RESUMO
INTRODUCTION: Patients with terminal heart failure have increased more than the available organs leading to a high mortality rate on the waiting list. Use of Marginal and expanded criteria donors has increased due to the heart shortage. OBJECTIVE: We analyzed all heart transplantations (HTx) in Sao Paulo state over 8 years for donor profile and recipient risk factors. METHOD: This multi-institutional review collected HTx data from all institutions in the state of Sao Paulo, Brazil. From 2002 to 2008 (6 years), only 512 (28.8%) of 1777 available heart donors were accepted for transplantation. All medical records were analyzed retrospectively; none of the used donors was excluded, even those considered to be nonstandard. RESULTS: The hospital mortality rate was 27.9% (n = 143) and the average follow-up time was 29.4 ± 28.4 months. The survival rate was 55.5% (n = 285) at 6 years after HTx. Univariate analysis showed the following factors to impact survival: age (P = .0004), arterial hypertension (P = .4620), norepinephrine (P = .0450), cardiac arrest (P = .8500), diabetes mellitus (P = .5120), infection (P = .1470), CKMB (creatine kinase MB) (P = .8694), creatinine (P = .7225), and Na+ (P = .3273). On multivariate analysis, only age showed significance; logistic regression showed a significant cut-off at 40 years: organs from donors older than 40 years showed a lower late survival rates (P = .0032). CONCLUSIONS: Donor age older than 40 years represents an important risk factor for survival after HTx. Neither donor gender nor norepinephrine use negatively affected early survival.
Assuntos
Seleção do Doador , Insuficiência Cardíaca/cirurgia , Transplante de Coração/mortalidade , Doadores de Tecidos/provisão & distribuição , Agonistas alfa-Adrenérgicos/uso terapêutico , Adulto , Fatores Etários , Brasil , Distribuição de Qui-Quadrado , Comorbidade , Feminino , Insuficiência Cardíaca/mortalidade , Transplante de Coração/efeitos adversos , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Norepinefrina/uso terapêutico , Razão de Chances , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
Coronary artery bypass surgery (CABG) without cardiopulmonary bypass (CPB) may potentially reduce the number of microembolic signals (MES) associated with aortic manipulation or generated by the pump circuit, resulting in a better neurologic outcome after surgery. Our aim was to compare the frequency of MES and neurologic complications in CABG with and without CPB. Twenty patients eligible to routine CABG without CPB were randomized to surgery with CPB and without CPB and continuously monitored by transcranial Doppler. Neurologic examination was performed in all patients before and after surgery. The two groups were similar with respect to demographics, risk factors, grade of aortic atheromatous disease and number of grafts. The frequency of MES in the nonCPB group was considerably lower than in CPB patients, however, we did not observe any change in the neurologic examination during the early postoperative period. Neurologic complications after CABG may be related to the size and composition of MES rather than to their absolute numbers. A large prospective multicentric randomized trial may help to elucidate this complex issue.
Assuntos
Ponte Cardiopulmonar/efeitos adversos , Ponte de Artéria Coronária/efeitos adversos , Embolia Intracraniana/diagnóstico por imagem , Complicações Intraoperatórias/diagnóstico por imagem , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/etiologia , Ponte Cardiopulmonar/instrumentação , Ponte de Artéria Coronária/instrumentação , Feminino , Humanos , Embolia Intracraniana/etiologia , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Fatores de Risco , Ultrassonografia Doppler TranscranianaRESUMO
It is well known that, subsequent to cardiopulmonary bypass, and particularly in children, an inflammatory response within the body can often result in a characteristic syndrome. Recently, it has been suggested that this phenomenon is due to a systemic inflammatory response, with significant involvement of cytokines. With this in mind, we investigated the behavior of tumour necrosis factor-alpha and interleukin-6 during the operative and in the immediate postoperative period in a group of children submitted to open heart surgery. We investigated any possible relation between the levels of these cytokines in the serum and the length of cardiopulmonary bypass, with the serum levels of lactate, and with the extent of use of inotropic drugs in postoperative period. The cytokines were measured in samples withdrawn after induction of anesthesia, after 10 minutes of cardiopulmonary bypass, after re-establishment of circulation, and then 2 and 24 hours after the end of cardiopulmonary bypass. The levels of tumour necrosis factor-alpha and interleukin-6 increased between the beginning and at two hours of the end of cardiopulmonary bypass. There was no correlation between the levels of these cytokines in the serum and the length of cardiopulmonary bypass, although there was a positive relation between levels of interleukin-6 and lactate in samples withdrawn at two hours of the end of bypass, and the measured levels of the cytokines correlated with the extent of inotropic drugs employed in the postoperative period.
