RESUMO
AIM: This study evaluated the effect of pleurotomy on respiratory system compliance and resistance in off-pump coronary artery bypass (OPCAB) using the left internal thoracic artery (LITA). METHODS: Thirty-two patients were prospectively allocated into two groups: OP group (n = 16 patients with open left pleural cavity); IP group (N.=16 patients with intact pleural cavity). Static and dynamic lung compliance and total respiratory system resistance calculation were recorded at anesthesia induction (before chest opening) and immediately after chest closure. RESULTS: Static lung compliance values significantly decreased after chest closure in both groups (P < 0.0001), but the OP group had a significantly greater decline (P = 0.0007). Dynamic lung compliance decreased in either groups after chest closure (P < 0.0001), however, no significant difference was found between groups (P = 0.228). Total respiratory system resistance increased in both groups (P < 0.05), however the OP group had a higher increase (P = 0.0005). Orotracheal intubation time (P = 0.041) and hospital stay (P = 0.0004) were higher in the OP group. CONCLUSION: Pleura opening and need of chest tube insertion induced significant reduction in static lung compliance and increase in total respiratory system resistance, furthermore contributing to impair pulmonary dysfunction in the early postoperative period after OPCAB.
Assuntos
Resistência das Vias Respiratórias , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Complacência Pulmonar , Pneumopatias/etiologia , Pleura/cirurgia , Adulto , Idoso , Brasil , Distribuição de Qui-Quadrado , Feminino , Humanos , Intubação Intratraqueal , Tempo de Internação , Pneumopatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
The objective of the present study was to determine the relationship between nitric oxide synthases (NOS) and heart failure in cardiac tissue from patients with and without cardiac decompensation. Right atrial tissue was excised from patients with coronary artery disease (CAD) and left ventricular ejection fraction (LVEF) <35 percent (N = 10), and from patients with CAD and LVEF >60 percent (N = 10) during cardiac surgery. NOS activity was measured by the conversion of L-[H ]-arginine to L-[H ]-citrulline. Gene expression was quantified by the competitive reverse transcription-polymerase chain reaction. Both endothelial NOS (eNOS) activity and expression were significantly reduced in failing hearts compared to non-failing hearts: 0.36 ± 0.18 vs 1.51 ± 0.31 pmol mg-1 min-1 (P < 0.0001) and 0.37 ± 0.08 vs 0.78 ± 0.09 relative cDNA absorbance at 320 nm (P < 0.0001), respectively. In contrast, inducible NOS (iNOS) activity and expression were significantly higher in failing hearts than in non-failing hearts: 4.00 ± 0.90 vs 1.54 ± 0.65 pmol mg-1 min-1 (P < 0.0001) and 2.19 ± 0.27 vs 1.43 ± 0.13 cDNA absorbance at 320 nm (P < 0.0001), respectively. We conclude that heart failure down-regulates both eNOS activity and expression in cardiac tissue from patients with LVEF <35 percent. In contrast, iNOS activity and expression are increased in failing hearts and may represent an alternative mechanism for nitric oxide production in heart failure due to ischemic disease.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Doença da Artéria Coronariana , Expressão Gênica , Insuficiência Cardíaca , Angiografia Coronária , Reação em Cadeia da Polimerase Via Transcriptase ReversaRESUMO
The objective of the present study was to determine the relationship between nitric oxide synthases (NOS) and heart failure in cardiac tissue from patients with and without cardiac decompensation. Right atrial tissue was excised from patients with coronary artery disease (CAD) and left ventricular ejection fraction (LVEF) <35% (N = 10), and from patients with CAD and LVEF >60% (N = 10) during cardiac surgery. NOS activity was measured by the conversion of L-[H(3)]-arginine to L-[H(3)]-citrulline. Gene expression was quantified by the competitive reverse transcription-polymerase chain reaction. Both endothelial NOS (eNOS) activity and expression were significantly reduced in failing hearts compared to non-failing hearts: 0.36 +/- 0.18 vs 1.51 +/- 0.31 pmol mg-1 min-1 (P < 0.0001) and 0.37 +/- 0.08 vs 0.78 +/- 0.09 relative cDNA absorbance at 320 nm (P < 0.0001), respectively. In contrast, inducible NOS (iNOS) activity and expression were significantly higher in failing hearts than in non-failing hearts: 4.00 +/- 0.90 vs 1.54 +/- 0.65 pmol mg-1 min-1 (P < 0.0001) and 2.19 +/- 0.27 vs 1.43 +/- 0.13 cDNA absorbance at 320 nm (P < 0.0001), respectively. We conclude that heart failure down-regulates both eNOS activity and expression in cardiac tissue from patients with LVEF <35%. In contrast, iNOS activity and expression are increased in failing hearts and may represent an alternative mechanism for nitric oxide production in heart failure due to ischemic disease.
