Myocardial Revascularization/surgery – ABC CARDIOL

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Editorial

The Role of Hemodynamic, Metabolic, and Biomarkers in Predicting Mortality after Coronary Artery Bypass Grafting: Are we there yet?

Nelson Americo Hossne Junior

Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure performed in Brazil and worldwide and has been one of the most studied procedures. Postprocedural aspects have been widely investigated and preoperative risk scores have been developed. Several postoperative markers and indexes, including hemodynamic, metabolic, and biomarkers, have been identified and proposed, aiming to accurately predict poor patient outcomes.^–

Dr. Yamaguti et al. conducted a prospective observational study in which hemodynamic, metabolic, and tissue hypoperfusion biomarkers were analyzed in 183 patients (ages between 35 and 83 years) with left ventricular dysfunction (ejection fraction between 40% and 42,5%) who underwent coronary artery bypass surgery with cardiopulmonary bypass, according to postoperative clinical course (complicated or uncomplicated). Patients with a complicated clinical course (defined as death within 30 days after surgery or more than 4 days of ICU stay) were older (66,3 vs 59,7; p=0.002) and had a higher EuroSCORE (6 vs 3; p<0.001). The authors also found that EuroSCORE, the lactate levels 6 hours after ICU admission, the venoarterial carbon dioxide partial pressure difference (ΔPCO2), and estimated respiratory quotient (eRQ = ΔPCO2/ Ca-vO2) 12 hours after ICU admission were independent predictors of complicated postoperative course, by multivariate logistic regression analysis.

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Letter to the Editor

Invasive Versus Conservative Management of NSTEMI Patients Aged ≥ 75 Years: Commentary

Sérgio Renato da Rosa Decker et al. Luiza Duarte Pittol Regis Goulart Rosa Marciane Maria Rover

Dear Editor,

In the edition of Arquivos Brasileiros de Cardiologia, Mengjin Hu et al. evaluated the benefit of early invasive strategy for elderly patients with non-ST-elevation myocardial infarction (NSTEMI), concluding that this strategy yields positive results in reducing myocardial infarction, major adverse cardiac events, and urgent revascularization outcomes. However, we have concerns regarding the authors’ claim of superiority and the relevance of the chosen outcomes for this specific population. Firstly, these outcomes (ischemia-driven outcomes) are mostly surrogate endpoints based on troponin levels. To establish the surrogacy of one outcome to another, several factors need to be considered, including biological plausibility, associations in observational studies, and, most importantly, proof of concept through trials where improving the surrogate endpoint also enhances clinical outcomes. In this sense, evidence shows that the association between nonfatal myocardial infarction and all-cause or cardiovascular mortality meets the first two levels; however, a meta-analysis of randomized clinical trials did not establish nonfatal myocardial infarction as a surrogate for all-cause or cardiovascular mortality. Indeed, this is a reproducible relationship in short and long term outcomes; the metanalysis of FRISC-II, ICTUS, and RITA-3 showed that, after five years, early invasive strategy for patients with NSTEMI did not result in reduced mortality despite the benefits seen in ischemia-driven outcomes.

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Editorial

PTEN in the Context of Myocardial Revascularization: The Iceberg Tip?

Leonardo Rufino Garcia et al. André Monti Garzesi Marcello Laneza Felicio Leonardo Antônio Mamede Zornoff

Cardiovascular diseases significantly contribute to morbidity and mortality in Brazil and worldwide. Within this group of diseases, coronary artery disease stands out, accounting for about 12% of total deaths in Brazil and is a leading cause of death in North America.

In addition to lifestyle changes such as smoking cessation, weight loss with regular physical activity, control of comorbidities, notably diabetes and arterial hypertension, and drug treatment with antiplatelet agents, beta-blockers, and statins, a significant number of patients require treatment aimed at myocardial revascularization. Diabetic, multivessel-diseased patients with obstructions in the left main coronary artery greater than 50% or with depressed left ventricular function benefit the most. This fact is due to different factors, including a decrease in ischemia and symptoms, an improvement in quality of life, a decrease in the occurrence of infarcts, and, above all, mortality improvement.

