Universidade Federal de São Paulo – EPM – São Paulo, SP
A insuficiência cardíaca, via final comum de variadas cardiomiopatias, se constitui no problema mais grave e atual nos âmbitos da cardiologia e da saúde pública. Apesar dos extraordinários progressos ocorridos nas últimas duas décadas no entendimento dos mecanismos mais íntimos da falência ventricular como uma síndrome endócrino-metabólica, a insuficiência cardíaca se constitui na principal causa de óbito da população adulta.
Justifica-se, assim, o uso da polifarmácia com cinco ou mais princípios ativos, com o objetivo de neutralizar etapas distintas da cascata de estimulação adrenérgica. O fascínio pela aplicação clínica desses princípios tem levado à postura de valorizar a síndrome de insuficiência cardíaca, às vezes aceitando sem maiores questionamentos a etiologia da enfermidade e, mais que isso, não identificando causas removíveis de insuficiência cardíaca.
A identificação do mecanismo causal e sua remoção ou neutralização representam significativo impacto na evolução, servindo como exemplo as cardiomiopatias isquêmicas, as taquimiopatias, e as doenças de depósito e metabólicas, entre outras.
Com os conceitos importantes e recentes da dinâmica ventricular sob a luz do mecanismo helicoidal em hélice dupla e o reconhecimento dos efeitos deletérios da esfericidade ventricular, torna-se necessária a abordagem da insuficiência cardíaca com visão mecanicista, que não é antagônica aos conceitos endócrino-metabólicos mas acrescenta expectativa de melhor manejo dessa síndrome.
Dentre as possibilidades de intervenção cirúrgica nessas situações, serão discutidas, de forma resumida, a revascularização no miocárdio isquêmico, a reconstrução ventricular e a correção da insuficiência mitral secundária.
A disfunção isquêmica do miocárdio pode ser revertida pelo tratamento cirúrgico, contrastando significantemente com o manejo clínico isolado como demonstram vários estudos, constituindo critério maior de indicação operatória1-5.
Mais recentemente, os estudos
Deve-se ressaltar que, com avaliações de isquemia por meio de cintilografia,
Dessa forma, é difícil negar a indicação de revascularização em pacientes com mau desempenho ventricular quando existem leitos coronarianos distais abordáveis.
Dúvidas persistem quanto ao benefício da revascularização quando os volumes ventriculares são aumentados, sendo os resultados não tão satisfatórios quanto a revascularização em pacientes com ventrículo esquerdo não dilatado6-8.
Essas observações constituem a base para a proposta de associação entre algum tipo de reconstrução ventricular e revascularização do miocárdio, sendo muito promissora a aplicação clínica de conceitos atuais que entendem a contração ventricular como decorrente de um músculo único que se enrola sobre si mesmo.
É reconhecido de longa data o impacto da ressecção de áreas discinéticas do ventrículo esquerdo na evolução da cardiopatia isquêmica9,10. Mais recentemente, os estudos
O conceito de "helical heart", originalmente descrito por Torrent-Guasp, trouxe a base para o entendimento de como realizar a reconstrução ventricular com maior eficiência, restituindo sua forma elíptica14,15.
Na atualidade, a possibilidade de melhorar o desempenho ventricular por meio da exclusão de áreas de fibrose transmural associada à revascularização do miocárdio constitui área de extraordinário interesse e possibilidade de progresso.
Estudos experimentais bem conduzidos apóiam o conceito de se evitar cirurgicamente a expansão de áreas infartadas com prejuízo da função do miocárdio remanescente16.
É, pois, recomendável, diante dessas evidências clínico-experimentais, que na indicação e no planejamento do tratamento cirúrgico de pacientes com cardiomiopatia isquêmica e fração de ejeção rebaixada se estude a presença de áreas de fibrose preferencialmente por meio de ressonância magnética cardíaca e motilidade regional
São aguardados com grande interesse os resultados do estudo STICH, composto por dois braços: um braço é o da revascularização isolada e o outro, da revascularização com plastias ventriculares associadas.
