Scielo RSS <![CDATA[Brazilian Journal of Cardiovascular Surgery]]> http://www.scielo.br/rss.php?pid=0102-763820160006&lang=es vol. 31 num. 6 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.br/img/en/fbpelogp.gif http://www.scielo.br <![CDATA[New Year - New Challenges - New Achievements]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-76382016000600000&lng=es&nrm=iso&tlng=es <![CDATA[Radiation Exposure in Endovascular Infra-Renal Aortic Aneurysm Repair and Factors that Influence It]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-76382016000600415&lng=es&nrm=iso&tlng=es Abstract Objective: The endovascular repair of aortic abdominal aneurysms exposes the patients and surgical team to ionizing radiation with risk of direct tissue damage and induction of gene mutation. This study aims to describe our standard of radiation exposure in endovascular aortic aneurysm repair and the factors that influence it. Methods: Retrospective analysis of a prospective database of patients with abdominal infra-renal aortic aneurysms submitted to endovascular repair. This study evaluated the radiation doses (dose area product (DAP)), fluoroscopy durations and their relationships to the patients, aneurysms, and stent-graft characteristics. Results: This study included 127 patients with a mean age of 73 years. The mean DAP was 4.8 mGy.m2, and the fluoroscopy time was 21.8 minutes. Aortic bilateral iliac aneurysms, higher body mass index, aneurysms with diameters larger than 60 mm, necks with diameters larger than 28 mm, common iliac arteries with diameters larger than 20 mm, and neck angulations superior to 50 degrees were associated with an increased radiation dose. The number of anatomic risk factors present was associated with increased radiation exposure and fluoroscopy time, regardless of the anatomical risk factors. Conclusion: The radiation exposure during endovascular aortic aneurysm repair is significant (mean DAP 4.8 mGy.m2) with potential hazards to the surgical team and the patients. The anatomical characteristics of the aneurysm, patient characteristics, and the procedure's technical difficulty were all related to increased radiation exposure during endovascular aortic aneurysm repair procedures. Approximately 40% of radiation exposure can be explained by body mass index, neck angulation, aneurysm diameter, neck diameter, and aneurysm type. <![CDATA[Aortic Valve Replacement: Treatment by Sternotomy <em>versus</em> Minimally Invasive Approach]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-76382016000600422&lng=es&nrm=iso&tlng=es Abstract Objective: To compare the results of aortic valve replacement with access by sternotomy or minimally invasive approach. Methods: Retrospective analysis of medical records of 37 patients undergoing aortic valve replacement by sternotomy or minimally invasive approach, with emphasis on the comparison of time of cardiopulmonary bypass and aortic clamping, volume of surgical bleeding, time of mechanical ventilation, need for blood transfusion, incidence of atrial fibrillation, length of stay in intensive care unit, time of hospital discharge, short-term mortality and presence of surgical wound infection. Results: Sternotomy was used in 22 patients and minimally invasive surgery in 15 patients. The minimally invasive approach had significantly higher time values of cardiopulmonary bypass (114.3±23.9 versus 86.7±19.8min.; P=0.003), aortic clamping (87.4±19.2 versus 61.4±12.9 min.; P&lt;0.001) and mechanical ventilation (287.3±138.9 versus 153.9±118.6 min.; P=0.003). No difference was found in outcomes surgical bleeding volume, need for blood transfusion, incidence of atrial fibrillation, length of stay in intensive care unit and time of hospital discharge. No cases of short-term mortality or surgical wound infection were documented. Conclusion: The less invasive approach presented with longer times of cardiopulmonary bypass, aortic clamping and mechanical ventilation than sternotomy, however without prejudice to the length of stay in intensive care unit, time of hospital discharge and morbidity. <![CDATA[Oxidative Stress in Human Aorta of Patients with Advanced Aortoiliac Occlusive Disease]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-76382016000600428&lng=es&nrm=iso&tlng=es Abstract Introduction: Oxidative stress seems to be a role in the atherosclerosis process, but research in human beings is scarce. Objective: To evaluate the role of oxidative stress on human aortas of patients submitted to surgical treatment for advanced aortoiliac occlusive disease. Methods: Twenty-six patients were divided into three groups: control group (n=10) formed by cadaveric organ donors; severe aortoiliac stenosis group (patients with severe aortoiliac stenosis; n=9); and total aortoiliac occlusion group (patients with chronic total aortoiliac occlusion; n=7). We evaluated the reactive oxygen species concentration, nicotinamide adenine dinucleotide phosphate-oxidase, superoxide dismutase and