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Original Article

Ventilatory Muscle Strength Six Months After Coronary Artery Bypass Grafting in Patients Submitted to Inspiratory Muscular Training Based on Anaerobioc Threshold: A Clinical Trial

André Luiz Lisboa Cordeiro et al. Larissa Costa Almeida Jackeline Ferreira Dos Santos Leite Hayssa de Cássia Mascarenhas Barbosa … André Raimundo França Guimarães Luiz Alberto Forgiarini Junior Jandesson Cena Jefferson Petto

Abstract

Introduction

Coronary artery bypass grafting (CABG) surgery is associated with a decline in ventilatory muscle strength and lung function. Inspiratory muscle training (IMT) based on anaerobic threshold (AT) has been used to minimize the impact of CABG on these parameters, but the long-term impact is unknown.

Objective

To test the hypothesis that AT-based IMT improves inspiratory muscle strength and lung function even six months after CABG.

Methods

This is a randomized controlled clinical trial. In the preoperative period, maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), vital capacity (VC) and peak expiratory flow (PEF) rate were assessed. On the first postoperative day, patients were randomized into two groups: AT-based IMT (IMT-AT) (n=21) where the load was prescribed based on glycemic threshold and conventional IMT (IMT-C) (n=21), with load of 40% of MIP. Patients were trained during hospitalization until the day of discharge and were assessed at discharge and six months later. For within-group comparison, paired Student’s t-test or Wilcoxon test was used, and independent Student’s t-test or the Mann-Whitney test was used to analyze the different time points. A p<0.05 was considered significant.

Results

At six months after CABG surgery, statistical difference was found between the IMT-AT and the IMT-C groups in MIP (difference between the means of -5cmH2; 95% CI=- 8.21to-1.79) and VC (difference between the means of -2ml/kg;95%CI=-3.87to-0.13). No difference was found between groups in the other variables analyzed.

Conclusion

IMT-AT promoted greater recovery of inspiratory muscle strength and VC after six months of CABG when compared to conventional training.

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Original Article

Factors That Impact the Decision to Perform Left Ventriculography in Coronary Artery Disease

Claudia de Castro Lima Santos et al. Ricardo Peixoto Oliveira Joberto Sena Adriano Dourado Oliveira … Marcelo Gottschald Ferreira Ademar Santos Filho Heitor Guissoni José Carlos Brito Gilson Soares Feitosa Gilson Soares Feitosa-Filho

Abstract

Background

Left ventriculography is an invasive method for assessment of left ventricular systolic function. Since the advent of noninvasive methods, its use has been questioned, as it carries some risk to the patient.

Objective

To assess which factors are independently associated with the decision to perform ventriculography in patients with coronary artery disease.

Methods

Analytical, retrospective, database review study of electronic medical records comparing 21 predefined variables of interest among patients undergoing coronary angiography. P-values <0.05 were considered significant.

Results

We evaluated 600 consecutive patients undergoing coronary angiography. Left ventriculography was performed in the majority of cases (54%). After multivariate analysis, patients with chronic coronary syndrome (OR 1.72; 95% CI: 1.20–2.46; p < 0.01) were more likely to undergo the procedure. Patients with known ventricular function (OR 0.58; 95% CI: 0.40–0.85; p < 0.01); those with a history of CABG (OR 0.31; 95% CI: 0.14–0.69; p < 0.01) or hypertension (OR 0.58; 95% CI: 0.36–0.94; p = 0.02); and those with higher creatinine levels (OR 0.42; 95% CI: 0.26–0.69; p < 0.01) had greater odds of not undergoing ventriculography.

Conclusions

In patients undergoing coronary angiography, a diagnosis of chronic coronary syndrome was independently associated with greater likelihood of left ventriculography, while having previously determined ventricular function, a history of hypertension or CABG, and higher creatinine levels were associated with a decreased likelihood of undergoing this procedure.

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Original Article

Frailty Among Non-Elderly Patients Undergoing Cardiac Surgery

Camila Bottura et al. Livia Arcêncio Hannah Miranda Araújo Chagas Paulo Roberto Barbosa Evora Alfredo José Rodrigues

Abstract

Background:

Usually viewed as a characteristic of old age, frailty may also occur in non-elderly people, primarily in those suffering from chronic disease. Frailty may increase operative risk.