Assuntos
Doença da Artéria Coronariana/complicações , Insuficiência Cardíaca/enzimologia , Óxido Nítrico Sintase/metabolismo , Idoso , Angiografia Coronária , Doença da Artéria Coronariana/cirurgia , Feminino , Expressão Gênica , Insuficiência Cardíaca/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Óxido Nítrico Sintase/genética , Óxido Nítrico Sintase Tipo II , Óxido Nítrico Sintase Tipo III , Reação em Cadeia da Polimerase Via Transcriptase ReversaRESUMO
Many surgical procedures for the implantation of anomalous left coronary artery from pulmonary artery have been described. A dual coronary system offers most benefit and is most advantageous for the patient. Two autogenous flaps of the pulmonary trunk and ascending aorta, without mobilizing the coronary artery, were created for use in this procedure. This technique was successfully used in an 8 month-old patient with severe myocardial dysfunction and moderate mitral regurgitation. This procedure allows 2 coronary systems to be repaired for any anatomic change of the left coronary artery without the use of prosthetic material. There were no technical complications. During the postoperative course minimal inotropic support was used. The magnetic resonance study, 11 months postoperative, showed wood flow of the left coronary artery and mild mitral regurgitation. The operative technique was simple and its execution easy. The follow-up in the intermediate and late period showed the growth of this endothelized tube.
Assuntos
Aorta/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Anomalias dos Vasos Coronários/cirurgia , Artéria Pulmonar/cirurgia , Anastomose Cirúrgica/métodos , Circulação Coronária/fisiologia , Anomalias dos Vasos Coronários/fisiopatologia , Humanos , Lactente , Masculino , Retalhos CirúrgicosRESUMO
OBJECTIVES: We sought to compare the maternal and fetal outcomes of patients with severe mitral stenosis submitted to percutaneous balloon dilation versus open mitral valve commissurotomy (MVC) during pregnancy. BACKGROUND: Heart failure in patients with mitral stenosis complicating pregnancy is a common problem in developing countries. Since 1984, percutaneous dilation of the mitral valve using a balloon catheter has become a therapeutic alternative to open heart surgery. Although the efficacy of percutaneous mitral valve balloon dilation is well established, its results have never before been compared with the results of commissurotomy during pregnancy. METHODS: We compared the clinical and obstetric complications in 45 women who were treated with percutaneous mitral valve balloon dilation (group I, n = 21; from 1990 to 1995) or open MVC (group II, n = 24; from 1985 to 1990) for severe heart failure due to mitral stenosis during pregnancy. RESULTS: In our study, percutaneous balloon dilation of the mitral valve had a success rate of 95% (Gorlin formula) and 90.5% (echocardiographic "pressure half-time" method), as demonstrated by the final mitral valve area achieved. This improvement was followed by a marked decrease in the mitral valve gradient, left atrial pressure and mean pulmonary artery pressure. Patients in both groups had similar improvements in symptoms. Patients who underwent percutaneous balloon dilation had significantly fewer fetal complications, with a reduction in fetal and neonatal mortality (1 death in group I vs. 8 in group II, p = 0.025). CONCLUSIONS: Percutaneous balloon mitral valvuloplasty is safe and effective and appears to be preferable for the fetus, compared with open MVC during pregnancy.