Assuntos
Ponte Cardiopulmonar , Cardiopatias Congênitas/imunologia , Cardiopatias Congênitas/cirurgia , Interleucina-6/metabolismo , Fator de Necrose Tumoral alfa/metabolismo , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Período Intraoperatório , Masculino , Período Pós-Operatório , Estudos Prospectivos , Fatores de TempoRESUMO
BACKGROUND: Anastomosis of a saphenous or mammary artery conduit to the coronary artery requires precise and reproducible microsurgical technique. Over the past 3 decades, the elective induction of cardiac arrest and circulatory support have provided the conditions suitable for microsurgical anastomosis to all coronary vessels. Beating heart coronary grafting was rejuvenated at our center in 1985 as an alternative to cardiopulmonary bypass and cardioplegic arrest. One of the requirements for off-pump grafting is local vascular control of the target vessel and prevention of bleeding into the field from the open coronary artery. The most common hemostasis technique in use today is the application of circumferential traction sutures and snares around the coronary artery. We performed a human cadaver study to evaluate the potential for local trauma to the native coronary artery caused by this method of hemostasis. METHODS: Our research team applied both 5-0 polypropylene and 2-0 polyester snares to the proximal and distal right coronary artery (RCA) and left anterior descending (LAD) in 25 isolated fresh human cadaver hearts. A total of 100 points of snare application to the native coronary vessels were induced and then investigated histologically, with hematoxylin-eosin, Weigert, and phosphotungstic hematoxylin staining. RESULTS: The results suggested a direct relationship between the severity of the arterial lesion induced by the snares and the degree of local atherosclerotic disease in the native coronary artery. Compression and buckling of the elastic lamellae with medial fractures (similar in nature to angioplasty but directed inward) were seen when snares were applied to a region with marked atherosclerotic disease. CONCLUSIONS: The application of snares to the coronary artery proximal and distal to the anastomotic site must be done with caution. In cases of marked atherosclerotic disease in the underlying coronary artery, a new intimal-medial lesion can occur with indiscriminate application of a tourniquet. This phenomenon may account for some of the reported cases of late peri-anastomotic or distal stenoses seen with off-pump coronary artery bypass grafting and significantly detract from the advantages offered by beating heart surgery. If one or both snares can be avoided entirely, or applied carefully to disease-free segments of the vessel, this problem may be avoided entirely.
Assuntos
Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Vasos Coronários/lesões , Complicações Intraoperatórias/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Cadáver , Constrição , Feminino , Técnicas Hemostáticas/efeitos adversos , Humanos , Complicações Intraoperatórias/prevenção & controle , Masculino , Pessoa de Meia-Idade , Medição de Risco , Sensibilidade e Especificidade , Técnicas de SuturaRESUMO
OBJECTIVE: To evaluate the early outcome of mitral valve prostheses implantation and left ventricular remodeling in 23 patients with end-stage cardiomyopathy and secondary mitral regurgitation (NYHA class III and IV). METHODS: Mitral valvular prosthesis implantation with preservation of papillary muscles and chordae tendinae, and plasty of anteriun cuspid for remodeling of the left ventricle. RESULTS: The surgery was performed in 23 patients, preoperative ejection fraction (echocardiography) varied from 13% to 44% (median: 30%). In 13 patients associated procedures were performed: myocardial revascularization (9), left ventricle plicature repair (3) and aortic prosthesis implantation (1). Early deaths (2) occurred on the 4th PO day (cardiogenic shock) and on the 20th PO day (upper gastrointestinal bleeding), and a late death in the second month PO (ventricular arrhythmia). Improvement occurred in NYHA class in 82. 6% of the patients (P<0.0001), with a survival rate of 86.9% (mean of 8.9 months of follow-up). CONCLUSION: This technique offers a promising therapeutic alternative for the treatment of patients in refractory heart failure with cardiomyopathy and secondary mitral regurgitation.