Objectives:

To determine the prevalence of frailty patients undergoing coronary artery bypass (CABG) and/or heart valve replacement or reconstruction and/or heart valve surgery, as well as the influence of frailty on postoperative outcomes.

Methods:

Our study comprised 100 adults who underwent consecutive elective cardiac operations. Frailty was assessed using the Fried scale. Patients also performed a 6-minute walk test, and we measured maximal inspiratory and expiratory pressures. A p value <0.05 was considered significant.

Results:

Of a cohort of 100 patients, based on the Fried frailty criteria, 17 patients (17%) were considered frail, 70 (70%) pre-frail and only 13 (13%) were non-frail. Among patients with valvular heart disease, 11 (18.6%) were considered frail and 43 (73%) pre-frail. Fifty three percent of the patients considered frail were less than 60 years old (median=48 years old). The differences in frailty phenotype between patients with valvular heart disease and coronary artery disease were not statistically significant (p=0.305). A comparison between non-frail, pre-frail, and frail patients showed no significant difference in the distribution of comorbidities and cardiac functional status, regardless of their cardiac disease. However, hospital mortality was significantly higher in frail patients (29.4%, p=0.026) than in pre-frail patients (8.6%) and non-frail patients (0%).

Conclusions:

Frailty is prevalent even among non-elderly patients undergoing CABG or valvular heart surgery and is associated with higher postoperative hospital mortality.

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Editorial

Short Editorial: Frailty among Non-Elderly Patients Undergoing Cardiac Surgery

Iran Castro et al. Hugo Fontana Filho

Frailty is recognized as a geriatric syndrome characterized by an excess of vulnerability to stressors, with a low ability to maintain or recover homeostasis after a destabilizing event. The analysis of frailty is a well-known and studied subject in elderly patients, having a direct relationship with the prognosis and even with measures to be instituted pre-procedure aiming to improve the quality of life and the outcome of the patients.

Despite the original description restricting the term to patients older than 65 years, the syndrome also affects younger patients.^, Frailty represents more biological and phenotypic aspects than age itself, and precursors of the syndrome appear at a young age.

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Editorial

Cardiopulmonary bypass in Myocardial Revascularization Surgery in the State of São Paulo. The REPLICCAR Study

Paulo Roberto B. Evora

Whether myocardial revascularization should be performed with or without the use of cardiopulmonary bypass, referred to as off-pump and on-pump CABG, is still up for debate. Intuitively, avoidance of cardiopulmonary bypass seems beneficial, as the systemic inflammatory response from extracorporeal circulation is omitted. Even so, no single randomized trial has been able to prove that off-pump CABG is superior to on-pump CABG, as regards the hard outcomes of death, stroke or myocardial infarction.

Nowadays, Off-pump coronary artery bypass grafting (OPCAB) has become a common practice for coronary artery bypass grafting (CABG). Also, it seems that organ dysfunctions (liver, kidney, bowel ischemia, stroke and other kinds of minor dysfunctions) should be definitively differentiated, considering the two myocardial revascularization operations. A limitation associated with the off-pump technique, namely hemodynamic instability, concerns the quality of the anastomosis, the ability to achieve complete revascularization and the on-pump conversion rate, constituting speculative concerns. Therefore, it is still unclear whether OPCAB is superior in terms of graft patency, the incidence of complications, long-term outcomes, and the associated mortality rate- compared with conventional CABG (CCABG).

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Image

Left and Right Internal Mammary Artery Angioplasties in a 3-year-old Patient with Kawasaki Disease and Failed Coronary Artery Bypass Graft Surgery

René Hameau et al. Daniel Springmuller Francisco Garay Alberto Fuensalida Gonzalo Martinez

A 3 years and 5 months old boy with a history of Kawasaki disease diagnosed at 6 months of age and a previous Non-ST myocardial infarction (NSTEMI) underwent Coronary Artery Bypass Graft (CABG) surgery due to a large perfusion defect and moderate systolic dysfunction on Single-photon emission computed tomography (SPECT) () and a coronary angiogram showing a partially thrombosed giant aneurysm on the Right coronary artery (RCA) and a complete occlusion of the proximal Left anterior descending artery (LAD) (). A Left internal mammary artery (LIMA) graft to LAD and a free Right internal mammary artery (RIMA) to Posterior descending artery (PDA) anastomosis of RCA was performed.

