Human Saphenous Vein Organ Culture Under Controlled Hemodynamic Conditions

INTRODUCTION: Saphenous vein grafting is still widely used to revascularize ischemic myocardium. The effectiveness of this procedure is limited by neointima formation and accelerated atherosclerosis, which frequently leads to graft occlusion. A better understanding of this process is important to clarify the mechanisms of vein graft disease and to aid in the formulation of strategies for prevention and/or therapeutics. OBJECTIVE: To develop an ex vivo flow system that allows for controlled hemodynamics in order to mimic arterial and venous conditions. METHODS: Human saphenous veins were cultured either under venous (flow: 5 ml/min) or arterial hemodynamic conditions (flow: 50 ml/min, pressure: 80 mmHg) for 1-, 2- and 4-day periods. Cell viability, cell density and apoptosis were compared before and after these intervals using MTT, Hoeschst 33258 stain, and TUNEL assays, respectively. RESULTS: Fresh excised tissue segments were well preserved prior to the study. Hoechst 33258 and MTT stains showed progressive losses in cell density and cell viability in veins cultured under arterial hemodynamic conditions from 1 to 4 days, while no alterations were observed in veins cultured under venous conditions. Although the cell density from 1-day cultured veins under arterial conditions was similar to that of freshly excised veins, the TUNEL assay indicated that most of these cells were undergoing apoptosis. CONCLUSION: The results observed resemble the events taking place during early in vivo arterial-vein grafting and provide evidence that an ex vivo perfusion system may be useful for the identification of new therapeutic targets that ameliorate vein graft remodeling and increase graft patency over time

Does the coronary disease increase the hospital mortality in patients with aortic stenosis undergoing valve replacement?

OBJETIVOS: Com o aumento da expectativa de vida nas últimas décadas, tem-se um aumento concomitante da prevalência da estenose aórtica degenerativa e da doença aterosclerótica arterial coronária. O presente estudo visa avaliar a influência da doença aterosclerótica arterial coronária crítica em pacientes portadores de estenose aórtica submetidos ao implante isolado de prótese valvar ou combinado à revascularização do miocárdio. MÉTODOS: No período de janeiro de 2001 a março de 2006, foram analisados 448 pacientes submetidos ao implante isolado de prótese valvar aórtica (Grupo I) e 167 pacientes submetidos à substituição valvar aórtica combinada à revascularização do miocárdio (Grupo II). As variáveis pré e intra-operatórias eleitas para análise foram: sexo, idade, índice de massa corpórea, acidente vascular cerebral, diabete melito, doença pulmonar obstrutiva crônica, febre reumática, hipertensão arterial sistêmica, endocardite, infarto agudo do miocárdio e tabagismo, fração de ejeção do ventrículo esquerdo, doença aterosclerótica arterial coronária crítica, fibrilação atrial crônica, operação valvar aórtica prévia (conservadora), classe funcional de insuficiência cardíaca congestiva, valor sérico de creatinina, colesterol total, tamanho da prótese utilizada, extensão e número de anastomoses distais da revascularização do miocárdio realizada, tempos de circulação extracorpórea de pinçamento aórtico. No estudo estatístico empregou-se análise univariada multivariada. RESULTADOS: A mortalidade hospitalar foi 14,3% (64 óbitos) no Grupo I, sendo 14,5% (58 óbitos) nos pacientes sem doença aterosclerótica arterial coronária crítica associada (Grupo IB) e 12,8% (6 óbitos) nos que apresentavam essa associação (Grupo IA). A mortalidade hospitalar no Grupo II foi 17,6% (29 óbitos), sendo 16,1% (20 óbitos) nos pacientes submetidos à substituição valvar aórtica combinada à revascularização completa do miocárdio (Grupo IIA) e 20,9% (nove óbitos) nos com revascularização incompleta do miocárdio (Grupo IIB). CONCLUSÕES: Nos pacientes submetidos à substituição valvar aórtica isolada, a presença de doença aterosclerótica arterial coronária crítica associada, em pelo menos duas artérias, influenciou a mortalidade hospitalar. Nos pacientes submetidos ao tratamento cirúrgico combinado, o número de artérias coronárias com doença aterosclerótica crítica e a extensão da revascularização do miocárdio (RM completa ou incompleta), não influenciaram a mortalidade hospitalar, mas a realização de mais de três anastomoses distais interferiu.OBJECTIVES: With the increase in life expectancy occurred in recent decades, it has been noted the concomitant increase in the prevalence of aortic stenosis and degenerative disease of atherosclerotic coronary artery. This study aims to evaluate the influence of atherosclerotic coronary artery disease in patients with critical aortic stenosis undergoing isolated or combined implant valve prosthesis and coronary artery by pass grafting. METHODS: In the period of January 2001 to March 2006, there were analyzed 448 patients undergoing isolated implant aortic valve prosthesis (Group I) and 167 patients undergoing aortic valve prosthesis implant combined with coronary artery bypass grafting (Group II). Pre- and intra-operative variables elected for analysis were: age, gender, body mass index, stroke, diabetes mellitus, chronic obstructive pulmonary disease, rheumatic fever, hypertension, endocarditis, acute myocardial infarction, smoking, Fraction of the left ventricular ejection, critical atherosclerotic coronary artery disease, chronic atrial fibrillation, aortic valve operation prior (conservative), functional class of congestive heart failure, value serum creatinine, total cholesterol, size of the prosthesis used, length and number of distal anastomoses held in myocardial revascularization, duration of cardiopulmonary bypass and aortic clamping time. The statistical study employed invariant and multivariate analysis. RESULTS: Hospital mortality was 14.3% (64 deaths) in Group I, and 14.5% (58 deaths) in patients with atherosclerotic coronary artery disease associated criticism (Group IB) and 12.8% (six deaths) in which had this association (Group IA). Hospital mortality in Group II was 17.6% (29 deaths), and 16.1% (20 deaths) in patients undergoing implantation of prosthetic aortic valve combined to complete myocardial revascularization (Group II) and 20.9% (nine deaths) in the myocardial revascularization with incomplete (Group IIB). CONCLUSIONS: In patients undergoing implant isolated from aortic valve prosthesis, the presence of atherosclerotic coronary artery disease associated critical in at least two arteries, influenced the hospital mortality. In patients undergoing surgical treatment combined the number of coronary arteries with critical atherosclerotic disease and extent of coronary artery bypass grafting (complete or incomplete), did not affect the hospital mortality, but the realization of more than three anastomoses in the distal myocardial revascularization interfered

