate was 11.3% (51/453), and 21.2% of the patients had 1 or more perioperative intercurrent events. In the final model, the following variables remained associated with the risk of intercurrent events: age ³ 70 years, female sex, hospitalization via SUS (Sistema Único de Saúde - the Brazilian public health system), cardiogenic shock, ischemia, and dependence on dialysis. Using multiple logistic regression for in-hospital mortality, the following variables participated in the model of risk prediction: age ³ 70 years, female sex, hospitalization via SUS, diabetes, renal dysfunction, and cardiogenic shock. According to the Cox regression model for death within the 7 days following surgery, the following variables remained associated with mortality: age ³ 70 years, female sex, cardiogenic shock, and hospitalization via SUS. CONCLUSION: The aspects linked to the structure of the Brazilian health system, such as factors of great impact on the results obtained, indicate that the events investigated also depend on factors that do not relate to the patient's intrinsic condition.

Assessment of factors that influence weaning from long-term mechanical ventilation after cardiac surgery

OBJECTIVE: To analyze parameters of respiratory system mechanics and oxygenation and cardiovascular alterations involved in weaning tracheostomized patients from long-term mechanical ventilation after cardiac surgery. METHODS: We studied 45 patients in their postoperative period of cardiac surgery, who required long-term mechanical ventilation for more than 10 days and had to undergo tracheostomy due to unsuccessful weaning from mechanical ventilation. The parameters of respiratory system mechanics, oxigenation and the following factors were analyzed: type of surgical procedure, presence of cardiac dysfunction, time of extracorporeal circulation, and presence of neurologic lesions. RESULTS: Of the 45 patients studied, successful weaning from mechanical ventilation was achieved in 22 patients, while the procedure was unsuccessful in 23 patients. No statistically significant difference was observed between the groups in regard to static pulmonary compliance (p=0.23), airway resistance (p=0.21), and the dead space/tidal volume ratio (p=0.54). No difference was also observed in regard to the variables PaO2/FiO2 ratio (p=0.86), rapid and superficial respiration index (p=0.48), and carbon dioxide arterial pressure (p=0.86). Cardiac dysfunction and time of extracorporeal circulation showed a significant difference. CONCLUSION: Data on respiratory system mechanics and oxygenation were not parameters for assessing the success or failure. Cardiac dysfunction and time of cardiopulmonary bypass, however, significantly interfered with the success in weaning patients from mechanical ventilation.

Association between coronary artery atherosclerosis and the intima-media thickness of the common carotid artery measured on ultrasonography

OBJECTIVE: To assess whether the intima-media thickness of the common carotid artery of patients with coronary artery disease is greater than that of individuals without that disease. METHODS: Case-control prospective study of prevalence assessing the thickness of the intima and media layers of 29 patients with coronary artery disease and 29 individuals without that disease by using ultrasonography of the carotid arteries. Diabetic patients and those with peripheral artery and cerebral vasculopathies were excluded from the study. RESULTS: The mean age was 51±7.5 years. Fifty-five per cent of the patients were males. Acute myocardial infarction was present in 62%; cardiac catheterization in 72%; saphenous bypass in 5%; and coronary angioplasty in 24%. The intima-media thickness of the common carotid artery in case patients and in control patients was, respectively, 0.81±0.25 mm and 0.62±0.18 mm (P=0.001). CONCLUSION: Intima-media thickness of the common carotid artery was significantly greater in patients with coronary artery disease.

Secular trends in a population with ischemic heart disease admitted to the Instituto do Coração in São Paulo

OBJECTIVE: To assess the clinical and demographic characteristics of a population with ischemic heart disease admitted in the final decades of the 20th century. METHODS: This study retrospectively assessed patients hospitalized with ischemic heart disease divided into the following 2 groups: acute group - 11.181 patients with acute myocardial infarction admitted from 1/1/82 to 12/31/94; and chronic group - 4.166 patients undergoing coronary artery bypass graft surgery from 1/1/84 to 12/31/94. RESULTS: In the acute group, an increase in the percentage of females (from 22.7% to 27.7%, P<0.001) and diabetic individuals (from 12.4% to 17.5%, P<0.001) was observed, as was an increase in age (from 57.4±11.5 to 59.9±12.1 years, P<0.05). In-hospital mortality was greater among females (27.8% and 15.7%, P=0.001), among diabetic individuals (24.2% and 17.8%, P=0.001), and among the elderly (60.9±15.2 and 57.7±11.8 years, P=0.0001). In the chronic group, an increase in the percentage of females (from 17.5% to 27.2%, P=0.001) was observed, as was an increase in age (from 56.3±8.6 to 60.5±9.6 years, P=0.0001). In-hospital mortality was greater among females (8.3% and 5.8%, P<0.05) and among the elderly (58.1±9.1 and 62.1±7.9 years, P=0.0001). CONCLUSION: The characteristics of the population studied with ischemic heart disease point towards a worse prognosis, due to the greater percentages of females, older patients, and diabetic patients, groups known to have greater in-hospital mortality.