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Original Article

Rapamycin Combined with α-Cyanoacrylate Contributes to Inhibiting Intimal Hyperplasia in Rat Models

Abstract

Background:

Vein graft restenosis has an adverse impact on bridge vessel circulation and patient prognosis after coronary artery bypass grafting.

Objectives:

We used the extravascular supporter α-cyanoacrylate (α-CA), the local application rapamycin/sirolimus (RPM), and a combination of the two (α-CA-RPM) in rat models of autogenous vein graft to stimulate vein graft change. The aim of our study was to observe the effect of α-CA, RPM, and α-CA-RPM on vein hyperplasia.

Methods:

Fifty healthy Sprague Dawley (SD) rats were randomized into the following 5 groups: sham, control, α-CA, RPM, and α-CA-RPM. Operating procedure as subsequently described was used to build models of grafted rat jugular vein on carotid artery on one side. The level of endothelin-1 (ET-1) was determined by enzyme-linked immunosorbent assay (ELISA). Grafted veins were observed via naked eye 4 weeks later; fresh veins were observed via microscope and image-processing software in hematoxylin-eosin (HE) staining and immunohistochemistry after having been fixed and stored” (i.e. First they were fixed and stored, and second they were observed); α-Smooth Muscle Actin (αSMA) and von Willebrand factor (vWF) were measured with reverse transcription-polymerase chain reaction (RT-PCR). Comparisons were made with single-factor analysis of variance and Fisher’s least significant difference test, with p < 0.05 considered significant.

Results:

We found that intimal thickness of the α-CA, RPM, and α-CA-RPM groups was lower than that of the control group (p < 0.01), and the thickness of the α-CA-RPM group was notably lower than that of the α-CA and RPM groups (p < 0.05).

Conclusion:

RPM combined with α-CA contributes to inhibiting intimal hyperplasia in rat models and is more effective for vascular patency than individual use of either α-CA or RPM.

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Review Article

Practical Implications of Myocardial Viability Studies

Wilter dos Santos Ker et al. Thais Helena Peixoto Nunes Marcelo Souto Nacif Claudio Tinoco Mesquita

Abstract

Many non-invasive methods, such as imaging tests, have been developed aiming to add a contribution to existing studies in estimating patients’ prognosis after myocardial injury. This prognosis is proportional to myocardial viability, which is evaluated in coronary artery disease and left ventricular dysfunction patients only.

While myocardial viability represents the likelihood of a dysfunctional muscle (resulting from decreased oxygen supply for coronary artery obstruction), hibernation represents post-interventional functional recovery itself.

This article proposes a review of pathophysiological basis of viability, diagnostic methods, prognosis and future perspectives of myocardial viability. An electronic bibliographic search for articles was performed in PubMed, Lilacs, Cochrane and Scielo databases, according to pre-established criteria.

The studies showed the ability of many imaging techniques in detecting viable tissues in dysfunctional areas of left ventricle resulting from coronary artery injuries. These techniques can identify patients who may benefit from myocardial revascularization and indicate the most appropriate treatment.

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Original Article

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

Fernanda Fuscaldi Almeida et al. Sandhi Maria Barreto Bráulio Roberto G. M. Couto Carlos E. F. Starling

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.