A insuficiência mitral secundária que se apresenta nas fases iniciais da insuficiência cardíaca é fator que onera consideravelmente o prognóstico17.
Essa regurgitação tem como base a esfericidade do ventrículo esquerdo, que determinará afastamento das papilares, dilatação do anel e perda adicional da função contrátil, com aumento da tensão da parede e maior gasto energético.
A proposta da correção dessa regurgitação por meio da plastia mitral foi feita inicialmente por Chen e cols.18 e amplamente divulgada por Bolling e cols.19.
Essa técnica tem como princípio corrigir sobrecarga adicional ao ventrículo esquerdo, eliminando o fluxo regurgitante e aumentando o volume sistólico sem ter primariamente a pretensão de melhorar a fração de ejeção.
Propusemos uma técnica mais abrangente, que, por meio do implante de uma prótese em posição A-V, corrige a insuficiência mitral, remodela o anel mitral e restitui o paralelismo dos músculos papilares20. Essa técnica foi modificada e aplicada por outros21,22.
A seleção de pacientes para esse tipo de procedimento merece consideração especial. Assim, a etiologia da cardiomiopatia não é fator relevante para a indicação, sendo fundamental a caracterização de insuficiência mitral moderada ou grave por meio da ecocardiografia transesofágica. Cumpre ressaltar que a detecção da insuficiência nessas situações, por meio de exame clínico e radiológico e mesmo por ventriculografia, freqüentemente a subestima.
Por outro lado, observa-se que o grau de insuficiência mitral não é estático, podendo variar com o grau de compensação do paciente. Nos casos de insuficiência mitral não grave e com dessincronização ventricular, a ressincronização pode substituir a intervenção valvar.
Nossos resultados recentemente publicados em uma série consecutiva de 116 pacientes permitem observar melhora consistente da classe funcional, aumento significante do volume de ejeção, eliminação da fração regurgitante, assim como diminuição da esfericidade do ventrículo esquerdo23.
Apesar da mortalidade hospitalar considerável (16,3%), a expectativa de vida ao final de cinco anos foi de cerca de 60%, incluindo a fase hospitalar, o que é semelhante a nossos resultados observados com transplante cardíaco.
Em conclusão, cremos ser válido propor a eliminação da insuficiência mitral secundária e a modelação da cavidade ventricular por meio do implante de prótese valvular em pacientes com insuficiência cardíaca avançada, com o objetivo de melhorar a qualidade de vida e protelar ou viabilizar um transplante cardíaco e, em poucos casos de cardiomiopatias reversíveis, como ponte para cura.
1. Passamani E, Davis KB, Gillespie MJ, Killip T. A randomized trial of coronary artery bypass surgery: survival of patients with a low ejection fraction. N Engl J Med. 1985; 312: 1665-71.
2. Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet. 1994; 344: 563-70.
3. Bell MR, Gersch BJ, Schaff HV, Holmes DR Jr, Fisher LD, Alderman EL, et al. Effect of completeness of revascularization on long-term outcome of patients with three vessel disease undergoing coronary artery bypass surgery: a report from the Coronary Artery Surgery Study (CASS) Registry. Circulation. 1992; 86 (2): 446-57.
4. Allman KC, Slaw LJ, Hachamoviteh R, Udelson JE. Myocardial viability testing an impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis. J Am Coll Cardiol. 2002; 39: 1151-8.
5. Luciani GB, Montalbano G, Casali G, Mazzucco A. A prediction long-term functional results after myocardial revascularization in ischemic cardiomyopathy. J Thorac Cardiovasc Surg. 2000; 120: 478-89.
6. Trachiotis GD, Wuntraus WS, Johnston TS, Jones EL, Guyton RA, Craver JM. Coronary artery bypass grafting in patients with advanced left ventricular dysfunction. Ann Thorac Surg. 1998; 66: 1632-9.