Assuntos
Cardiomiopatia Dilatada/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Insuficiência da Valva Mitral/cirurgia , Adulto , Idoso , Cardiomiopatia Dilatada/diagnóstico por imagem , Cardiomiopatia Dilatada/fisiopatologia , Feminino , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/diagnóstico por imagem , Resultado do Tratamento , UltrassonografiaRESUMO
BACKGROUND: A new form of postperfusion manifestation is detailed, a vasoplegic syndrome presenting in the postoperative period after cardiopulmonary bypass (CPB) heart surgery. METHODS: This retrospective study included sixteen patients who underwent cardiovascular surgery using CPB and exhibited clinical and hemodynamic features compatible with vasoplegic syndrome. The technique of CPB was hypothermic (28 degrees C) in 15 and normothermic in 1 patient, and hypothermic blood cardioplegia was employed in all patients, except 1. The mean CPB time was 121 minutes, ranging from 80 to 210 minutes. RESULTS: The patients presented a severe feature comprising hypotension, tachycardia, normal or elevated cardiac output, low systemic vascular resistance and decreased filling pressures. Fluid administration alone was not capable of restoring hemodynamic parameters. Physical examination revealed normal capillary filling at the extremities although oliguria and hypotension were observed. These patients needed a high dosage of vasoconstrictor drugs (norepinephrine) for blood pressure control but even high dose norepinephrine did not produce the classical situation of cool extremities and weak peripheral pulses, with increased morbidity and mortality. Severe systemic complications could develop if the vasoplegic syndrome persisted 36-48 hours after its onset. All patients, except 3, presented associated postoperative complications and 4 patients died. The characteristics of vasoplegic syndrome are similar to those observed in septic shock, where the alterations are mediated by cytokines and tumor necrosis factor-alpha. CONCLUSIONS: The appearance of vasoplegic syndrome augmented operative morbidity with a consequent increased risk to the patient in the early postoperative period.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Hipotensão/etiologia , Complicações Pós-Operatórias , Taquicardia/etiologia , Adulto , Idoso , Ponte Cardiopulmonar/efeitos adversos , Feminino , Seguimentos , Hemodinâmica/efeitos dos fármacos , Humanos , Hipotensão/tratamento farmacológico , Hipotensão/mortalidade , Masculino , Pessoa de Meia-Idade , Norepinefrina/uso terapêutico , Estudos Retrospectivos , Taxa de Sobrevida , Síndrome , Taquicardia/tratamento farmacológico , Taquicardia/mortalidade , Vasoconstritores/uso terapêuticoRESUMO
OBJECTIVE: To evaluate the neurologic morbidity after orthotopic heart transplantation (OHT), we examined consecutive Chagas' (Ch) and non-Chagas' (NCh) patients, before and after surgery. MATERIAL AND METHODS: We undertook neurological and neuropsychological evaluations in Ch and NCh patients with end-stage cardiac failure, from September 1993 to September 1995. RESULTS: Of 10 Ch patients (mean age = 33.6 years; 7 male; mean follow-up = 10.8 months) and 13 NCh patients (mean age = 50.9 years; 12 male; mean follow-up = 15 months) 3 died (rejection and sepsis) without neurologic symptoms. Neurologic complications occurred in 4 Ch and 5 NCh patients. Two Ch patients had skin and myocardial Chagas' reactivation successfully treated, without CNS involvement. NPS performance and return to work rates were similar in both groups. CONCLUSION: Although Ch patients are potentially at a higher risk of Trypanosoma cruzi reactivation, in addition to all known neurologic complications of OHT, early neurologic complications detected in this sample were similar in Ch and NCh patients and could not be specifically related to Chagas' disease.
Assuntos
Cardiomiopatia Chagásica/cirurgia , Transplante de Coração/fisiologia , Transtornos Neurocognitivos/fisiopatologia , Exame Neurológico , Testes Neuropsicológicos , Doenças do Sistema Nervoso Periférico/fisiopatologia , Complicações Pós-Operatórias/fisiopatologia , Adulto , Cardiomiopatia Chagásica/diagnóstico , Cardiomiopatia Chagásica/fisiopatologia , Doença de Chagas/diagnóstico , Doença de Chagas/fisiopatologia , Feminino , Rejeição de Enxerto/diagnóstico , Rejeição de Enxerto/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Neurocognitivos/diagnóstico , Doenças do Sistema Nervoso Periférico/diagnóstico , Complicações Pós-Operatórias/diagnóstico , RecidivaRESUMO
PURPOSE: Our experience with surgical treatment of heart diseases in Indians living in the Amazon rain forest in primitive stages was reviewed. METHODS: From 1988 to 1995, 18 patients underwent cardiovascular surgical procedures at the São Paulo Hospital of the Escola Paulista de Medicina. Seven patients had valvar disease, nine congenital heart defects, one submitral aneurysm and one arrhythmia. Thirteen Indians came from tribes of the Amazon rain forest area: three from the Xavante, two from Waiapi, two from Tucano, two from Macuxi, two from Mayoruna, and one of each tribe of Xikrin, Guajajara, Terena, Surui, Galibi, Cinta-Larga and Pataxó. RESULTS: We performed 22 operations, with two hospital deaths. Follow-up was possible in 87.5% of cases, with one late death. The majority of cases were due to congenital heart defects and in this series it was noted the absence of operations to treat coronary artery disease. The incidence of valve disease was higher in accultured or semi-accultured Indians. CONCLUSION: The surgical treatment of cardiovascular disease has made possible to the surviving indians to return to and be accepted by their fellow tribesmen.