Degree of risk related to procedures performed in conjunction with surgical myocardial revascularization in octogenarians

INTRODUCTION/OBJECTIVES: We determined the degree of risk produced by the association of other surgical procedures with surgical myocardial revascularization in octogenarian patients and identified the risk factors that best explain hospital mortality. METHODS: This study was an observational analytical historical cohort study involving octogenarians operated on at our institution between January 1, 2000 and January 1, 2005. We stratified the objective population as follows: Group 1 comprised octogenarians revascularized without associated procedures, and Group 2 comprised octogenarians revascularized with associated procedures. Statistical analyses included the t test for independent samples and multiple logistic regression analysis. Significance was accepted with an alpha error of 5%. RESULTS: Univariate analyses revealed the following clinical and statistically significant variables: hospital mortality (P=0.002), diabetes mellitus (P=0.017), preoperative endocarditis (P=0.001), cardiogenic shock (P=0.019), use of an intra-aortic balloon pump (P=0.026), preoperative risk score (Parsonnet), P<0.001, procedure associated with revascularization (P<0.001), medium number of affected coronary arteries (P<0.001), use of extracorporeal circulation (P<0.001), time of extracorporeal circulation (P<0.001), number of distal anastomoses (P=0.002), graft type (P<0.001), postoperative breathing support (P<0.001), stroke (P<0.001), infection (P=0.002), creatinine level (P=0.018), and quality of life score (P=0.050). DISCUSSION/CONCLUSIONS: In octogenarian patients, the need for a procedure associated with surgical myocardial revascularization produces an absolute increase in hospital mortality risk of 45%. The variables that contributed to hospital mortality were preoperative endocarditis, preoperative cardiogenic shock, the use of extracorporeal circulation, the length of time of extracorporeal circulation, postoperative creatinine level, and postoperative need for prolonged respiratory support