7. Vanoverschelde JL, Depre C, Gerber BL, Borges M, Wijns W, Robert A, et al. Time course of functional recovery after coronary artery bypass graft surgery in patients with chronic left ventricular ischemic dysfunction. Am J Cardiol. 2000; 85: 1432-9.
8. Yamaguchi A, Ino T, Adachi H, Murata S, Kamio H, Okada M, Tsuboi J. Left ventricular volume predicts postoperative course in patients with ischemic cardiomyopathy. Ann Thorac Surg. 1998; 65: 434-8.
9. Jatene AD. Left ventricular aneurysmectomy: resection or reconstruction? J Thorac Cardiovasc Surg. 1985; 89: 321-31.
10. Dor V, Sabaier M, Di Donato M, Maioli M, Toso A, Montiglio F. Late hemodynamic results after left ventricular patch repair associated with coronary grafting in patients with post infarction: a kynetic or dyskinetic aneurysm of left ventricle J Thorac Cardiovasc Surg. 1995; 110: 1291-301.
11. Athanasuleas GL, Stanley ANH, Buckberg GD, Dor V, DiDonato M, Blackstone EH. Surgical Anterior Ventricular Restoration – SAVER in the dilated remodeled ventricle following anterior myocardial infarction. J Am Coll Cardiol. 2000; 37: 1199-209.
12. Cox JL, Buckberg GD, Athanasuleas CL. The restore group seminars in thoracic and cardiovascular surgery. J Thorac Cardiovasc Surg. 2001;13:301-19.
13. Dor V, Di Donato M, Labatur M. The RESTORE group. Left ventricular reconstruction by endoventricular circular patch repair: a 17 years experience. Semin Thorac Cardiovasc Surg. 2001;13:435-7.
14. Buckberg GD. Basic scence review: the helix and the heart. J Thorac Cardiovasc Surg. 2002; 124: 863:83.
15. Buckberg G, Loghlan HC, Torrent-Guasp F. The structure and function of the helical heart and its buttress wrapping. Geometric concepts of heart failure and use for structural correction. Semin Thorac Cardiovasc Surg. 2001; 13: 386-401.
16. Kanashiro R, Nozawa E, Murad N, Gerola LR, Moises VA, Tucci PJ. Myocardial infarction scar plication in the rat: cardiac mechanics in the animal model for surgical procedures. Ann Thorac Surg. 2002; 73: 1507-13.
17. Romeo F, Pellicia F, Ciafrocca C, Gallo P, Barilla F, Cristofani R. Determinants of end-stage idiopathic dilated cardiomyopathy: a multi variate analysis of 104 patients. Clin Cardiol. 1989; 12 (7): 387-92.
18. Chen FY, Adams DH, Cohn LH. Mitral valve repair in cardiomyopathy. Circulation. 1998; 98: 124-7.
19. Bolling SF, Pagani FD, Deev GM. Intermediate term outcome of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg. 1998; 115: 381-8.
20. Buffolo E, De Paula IAM, Palma H, Branco JN. Nova abordagem cirúrgica para o tratamento de pacientes em insuficiência cardíaca refratária com miocardiopatia dilatada e insuficiência mitral secundária. Arq Bras Cardiol. 2000; 74 (2): 129-34.
21. Puig LB, Gaiotto FA, Oliveira JL, et al. Mitral valve replacement and remodeling of the left ventricle in dilated cardiomyopathy with regurgitation. Initial results. Arq Bras Cardiol. 2002;78:224-9.
22. Calafiore AM, Gallina S, Contini M, Iaco A, Barsotti A, Gaeta F, et al. Surgical treatment of dilated cardiomyopathy with conventional techniques. Eur J Cardiothorac Surg. 1999; 16 (Suppl 1): 73-8.
23. Buffolo E, Branco JNR, Catani R, RESTORE Group. End-stage cardiomyopathy and secondary mitral insufficiency – Surgical alternative with prostheses implant and left ventricular restoration. Eur J Cardiothorac Surg. 2006; 29: S266-S271.
