Efficacy of aneurysmectomy in patients with severe left ventricular dysfunction: favorable short‐ and long‐term results in ischemic cardiomyopathy

INTRODUCTION: The purpose of this study was to (1) identify the functional results after aneurysm surgery in patients with ischemic cardiomyopathy and (2) identify predictors of favorable outcomes. METHODS AND MATERIAL: Patients (n = 169) with angiographic left ventricular ejection fraction of 22±5% underwent aneurysm surgery and were prospectively followed for three years. Prior to surgery, 40% and 60% of the patients were in congestive heart failure NYHA class I/II and III/IV, respectively. Concomitant revascularization was performed on 95% of the patients. RESULTS: Cumulative in-hospital and 36-month mortalities were 7% and 15%, respectively. These respective rates varied according to preoperative parameters: CHF class I-II, 4% and 13%; CHF class III-IV, 8% and 16%; LVEF,20%, 12% and 26%; LVEF 21-30%, 2% and 6%; gated LVEF exercise/rest .5%, ,1% and 4%; and gated LVEF exercise/rest #5%, 17% and 38%. Higher LVEF ex/rest ratio (p = 0.01), male sex (p = 0.05), and a higher number of grafts (p = 0.01) were predictive of improvement in CHF class at follow-up based on the results of a multivariate analysis. After three years of follow-up, 84% of the patients were in class I/II, LVEF was 45±7%, and gated LVEF ex/rest ratio was 13% higher (p,0.01) compared to the beginning of the study. CONCLUSIONS: These data suggest that aneurysmectomy among patients with severe LV dysfunction result in shortand long-term favorable functional outcome and survival. Selection of appropriate surgical candidates may substantially improve survival rates among these patients

Efficacy of aneurysmectomy in patients with severe left ventricular dysfunction: favorable short-and long-term results in ischemic cardiomyopathy

INTRODUCTION: The purpose of this study was to (1) identify the functional results after aneurysm surgery in patients with ischemic cardiomyopathy and (2) identify predictors of favorable outcomes. METHODS AND MATERIAL: Patients (n = 169) with angiographic left ventricular ejection fraction of 22±5% underwent aneurysm surgery and were prospectively followed for three years. Prior to surgery, 40% and 60% of the patients were in congestive heart failure NYHA class I/II and III/IV, respectively. Concomitant revascularization was performed on 95% of the patients. RESULTS: Cumulative in-hospital and 36-month mortalities were 7% and 15%, respectively. These respective rates varied according to preoperative parameters: CHF class I-II, 4% and 13%; CHF class III-IV, 8% and 16%; LVEF,20%, 12% and 26%; LVEF 21-30%, 2% and 6%; gated LVEF exercise/rest .5%, ,1% and 4%; and gated LVEF exercise/rest #5%, 17% and 38%. Higher LVEF ex/rest ratio (p = 0.01), male sex (p = 0.05), and a higher number of grafts (p = 0.01) were predictive of improvement in CHF class at follow-up based on the results of a multivariate analysis. After three years of follow-up, 84% of the patients were in class I/II, LVEF was 45±7%, and gated LVEF ex/rest ratio was 13% higher (p,0.01) compared to the beginning of the study. CONCLUSIONS: These data suggest that aneurysmectomy among patients with severe LV dysfunction result in shortand long-term favorable functional outcome and survival. Selection of appropriate surgical candidates may substantially improve survival rates among these patients

Myocardial revascularization surgery in a patient with Situs Inversus Totalis: A case report

Dextrocardia with situs inversus totalis is a rare congenital abnormality. Most coronary artery bypass grafting surgeries in patients with dextrocardia were performed with anastomosis, using the right internal thoracic artery to revascularize the left anterior descending. It should be noted that in the literature there are few reports of coronary artery bypass grafting surgery, in a patient with this abnormality, its anatomical complexity constitutes a challenge in planning the surgical technique and the grafts to be used. We present an unusual case of a patient with situs inversus totalis and coronary artery disease who underwent coronary artery bypass grafting surgery making it a more technically complex procedure for surgeons, in addition to the difficulty in choosing grafts.La dextrocardia con situs inversus totalis es una anomalía congénita poco frecuente. La mayoría de las cirugías de injerto de derivación de arteria coronaria en pacientes con dextrocardia se realizaron con anastomosis, utilizando la arteria torácica interna derecha para revascularizar la descendente anterior izquierda. Cabe señalar que en la literatura existen pocos reportes de cirugía de injerto de bypass coronario, en un paciente con esta anomalía. Su complejidad anatómica constituye un desafío en la planificación de la técnica quirúrgica y los injertos a utilizar. Presentamos un caso inusual de un paciente con situs inversus totalis y enfermedad arterial coronaria que se sometió a una cirugía de revascularización coronaria, lo que lo convierte en un procedimiento técnicamente más complejo para los cirujanos, además de la dificultad para elegir los injertos

Coronary artery bypass grafting in acute myocardial infarction: analysis of predictors of in-hospital mortality