Hybrid CABG: an alternative for perfusion time decrease

OBJETIVO: Avaliar a possibilidade da redução do tempo de circulação extracorpórea (CEC) e das complicações relacionadas a esta variável na revascularização do miocárdio (RM), utilizando o método híbrido como alternativa. MÉTODOS: Noventa pacientes foram analisados, retrospectivamente, entre março/2000 e agosto/2006. Todos foram revascularizados com três ou mais enxertos e divididos em doisgrupos: híbrido - 45 pacientes que foram operados pela técnica híbrida; total - 45 pacientes operados com CEC. RESULTADOS: No grupo híbrido, o tempo de CEC variou de 20 a 81 minutos e, no grupo total, de 60 a 210 minutos (p<0,001). O tempo de pinçamento aórtico variou de 7 a 70 minutos no primeiro grupo e de 34 a 100 minutos (p<0,001) no segundo grupo. Foi encontrada diferença estatisticamente significativa entre os grupos em relação à incidência de fibrilação atrial e à disfunção renal. CONCLUSÃO: Utilizando-se a técnica híbrida é possível reduzir o tempo de CEC e a incidência de algumas complicações pós-operatórias. Provavelmente, esta redução nas incidências de fibrilação atrial e disfunção renal podem ser explicadas por uma redução na resposta da inflamatória conseqüente a um tempo de CEC menor.OBJECTIVE: To evaluate the decrease of CPB time and its related complications in CABG using a hybrid alternative method. METHODS: Ninety patients were retrospectively analyzed between March 2000 and August 2006. All were treated with three or more grafts and divided into two groups: Group 1 was the hybrid group - 45 patients who had been operated by the hybrid technique; Group 2 was the total group - 45 patients operated in on-pump. RESULTS: In the hybrid group, the CPB time varied from 20 min. to 81 min. In the total group, the CPB time varied from 60 min. to 210 min. (p<0.001). The aorta cross-clamping time varied in the first group from 7 min. to 70 min. In Group 2, from 34 to 100 min. (p<0.001). A statistically significant difference was found between these two groups in relation to the occurrence of postoperative atrium fibrillation and renal dysfunction. CONCLUSION: Using the hybrid technique it is possible to reduce the CPB time, as well as the occurrence of some postoperative complications. Probably, this decreasing in atrial fibrillation and renal dysfunction incidences could be explained due to a less significant inflammatory activation, which is a consequence of a shorter CPB time

Degree of risk related to procedures performed in conjunction with surgical myocardial revascularization in octogenarians

INTRODUCTION/OBJECTIVES: We determined the degree of risk produced by the association of other surgical procedures with surgical myocardial revascularization in octogenarian patients and identified the risk factors that best explain hospital mortality. METHODS: This study was an observational analytical historical cohort study involving octogenarians operated on at our institution between January 1, 2000 and January 1, 2005. We stratified the objective population as follows: Group 1 comprised octogenarians revascularized without associated procedures, and Group 2 comprised octogenarians revascularized with associated procedures. Statistical analyses included the t test for independent samples and multiple logistic regression analysis. Significance was accepted with an alpha error of 5%. RESULTS: Univariate analyses revealed the following clinical and statistically significant variables: hospital mortality (P=0.002), diabetes mellitus (P=0.017), preoperative endocarditis (P=0.001), cardiogenic shock (P=0.019), use of an intra-aortic balloon pump (P=0.026), preoperative risk score (Parsonnet),

Estudo comparativo de duas diferentes modalidades de analgesia controlada pelo paciente após cirurgia cardíaca