Enio Buffolo R. Borges Lagoa, 1080 – 7o andar 04038-030 – São Paulo, SP E-mail:
Artigo recebido em 31/08/06; aceito em 14/09/06.
Universidade Federal de São Paulo – EPM – São Paulo, SP, Brazil
Heart failure, a final outcome of different cardiomyopathies is currently the most serious problem in the field of cardiology and public health.
Despite the extraordinary progress made over the last two decades regarding the understanding of the deeper mechanisms of ventricular failure as an endocrine-metabolic syndrome, it is the major cause of death in the adult population.
This justifies the use of polypharmacy with five or more active principles with a view to neutralizing different stages of the adrenergic stimulation cascade.
The clinical application of these active principles fascinates professionals, leading them to attach great importance to the heart failure syndrome, so much so that they sometimes accept the etiology of the disease without further questioning and, beyond that, fail to identify causes of heart failure that could be removed.
The identification of the causal mechanism of the disease and its removal or neutralization translates into a significant impact on the progression of the disease. This is the case of ischemic myocardiopathies, tachymyopathies, deposit and metabolic diseases and others.
With the emergence of important and recent concepts on ventricular dynamics under the light of the double helix helicoidal mechanism and the acknowledgement of the harmful effects of ventricular sphericity, it is necessary to approach heart failure from a mechanicist point of view that is not opposed to the endocrine-metabolic concepts, but allows the expectation of a better management of this syndrome.
Among the possibilities of surgical intervention in these situations, we will briefly discuss the revascularization of ischemic myocardium, ventricular reconstruction and the repair of secondary mitral insufficiency.
Myocardial ischemic dysfunction can be reversed by surgical treatment, in sharp contrast with clinical management alone, as demonstrated by several studies; it constitutes a major criterion for surgery indication1-5.
More recently, the Ephesus and Valiant studies, with cut-off values for ejection fraction between 0.35 and 0.40 have proved the advantages of surgical revascularization over clinical management in the medium to long term.
It is worthy of notice that with the assessment of ischemia using scintigraphy, stress-echo test and more recently nuclear magnetic resonance imaging, the results are predictable to a high degree, whereas the statement of absence of ischemia, even if a pet scan is conducted, is subject to an error risk of approximately 20%.
It is therefore difficult to deny the indication of revascularization in patients with poor ventricular performance when there are approachable distal coronary beds.
There are doubts as to the benefit of revascularization when ventricular volumes are increased, and the results are not as satisfactory as revascularization in patients without an enlarged left ventricle6-8.
These observations constitute the basis for the proposal of associating some type of ventricular reconstruction with myocardial revascularization, and the clinical application of current concepts that state that ventricular contraction is due to a single muscle that curls over itself is very promising.
The impact of the resection of dyskinetic areas of the left ventricle on the progression of ischemic cardiomyopathy9,10 has long been known. More recently the SAVER11 and RESTORE12,13 studies pointed to the need for resection of fibrotic areas, even those that are akinetic, thus justifying the design of the recently completed STICH study.
The concept of "helical heart" originally described by Torrent Guasp embodies the basis for understanding how ventricular reconstruction can be performed with greater efficiency so as to restore the heart's elliptical form14,15.
At present, the possibility of improving ventricular performance by excluding transmural fibrosis areas in association with myocardial revascularization is a field of extraordinary interest and shows a possibility of progress.
Well conducted experimental studies support the idea of preventing, through surgery, the expansion of infarcted areas which show an impairment of the function of the remaining myocardium16.
It is advisable, in view of this clinical and experimental evidence, that when indicating and planning the surgical treatment of patients with ischemic cardiomyopathy and lowered ejection fraction, the presence of areas with fibrosis should be studied, preferably by cardiac magnetic resonance and the tagging of regional motility.
The results of the STICH study are expected with great interest: one of its arms is isolated revascularization and the other is revascularization with associated ventricular plasties.