OBJETIVO: A cirurgia de revascularização miocárdica (CRM) na fase aguda do infarto do miocárdio (IAM) está associada a aumento do risco operatório. O objetivo do estudo foi determinar fatores preditores de mortalidade intra-hospitalar nos pacientes submetidos a CRM no IAM. MÉTODOS: Durante três anos, todos os pacientes submetidos a CRM no IAM foram analisados retrospectivamente, utilizando o banco de dados institucional. Sessenta variáveis por paciente foram avaliadas: 49 variáveis pré-operatórias provenientes dos escores 2000 Bernstein-Parsonnet e EuroSCORE; 4 variáveis pré-operatórias não consideradas por esses escores (tempo entre o IAM e a CRM, valor máximo de CKMB, valor máximo de troponina e supradesnivelamento do segmento ST) e 7 variáveis intraoperatórias [uso de circulação extracorpórea (CEC), tempo de CEC, tipo de cardioplegia, endarterectomia, número de enxertos, uso da artéria torácica interna e revascularização completa]. Análise univariada e multivariada para o desfecho mortalidade intra-hospitalar foram realizadas. RESULTADOS: O tempo médio entre o IAM e a CRM foi de 3,8 ± 3 dias. A mortalidade global foi 19%. Na análise multivariada: idade > 65 anos [OR 16,5 (IC 1,8-152), P=0,013]~ CEC >108 minutos [OR 40 (IC 2,7-578), P=0,007], creatinina > 2 mg/dl [OR 35,5 (IC 1,7-740), P=0,021] e pressão pulmonar sistólica > 60 mmHg [OR 31(IC 1,6-591), P=0,022] foram preditores de mortalidade intra-hospitalar. CONCLUSÃO: Variáveis pré-operatórias clássicas como idade > 65 anos, creatinina > 2 mg/dl e pressão pulmonar sistólica > 60 mmHg foram preditoras de mortalidade intra-hospitalar nos pacientes operados de revascularização miocárdica na fase aguda do infarto

Does prior coronary angioplasty affect outcomes of surgical coronary revascularization? Insights from the STICH trial

Background: The STICH trial showed superiority of coronary artery bypass plus medical treatment (CABG) over medical treatment alone (MED) in patients with left ventricular ejection fraction (LVEF) ≤35%. In previous publications, percutaneous coronary intervention (PCI) prior to CABG was associated with worse prognosis. Objectives: The main purpose of this study was to analyse if prior PCI influenced outcomes in STICH. Methods and results: Patients in the STICH trial (n = 1212), followed for a median time of 9.8 years, were included in the present analyses. In the total population, 156 had a prior PCI (74 and 82, respectively, in the MED and CABG groups). In those with vs. without prior PCI, the adjusted hazard-ratios (aHRs) were 0.92 (95% CI = 0.74–1.15) for all-cause mortality, 0.85 (95% CI = 0.64–1.11) for CV mortality, and 1.43 (95% CI = 1.15–1.77) for CV hospitalization. In the group randomized to CABG without prior PCI, the aHRs were 0.82 (95% CI = 0.70–0.95) for all-cause mortality, 0.75 (95% CI = 0.62–0.90) for CV mortality and 0.67 (95% CI = 0.56–0.80) for CV hospitalization. In the group randomized to CABG with prior PCI, the aHRs were 0.76 (95% CI = 0.50–1.15) for all-cause mortality, 0.81 (95% CI = 0.49–1.36) for CV mortality and 0.61 (95% CI = 0.41–0.90) for CV hospitalization. There was no evidence of interaction between randomized treatment and prior PCI for any endpoint (all adjusted p > 0.05). Conclusion: In the STICH trial, prior PCI did not affect the outcomes of patients whether they were treated medically or surgically, and the superiority of CABG over MED remained unchanged regardless of prior PCI. Clinical trial registration: Clinicaltrials.gov; Identifier: NCT0002359

InsCor: A Simple and Accurate Method for Risk Assessment in Heart Surgery

FUNDAMENTO: Escores de risco apresentam dificuldades para obter o mesmo desempenho em diferentes populações. OBJETIVO: Criar um modelo simples e acurado para avaliação do risco nos pacientes operados de doença coronariana e/ou valvar no Instituto do Coração da Universidade de São Paulo (InCor-HCFMUSP). MÉTODOS: Entre 2007 e 2009, 3.000 pacientes foram operados consecutivamente de doença coronariana e/ou valvar no InCor-HCFMUSP. Desse registro, dados de 2/3 dos pacientes foram utilizados para desenvolvimento do modelo (técnica de bootstrap) e de 1/3 para validação interna do modelo. O desempenho do modelo (InsCor) foi comparado aos complexos 2000 Bernstein-Parsonnet (2000BP) e EuroSCORE (ES). RESULTADOS: Apenas 10 variáveis foram selecionadas: Idade > 70 anos; sexo feminino; cirurgia de revascularização coronariana + valva; infarto de miocárdio < 90 dias; reoperação; tratamento cirúrgico da valva aórtica; tratamento cirúrgico da valva tricúspide; creatinina < 2mg/dL; fração de ejeção < 30%; e eventos. O teste de Hosmer Lemeshow para o InsCor foi de 0,184, indicando uma excelente calibração. A área abaixo da curva ROC foi de 0,79 para o InsCor, 0,81 para o ES e 0,82 para o 2000BP, confirmando que os modelos são bons e similares na discriminação. CONCLUSÕES: O InsCor e o ES tiveram melhor desempenho que o 2000BP em todas as fases da validação; pórem o novo modelo, além de se identificar com os fatores de risco locais, é mais simples e objetivo para a predição de mortalidade nos pacientes operados de doença coronariana e/ou valvar no InCor-HCFMUSP