INTRODUCTION: Acute and severe pain is frequent in patients who undergo cardiothoracic surgery. Patient controlled analgesia (PCA) can be used to manage postoperative pain. OBJECTIVE: To compare analgesia of morphine PCA alone (without continous infusion) with morphine PCA plus a continuous infusion on postoperative period after cardiac surgery and to evaluate pain scores, morphine consumption, number of demand, patient satisfaction and side effects. METHODS: Randomized trial was conducted to assess patients who underwent cardiac surgery receiving either morphine PCA alone or morphine PCA plus continous infusion. In the post operative period, PCA was started at extubation in both regiments according to randomization. Pain intensity, morphine consumption, number of demand, satisfaction and side effects were assessed at zero, six, twelve, eighteen, twenty four and thirty hours after patients' extubation. RESULTS: The study enrolled 100 patients. 50 patients received morphine PCA alone, (Group A) and 50 patients received morphine PCA plus a background infusion, (Group B). Group B patients had less demand, consumed more morphine and were more satisfied regarding analgesia. No statistical differences were shown between groups related to pain intensity, and side effects. CONCLUSIONS: Pain control was effective and similar in both groups. Morphine PCA alone seems to be better for postoperative pain manage in cardiac surgery, due to its less morphine expense with the same effectiveness.INTRODUÇÃO: A dor aguda e intensa faz parte do cotidiano dos pacientes que realizam cirurgia cardíaca, e para o controle da dor, pode-se dispor da analgesia controlada pelo paciente (PCA -Patient controlled analgesia). OBJETIVO: Comparar a analgesia utilizando PCA sem infusão contínua com PCA mais infusão contínua de morfina no pós-operatório de cirurgia cardíaca e avaliar a intensidade dolorosa, consumo analgésico, número de solicitações analgésicas, satisfação e efeitos colaterais. MÉTODOS: Ensaio clínico randomizado em que foram estudados pacientes submetidos a cirurgias cardíacas, que utilizaram PCA com e sem infusão intravenosa de morfina. No pós-operatório, ao se extubar os pacientes, foi instalada PCA nas duas modalidades, conforme o sorteio. Intensidade dolorosa, consumo analgésico, número de solicitações analgésicas, satisfação e efeitos colaterais foram avaliados no momento da extubação e nas 6, 12, 18, 24 e 30 horas seguintes. RESULTADOS: Foram avaliados 100 pacientes, sendo 50 no grupo (A) que recebeu PCA sem infusão contínua de morfina, e 50 no grupo (B) que utilizou PCA com infusão contínua de morfina. Pacientes do grupo (B) consumiram mais morfina, solicitaram menos vezes, e ficaram mais satisfeitos com a analgesia. Não se observaram diferenças significantes entre os grupos quanto à intensidade da dor e aos efeitos colaterais. CONCLUSÕES: O controle da dor foi eficiente e similar em ambos os grupos estudados. A mesma eficácia de analgesia e o menor consumo de morfina sugerem que PCA sem infusão contínua de morfina seja a melhor opção no controle da dor no pós-operatório de cirurgia cardíaca.Clinics HospitalFederal University of São PauloHeart InstituteHeart Institute Heart Surgical Diseases GroupUNIFESPSciEL

Adherence to the cardiac surgery checklist decreased mortality at a teaching hospital: A retrospective cohort study

Objective: To evaluate the impact of adherence to the cardiac surgical checklist on mortality at the teaching hospital. Methods: A retrospective cohort study after the implementation of the cardiac surgical safety checklist in a reference hospital in Latin America. All patients undergoing coronary artery bypass surgery and/or heart valve surgery from&nbsp;2013 to&nbsp;2019 were analyzed. After the implementation of the project InCor-Checklist “Five steps to safe cardiac surgery” in&nbsp;2015, the correlation between adherence and completeness of this instrument with surgical mortality was assessed. The EuroSCORE&nbsp;II was used as a reference to assess the risk of expected mortality for patients. Cross-sectional questionnaires were during the implementation of the InCor-Checklist. To perform the correlation, Pearson's coefficient was calculated using R software. Results: Since&nbsp;2013, data from&nbsp;8139&nbsp;patients have been analyzed. The average annual mortality was&nbsp;5.98%. In&nbsp;2015, the instrument was used in only&nbsp;58% of patients; in contrast, it was used in&nbsp;100% of patients in&nbsp;2019. There was a decrease in surgical mortality from&nbsp;8.22% to&nbsp;3.13% for the same group of procedures. The results indicate that the greater the checklist use, the lower the surgical mortality (r&nbsp;=&nbsp;88.9%). In addition, the greater the InCor-Checklist completeness, the lower the surgical mortality (r&nbsp;=&nbsp;94.1%). Conclusion: In the formation of the surgical patient safety culture, the implementation and adherence to the InCor-Checklist “Five steps to safe cardiac surgery” was associated with decreased mortality after cardiac surgery