The secondary mitral insufficiency that appears in the initial stages of heart failure is a factor with considerable negative impact on the prognosis17.
This regurgitation is based on the left ventricle sphericity, which will determine the distancing of the papillaries, the dilation of the ring and additional loss of contractile function with an increase in wall tension and energy consumption.
The proposal for repairing this regurgitation using mitral repair was first put forward by Chen et al18 and later publicized by Bolling et al19.
This technique aims at repairing an additional overload of the left ventricle, eliminating the regurgitant flow and increasing the systolic volume without having the improvement of the ejection fraction as a primary objective.
We proposed a more comprehensive technique. Through the implant of prosthesis in A-V position, the mitral insufficiency is repaired, the mitral ring is remodeled and the parallelism of the papillary muscles is restored20. This technique has been modified and applied by others21,22.
The selection of patients for this type of procedure requires special care. The etiology of myocardiopathy is not a relevant factor for its indication. It is fundamental to identify moderate or severe mitral insufficiency using transesophageal echocardiography. It is worth highlighting that the detection of insufficiency in these situations through physical examination, radiology tests and ventriculography often underestimates its importance.
On the other hand, it is known that the degree of mitral insufficiency is not static, and may vary according to the patient's degree of compensation. In cases of non severe mitral insufficiency with ventricular desynchrony, the resynchronization may replace valve surgery.
Our recently published results for a consecutive series of 116 patients allowed us to observe a consistent improvement in functional class, a significant increase of the ejection volume, the elimination of a regurgitant fraction and a decrease in LV sphericity23.
Although the hospital mortality was considerable (16.3%), life expectancy at the end of 5 years was in the region of 60% including the hospital stay, which is similar to the results obtained with heart transplant.
In conclusion, we believe that it is valid to propose the elimination of secondary mitral insufficiency and the modeling of the ventricular cavity with the implant of a valvular prosthesis in patients with advanced heart failure, in order to improve the patient's quality of life, delay or create conditions for a heart transplant and, in few cases of reversible myocardiopathies, as a transition path to cure.
1. Passamani E, Davis KB, Gillespie MJ, Killip T. A randomized trial of coronary artery bypass surgery: survival of patients with a low ejection fraction. N Engl J Med. 1985; 312: 1665-71.
2. Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet. 1994; 344: 563-70.
3. Bell MR, Gersch BJ, Schaff HV, Holmes DR Jr, Fisher LD, Alderman EL, et al. Effect of completeness of revascularization on long-term outcome of patients with three vessel disease undergoing coronary artery bypass surgery: a report from the Coronary Artery Surgery Study (CASS) Registry. Circulation. 1992; 86 (2): 446-57.
4. Allman KC, Slaw LJ, Hachamoviteh R, Udelson JE. Myocardial viability testing an impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis. J Am Coll Cardiol. 2002; 39: 1151-8.
5. Luciani GB, Montalbano G, Casali G, Mazzucco A. A prediction long-term functional results after myocardial revascularization in ischemic cardiomyopathy. J Thorac Cardiovasc Surg. 2000; 120: 478-89.
6. Trachiotis GD, Wuntraus WS, Johnston TS, Jones EL, Guyton RA, Craver JM. Coronary artery bypass grafting in patients with advanced left ventricular dysfunction. Ann Thorac Surg. 1998; 66: 1632-9.
7. Vanoverschelde JL, Depre C, Gerber BL, Borges M, Wijns W, Robert A, et al. Time course of functional recovery after coronary artery bypass graft surgery in patients with chronic left ventricular ischemic dysfunction. Am J Cardiol. 2000; 85: 1432-9.
8. Yamaguchi A, Ino T, Adachi H, Murata S, Kamio H, Okada M, Tsuboi J. Left ventricular volume predicts postoperative course in patients with ischemic cardiomyopathy. Ann Thorac Surg. 1998; 65: 434-8.