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Artigo Original

Ministernotomy in myocardial revascularization preserves postoperative pulmonary function

Solange Guizilini et al. Douglas W. Bolzan Sonia M. Faresin Francisco A. Alves Walter J. Gomes

BACKGROUND: In coronary artery bypass graft (CABG) surgery, the need to perform a midsternotomy has been considered a factor for the decrease in postoperative pulmonary function. OBJECTIVE: To prospectively evaluate early postoperative (PO) pulmonary function in patients submitted to off-pump CABG, comparing the conventional midsternotomy with the ministernotomy approach. METHODS: A total of 18 patients were evaluated and assigned to the two groups: Group Conventional Midsternotomy (CMS, n=10) and Group Ministernotomy (MS, n=8). Spirometric results of the forced vital capacity (FVC) and the Forced Expiratory Volume in one second (FEV1) were obtained on the 1st, 3rd and 5th PO days and the arterial gasometry was obtained before and on the 1st PO day. The pulmonary shunt percentage and the pain score were also assessed. RESULTS: When compared in terms of percentage of the preoperative value, the FVC was higher in the MS group than in the CMS group on the 1st, 3rd and 5th PO days (p<0.001). Similar results were obtained for FEV1. The recovery of the FVC between the 1st and the 5th PO days was higher in the MS than in the CMS group (p=0,043). The PaO2 decreased on the 1st PO day in both groups (p<0.05), with a higher decrease in the CMS group (p=0.002). The shunt increased in the two groups on the 1st PO day (p<0.05); however, it was lower in the MS group (p=0.02). The reported pain score was lower and the duration of the hospital stay was shorter in the MS group. CONCLUSION: Patients submitted to CABG by MS present better preservation and recovery of pulmonary function than those submitted to CMS.

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Artigo Original

Morbimortality in octogenarian patients submitted to coronary artery bypass graft surgery

Fernando Pivatto Júnior et al. Renato A. K. Kalil Altamiro R. Costa Edemar M. C. Pereira … Eduardo Z. Santos Felipe H. Valle Luciano P. Bender Marcelo Trombka Thaís B. Modkovski Ivo A. Nesralla

BACKGROUND: Given the progressive increase in longevity and the need of an increasingly elderly population to undergo myocardial revascularization surgery (MRS), it becomes necessary to know its risks and benefits. OBJECTIVE: To evaluate the in-hospital morbimortality of patients aged 80 and older submitted to MRS and identify its predictor variables. METHODS: A total of 140 consecutive cases were studied between January 2002 and December 2007. The patients’ mean age was 82.5 ± 2.2 years (range: 80-89) and 55.7% were males. In the sample,72.9% had arterial hypertension, 26.4% had diabetes, 65.7% presented severe lesion in three or more vessels and 28.6% presented a severe lesion in the left coronary trunk. An associated surgery was present in 35.7% of the cases, with aortic valve in 26.4% and mitral valve in 5.6%. RESULTS: The mortality rate was 14.3% (isolated MRS 10.0% vs 22.0% with associated procedure; p = 0.091) and the morbidity was 37.9% (isolated MRS 34.4% vs 44.0% with associated procedure; p = 0.35). The most frequent complications were low cardiac output (27.9%), renal dysfunction (10.0%) and prolonged ventilatory support (9.6%). At the bivariate analysis, the most important mortality predictors were sepsis (RR 10.2; 95%CI: 6.10-17.7), previous MRS (RR 8.06; 95%CI: 5.16-12.6), postoperative low cardiac output (RR 7.77; 95%CI: 3.03-19.9) and postoperative renal dysfunction (RR 7.36; 95%CI: 3.71-14.6). The morbidity predictors were extracorporeal circulation time > 120 min. (RR: 2.34; 95%CI: 1.62-3.38) and time of ischemia > 90 min. (RR: 2.29 95%CI: 1.56-3.37). CONCLUSION: The MRS in octogenarians is associated with a higher morbimortality when compared to younger patients, which, however, does not prevent the procedure if the indication is justified by clinical condition.

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Artigo Original

Functional assessment of coronary grafts on dobutamine pharmacological stress echocardiogram

Felipe José Monassa Pittella et al. Ademir Batista da Cunha Luiz José Martins Romeu Filho Marta Moraes Labrunie … Luis Henrique Weitzel Júlio César Melhado Antônio Sergio Cordeiro da Rocha