Freqüência cardíaca máxima em testes de exercício em esteira rolante e em cicloergômetro de membros inferiores

OBJETIVO: Comparar, retrospectivamente, os valores de freqüência cardíaca máxima (FCM) e o descenso da freqüência cardíaca no primeiro minuto da recuperação (dFC), obtidos em teste de exercício (TE) realizados em dois ergômetros e momentos distintos. MÉTODOS: Sessenta indivíduos (29 a 80 anos de idade), submetidos a TE cardiopulmonar em ciclo de membros inferiores (CMI) em nosso laboratório e que possuíam TE prévio (até 36 meses) em esteira (EST) em outros laboratórios, nas condições idênticas de medicações de ação cronotrópica negativa. RESULTADOS: FCM foi semelhante no CMI: 156±3 e EST: 154±2 bpm (p=0,125), enquanto o dFC foi maior em CMI: 33±2, EST: 26±3 bpm (média ± erro padrão da média) (p<0,001). Nas variáveis hemodinâmicas estudadas, a pressão arterial sistólica e o duplo produto foram maiores no TE-CMI (p<0,001). O eletrocardiograma (ECG) foi semelhante nos dois TEs, exceto por arritmias supraventriculares mais freqüentes no CMI. CONCLUSÃO: a) É possível, com empenho do examinador e conhecimento prévio do resultado de FCM em um TE anterior, obter níveis altos de FCM em um TE-CMI; b) interromper o TE baseado em FCM prevista por equações tende a levar a esforços submáximos; c) o dFC difere nas recuperações ativa e passiva; d) novas formas de analisar o comportamento da FC no exercício, que não apenas o valor da FCM, são necessárias para caracterizar um TE como máximo.

Hipertrofia ventricular esquerda do atleta: resposta adaptativa fisiológica do coração

OBJETIVO: Verificar se a hipertrofia ventricular esquerda (HVE) de atletas competitivos de resistência (maratonistas) representa processo adaptativo, puramente fisiológico, ou se pode envolver aspectos patológicos em suas características anatômicas e funcionais. MÉTODOS: De novembro de 1999 a dezembro de 2000, foram separados consecutivamente de 30 maratonistas em atividade esportiva plena, idade inferior a 50 anos, com HVE, previamente documentada, e sem cardiopatia subjacente. Foram submetidos aos exames: clínico, eletrocardiograma, ecodopplercardiograma, e teste ergométrico (TE). Quinze foram sorteados para realizar, também, teste ergoespirométrico e ressonância magnética (RM) do coração. RESULTADOS: Nos TE, todos apresentavam boa capacidade física cardiopulmonar, sem evidências de resposta isquêmica ao exercício, sintomas ou arritmias. No ecodopplercardiograma, os valores do diâmetro e espessura diastólica da parede posterior do ventrículo esquerdo (VE), do septo interventricular, massa do VE e diâmetro do átrio esquerdo, foram significativamente maiores que os do grupo de não atletas, com idades e medidas antropométricas semelhantes. A média da massa do VE dos atletas indexada à superfície corpórea (126 g/m2) foi significativamente maior que a do grupo controle (70 g/m2) (p<0,001). A RM mostrou que não havia prejuízo da força contrátil ou da performance ventricular esquerda e valores de volume diastólico final, volume sistólico final e fração de ejeção dentro dos limites da normalidade. Por outro lado, a massa do VE média, 162,93±17,90 g, e a espessura parietal ventricular, 13,67±2,13 mm, ao final da diástole no grupo atleta, diferiu significativamente do controle: 110±14,2 g (p=0,0001) e 8±0,9 mm, respectivamente (p=0,0001). O mesmo ocorreu na média da espessura ao final da sístole, que foi 18,87±3,40 mm (controle: 10± 1,80 mm, p=0,0001). CONCLUSÃO: Os resultados permitiram concluir que a HVE de maratonistas em período de atividade esportiva plena, avaliada por métodos não invasivos, representa resposta adaptativa ao treinamento físico intensivo e prolongado, com características fisiológicas.