9. Jatene AD. Left ventricular aneurysmectomy: resection or reconstruction? J Thorac Cardiovasc Surg. 1985; 89: 321-31.
10. Dor V, Sabaier M, Di Donato M, Maioli M, Toso A, Montiglio F. Late hemodynamic results after left ventricular patch repair associated with coronary grafting in patients with post infarction: a kynetic or dyskinetic aneurysm of left ventricle J Thorac Cardiovasc Surg. 1995; 110: 1291-301.
11. Athanasuleas GL, Stanley ANH, Buckberg GD, Dor V, DiDonato M, Blackstone EH. Surgical Anterior Ventricular Restoration – SAVER in the dilated remodeled ventricle following anterior myocardial infarction. J Am Coll Cardiol. 2000; 37: 1199-209.
12. Cox JL, Buckberg GD, Athanasuleas CL. The restore group seminars in thoracic and cardiovascular surgery. J Thorac Cardiovasc Surg. 2001;13:301-19.
13. Dor V, Di Donato M, Labatur M. The RESTORE group. Left ventricular reconstruction by endoventricular circular patch repair: a 17 years experience. Semin Thorac Cardiovasc Surg. 2001;13:435-7.
14. Buckberg GD. Basic scence review: the helix and the heart. J Thorac Cardiovasc Surg. 2002; 124: 863:83.
15. Buckberg G, Loghlan HC, Torrent-Guasp F. The structure and function of the helical heart and its buttress wrapping. Geometric concepts of heart failure and use for structural correction. Semin Thorac Cardiovasc Surg. 2001; 13: 386-401.
16. Kanashiro R, Nozawa E, Murad N, Gerola LR, Moises VA, Tucci PJ. Myocardial infarction scar plication in the rat: cardiac mechanics in the animal model for surgical procedures. Ann Thorac Surg. 2002; 73: 1507-13.
17. Romeo F, Pellicia F, Ciafrocca C, Gallo P, Barilla F, Cristofani R. Determinants of end-stage idiopathic dilated cardiomyopathy: a multi variate analysis of 104 patients. Clin Cardiol. 1989; 12 (7): 387-92.
18. Chen FY, Adams DH, Cohn LH. Mitral valve repair in cardiomyopathy. Circulation. 1998; 98: 124-7.
19. Bolling SF, Pagani FD, Deev GM. Intermediate term outcome of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg. 1998; 115: 381-8.
20. Buffolo E, De Paula IAM, Palma H, Branco JN. Nova abordagem cirúrgica para o tratamento de pacientes em insuficiência cardíaca refratária com miocardiopatia dilatada e insuficiência mitral secundária. Arq Bras Cardiol. 2000; 74 (2): 129-34.
21. Puig LB, Gaiotto FA, Oliveira JL, et al. Mitral valve replacement and remodeling of the left ventricle in dilated cardiomyopathy with regurgitation. Initial results. Arq Bras Cardiol. 2002;78:224-9.
22. Calafiore AM, Gallina S, Contini M, Iaco A, Barsotti A, Gaeta F, et al. Surgical treatment of dilated cardiomyopathy with conventional techniques. Eur J Cardiothorac Surg. 1999; 16 (Suppl 1): 73-8.
23. Buffolo E, Branco JNR, Catani R, RESTORE Group. End-stage cardiomyopathy and secondary mitral insufficiency – Surgical alternative with prostheses implant and left ventricular restoration. Eur J Cardiothorac Surg. 2006; 29: S266-S271.
Enio Buffolo R. Borges Lagoa, 1080 – 7o andar 04038-030 – São Paulo, SP, Brazil E-mail:
Article received August 31, 2006; accepted September 14, 2006.
23. Buffolo E, Branco JNR, Catani R, RESTORE Group. End-stage cardiomyopathy and secondary mitral insufficiency – Surgical alternative with prostheses implant and left ventricular restoration. Eur J Cardiothorac Surg. 2006; 29: S266-S271.