OBJECTIVE: To verify the sensitivity, specificity and diagnostic accuracy of dobutamine stress echocardiogram (DSE) when assessing the functional status of coronary grafts: sufficient (SUF) or insufficient (INS). METHODS: We carried out a prospective, observational study which included 25 patients submitted to coronary artery bypass grafting (CABG). The DSE and the coronary angiography were performed before the CABG and three months after the CABG. The left ventricle was divided into three territories per patient according to the three major coronary arterie: the anterior descending (AD), the circumflex (CX) and the right coronary (RC). Of the 75 possible territories, 54 were revascularized: 25 were specific to the AD artery and 29 of the CX/RC arteries. INS means luminal obstruction or occlusion greater than or equal to 50%. RESULTS: In 14 (26%) of the 54 revascularized territories the grafts were INS. The DSE detected ischemia in 16 (28%) territories; 10 of which had INS grafts. The DSE detected ischemia in 6 (15%) of the 40 territories whose grafts were SUF. Therefore, the DSE had a sensitivity of 71.4%, specificity of 85% and diagnostic accuracy of 81.4%. CONCLUSION: The DSE is a diagnostic method with high specificity and diagnostic accuracy, and good sensitivity for the functional assessment of coronary grafts.

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Artigo Original

Prospective risk analysis in patients submitted to myocardial revascularization surgery

Antonio Carlos Mugayar Bianco et al. Ari Timerman Ângela Tavares Paes Carlos Gun … Rui Fernando Ramos Ronald Brewer Pereira Freire César Nicolas Conde Vela Antonio Aurélio de Paiva Fagundes Junior Luís Cláudio Behrmann Martins Leopoldo Soares Piegas

OBJECTIVE: To perform a stratified risk analysis in Myocardial Revascularization Surgery (MRS). METHODS: 814 patients were prospectively studied by applying two prognostic indexes (PI): Parsonnet and Modified Higgins. The Higgins PI was modified by substituting the variable “cardiac index value” by “low cardiac output syndrome” at the Intensive Care Unit (ICU) admission. The discriminatory capacity for morbimortality of both indexes was analyzed by ROC (receiver operating characteristic) curve. Logistic reaction identified the associated factors, independently from the events. RESULTS: Mortality and morbidity rates were 5.9% and 35.5%, respectively. The Modified Higgins PI, which analyzes pre- and intra-operative and physiological variables at the ICU admission showed areas under the ROC curve of 77% for mortality and 67% for morbidity. The Parsonnet PI, which only analyzes pre-operative variables, showed areas of 62.2% and 62.4%, respectively. Twelve variables were characterized as independent prognostic factors: age, diabetes mellitus, low body surface, creatinine levels (>1.5 mg/dL), hypoalbuminemia, non-elective surgery, prolonged time of extracorporeal circulation (ECC), necessity of post-ECC intra-aortic balloon, low cardiac output syndrome at the ICU admission, elevated cardiac frequency, decrease in serum bicarbonate concentrations and increase of the alveolar-arterial oxygen gradient within this period. CONCLUSION:The Modified Higgins PI showed to be superior to the Parsonnet PI at the surgical risk stratification, showing the importance of the analysis of intraoperative events and physiological variables at the patient’s ICU admission, when prognostic definition is achieved.

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Artigo Original

Myocardial revascularization without extracorporeal circulation in patients over 75 years of age: analysis of immediate results

Rodrigo Milani et al. Paulo Brofman Alexandre Varela Jose Augusto Souza … Maximiliano Guimarães Rafael Pantarolli Alexandre Barbosa Laura Barbosa Thaise Sandri Luiz Gustavo Emed Fernanda Ceccon Francisco Maia

OBJECTIVE: To assess the immediate results of myocardial revascularization surgery without extracorporeal circulation in a group of patients over 75 years of age. METHODS: From January 2001 to December 2003, 193 (121 men and 72 women) patients with ages ranging from 75 to 94 years, corresponding to 100% of the coronary surgeries performed in patients over the age of 75 years, underwent myocardial revascularization without extracorporeal circulation. Their hospitalization data were retrospectively analyzed. RESULTS: Arterial hypertension was present in 174 (90%), dyslipidemia in 115 (59%), smoking in 89 (46%), and diabetes in 57 (29%). Ninety-six (49.7%) patients had had a previous myocardial infarction, 53 of whom (27.4%) had experienced an acute ischemic event in a period < 30 days after surgery. Critical obstructive lesions in 3 or more coronary vessels were present in 156 (80.95%) patients, while 30 (15%) patients had an important obstruction of the left main coronary artery, and 30 (15%) patients had an ejection fraction < 30%. The score obtained according to the EUROSCORE ranged from 3 to 18, with an expected mortality rate for the group of 7.54±2.69%. The total number of distal anastomoses was 639. Seven (3.62%) patients died, 3 due to bronchopneumonia, 1 due to mediastinitis, 1 due to metabolic causes, 1 due to cardiogenic shock, and another died suddenly after refixation of a sternal dehiscence. Reoperation due to bleeding, orotracheal reintubation, and prolonged mechanical ventilation were factors associated with an increase in mortality. CONCLUSION: The surgery adopted for myocardial revascularization was associated with a low mortality rate, a low complication index, and a short length of stay at the hospital.