Assuntos
Cateterismo , Estenose da Valva Mitral/terapia , Valva Mitral/cirurgia , Complicações Cardiovasculares na Gravidez/terapia , Adulto , Feminino , Humanos , Gravidez , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: During coronary surgery without CPB, exposure of posterior vessel via sternotomy can cause deterioration of cardiac hemodynamics requiring inotrope drugs support. Recent animal experiments demonstrate hemodynamic benefit of right heart support (RHS) with the AMED system. The purpose of this study was to evaluate the hemodynamic effects during cardiac manipulation to expose the posterior coronary arteries, and determine the effect of RHS in restoring hemodynamics, increasing anastomotic exposure and reducing inotropic requirements. MATERIAL AND METHODS: From July 28 to December 29, 32 patients (25 men/7 women), mean age of 63.4 (+/- 6.2 years, ages: 49-78) received coronary revascularization with the A-Med RHS device. They were divided into two groups of 16 patients, A and B. Group A patients had at least one circumflex branch bypassed. The anterior wall was systematically bypassed off-pump without RHS. The right coronary artery (RCA) and the obtuse coronary artery (OM) were completed utilizing RHS. In group B patients, all vessels including anterior vessels were bypassed with the RHS. Mean arterial pressure (MAP), mean pulmonary arterial pressure (PAP), cardiac output (CO) and the average pump flow (APF) were recorded during the OM and RCA bypass for group A, and for group B LAD data was also recorded. RESULTS: Elective beating heart coronary artery bypass graft (CABG) was successfully accomplished in 32 patients with RHS. Data measurements recorded in Group A showed the improved hemodynamic recovery for OM and RCA bypass with RHS. The MAP increased from 44 to 68 mmHg (OM) and from 63 to 81 mmHg (RCA); the CO from 2.1 to 4.4 L/min (OM) and from 3.3 to 4.7 L/min (RCA). In group B, the data recorded showed the stability of the MAP in all vessels bypassed (LAD, OM and RCA). No device-related patient incidents occurred. All 32 patients were discharged to their homes. CONCLUSIONS: The AMED system, as RHS support, facilitated coronary bypass without CPB to posterior vessels, restoring hemodynamics, providing better exposure to anastomotic sites and apparently reducing inotropes need. Prospective randomize trials are necessary to confirm this initial experience.
Assuntos
Ponte de Artéria Coronária/métodos , Coração Auxiliar , Idoso , Ponte de Artéria Coronária/instrumentação , Circulação Extracorpórea/instrumentação , Circulação Extracorpórea/métodos , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: This prospective nonrandomized study is the critical assessment of conventional ultrafiltration (CUF) and modified ultrafiltration (MUF) techniques and their efficiency in congenital heart disease surgeries. Use of cardiopulmonary bypass (CPB) in children is associated with body water retention as a consequence of prime volume and systemic inflammatory reaction. The CUF during CPB has reduced body water excess and the MUF after CPB, removes inflammatory mediators, improves hemodynamic performance, and decreases transfusion requirements. METHODS: Forty-one patients, aged 9 to 36 months, submitted to surgical correction for cardiac defects, using CPB, were divided into 2 similar groups: CUF (21 patients) operated between 1996-1997 were ultrafiltered during CPB, and CUF+MUF, (20 patients) operated between 1997-1998 and ultrafiltered during and after CPB. Postoperative duration of ventilator support, pediatric intensive care unit stay (PICU), hospital stay of the groups with and without preoperative pulmonary hypertension (PH), as well as transfusion requirement, hematocrit and platelet counts were compared. RESULTS: There were no technical complications and a significant ultrafiltrate in the CUF+MUF group was observed as compared to the CUF group. No significant differences were observed between the CUF and CUF+MUF groups regarding ventilatory support, PICU stay and hospital stay. Requirements for red cell transfusion, Ht and platelet counts were not statistically different. CONCLUSIONS: CUF and CUF+MUF were safe and efficient methods for patient stabilization independent of diagnosis and complexity of surgery. Future clinical evaluation should address a larger population of patients to research the different variables.
Assuntos
Ponte Cardiopulmonar/métodos , Hemofiltração/métodos , Algoritmos , Transfusão de Sangue/estatística & dados numéricos , Pré-Escolar , Feminino , Cardiopatias Congênitas/cirurgia , Humanos , Lactente , Tempo de Internação , Masculino , Monitorização Intraoperatória , Estudos Prospectivos , Respiração Artificial , Risco , 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.