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Artigo Original

Immediate results of myocardial revascularization: comparison between men and women

Vivian Lerner Amato et al. Ari Timerman Ângela T. Paes Valéria T. Baltar … Pedro S. Farsky Jorge A. Farran Carlos Gun Paulo Paredes Paulista Leopoldo S. Piegas J. Eduardo M. R. Sousa

OBJECTIVE: To assess morbidity and mortality in men and women undergoing isolated myocardial revascularization and to analyze the factors related to differences occasionally found. METHODS: Comparative analysis of 2032 patients, 1402 (69%) men and 630 (31%) women, who consecutively underwent surgery from January 1999 to December 2002. RESULTS: Women had a greater mean age, more risk factors, and a greater incidence of unstable angina. Internal thoracic artery grafts were more frequently used in men, 85.6% vs 78.3%, P < 0.001. No differences in the postoperative complication rates were observed, except for infections, more frequent in women. In-hospital mortality rates were 4.1% and 6.3% for men and women, respectively (P = 0.026). On multivariate analysis, neither the female sex was identified as an independent prognostic factor for death nor was the use of thoracic artery grafts identified as an isolated protective factor. However, sex-internal thoracic artery graft interaction was significant. The following variables were also selected: age (OR = 1.03; 95% CI = 1.01 to 1.06; P = 0.004), preoperative renal failure (OR = 1.82; 95% CI = 1.07 to 3.11; P = 0.028) and urgent/emergency surgery (OR = 2.85; 95% CI = 1.32 to 6.14; P = 0.008). CONCLUSION: The female sex had a greater surgical mortality; this, however, was not an independent prognostic factor for death. The use of thoracic artery grafts proved to be protective. Older patients with renal failure in an emergency situation had greater indices of in-hospital death.

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Original Article

Consequences of the Prolonged Waiting Time for Patients Candidates for Heart Surgery

Nagib Haddad et al. Olímpio J. N. V. Bittar Ana A. M. Pereira Maria Barbosa da Silva … Vivian L. Amato Pedro S. Farsky Auristela I. O. Ramos Marcelo Sampaio Tarcísio L. V. Almeida Dikran Armaganijan José Eduardo M. R. Sousa

OBJECTIVE – To assess mortality and the psychological repercussions of the prolonged waiting time for candidates for heart surgery. METHODS – From July 1999 to May 2000, using a standardized questionnaire, we carried out standardized interviews and semi-structured psychological interviews with 484 patients with coronary heart disease, 121 patients with valvular heart diseases, and 100 patients with congenital heart diseases. RESULTS – The coefficients of mortality (deaths per 100 patients/year) were as follows: patients with coronary heart disease, 5.6; patients with valvular heart diseases, 12.8; and patients with congenital heart diseases, 3.1 (p<0.0001). The survival curve was lower in patients with valvular heart diseases than in patients with coronary heart disease and congenital heart diseases (p<0.001). The accumulated probability of not undergoing surgery was higher in patients with valvular heart diseases than in the other patients (p<0.001), and, among the patients with valvular heart diseases, this probability was higher in females than in males (p<0.01). Several patients experienced intense anxiety and attributed their adaptive problems in the scope of love, professional, and social lives, to not undergoing surgery. CONCLUSION – Mortality was high, and even higher among the patients with valvular heart diseases, with negative psychological and social repercussions.

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