catalase activities as well as nitrite levels in samples of aortas harvested during aortofemoral bypass for treatment of advanced aortoiliac occlusive disease. Results: We observed a higher level of reactive oxygen species in total aortoiliac occlusion group (48.3±9.56 pmol/mg protein) when compared to severe aortoiliac stenosis (33.5±7.4 pmol/mg protein) and control (4.91±0.8 pmol/mg protein) groups (P&lt;0.05). Nicotinamide adenine dinucleotide phosphate oxidase activity was also higher in total aortoiliac occlusion group when compared to the control group (3.81±1.7 versus 1.05±0.31 µmol/min.mg protein; P&lt;0.05). Furthermore, superoxide dismutase and catalase activities were significantly higher in the severe aortoiliac stenosis and total aortoiliac occlusion groups when compared to the control cases (P&lt;0.05). Nitrite concentration was smaller in the severe aortoiliac stenosis group in comparing to the other groups. Conclusion: Our results indicated an increase of reactive oxygen species levels and nicotinamide adenine dinucleotide phosphate-oxidase activity in human aortic samples of patients with advanced aortoiliac occlusive disease. The increase of antioxidant enzymes activities may be due to a compensative phenomenon to reactive oxygen species production mediated by nicotinamide adenine dinucleotide phosphate oxidase. This preliminary study offers us a more comprehensive knowledge about the role of oxidative stress in advanced aortoiliac occlusive disease in human beings. <![CDATA[Intraperitoneal Administration of Silymarin Protects End Organs from Multivisceral Ischemia/Reperfusion Injury in a Rat Model]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-76382016000600434&lng=es&nrm=iso&tlng=es Abstract Objective: To determine whether intraperitoneal silymarin administration has favorable effects on the heart, lungs, kidney, and liver and on oxidative stress in a rat model of supraceliac aorta ischemia/reperfusion injury. Methods: Thirty male Wistar albino rats were divided equally into three groups: sham, control, and silymarin. The control and silymarin groups underwent supraceliac aortic occlusion for 45 min, followed by a 60 min period of reperfusion under terminal anesthesia. In the silymarin group, silymarin was administered intraperitoneally during ischemia at a dose of 200 mg/kg. Rats were euthanized using terminal anesthesia, and blood was collected from the inferior vena cava for total antioxidant capacity, total oxidative status, and oxidative stress index measurement. Lungs, heart, liver and kidney tissues were histologically examined. Results: Ischemia/reperfusion injury significantly increased histopathological damage as well as the total oxidative status and oxidative stress index levels in the blood samples. The silymarin group incurred significantly lesser damage to the lungs, liver and kidneys than the control group, while no differences were observed in the myocardium. Furthermore, the silymarin group had significantly lower total oxidative status and oxidative stress index levels than the control group. Conclusion: Intraperitoneal administration of silymarin reduces oxidative stress and protects the liver, kidney, and lungs from acute supraceliac abdominal aorta ischemia/reperfusion injury in the rat model. <![CDATA[Experimental Model for Sutureless Proximal Anastomosis by the Viabahn Open Revascularization TEChnique (VORTEC)]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-76382016000600440&lng=es&nrm=iso&tlng=es Abstract Introduction: In the treatment of complex aneurysms, debranching is an extra-anatomical revascularization of visceral arteries followed by endograft coverage of the thoracoabdominal aorta. It eliminates the need for a thoracotomy and aortic clamping, but requires the performance of several technically demanding visceral anastomosis. In 2008, Lachat described visceral revascularization with the use of a sutureless distal anastomosis, performed by the telescoping of an endograft in the visceral branch, named VORTEC (Viabahn Open Revascularization TEChnique). Objective: An experimental model was created to test the feasibility and short term results of performing a telescoped proximal anastomosis to the abdominal aorta. Methods: Swine model. The abdominal aorta was dissected and ligated between the renal arteries and the iliac vessels. Three centimeters bellow the renal arteries a Viabahn endograft was telescoped for 2 cm into the proximal aorta. The other extremity was conventionally anastomosed to the distal aorta. Patency, sealing and tensile strength of the anastomosis were tested. Results: Time for performing the telescoped anastomosis was shorter (5.4±2.8 min versus 10.3±3.4 min, P&lt;0.05). All grafts were patent and both types of anastomosis presented no bleeding. Immediate tensile strength showed a higher strength of the conventional suture (22.7 x 14.3 N, P&lt;0.09). After 30 days there was no pseudo-aneurysms and the strength of the conventional and VORTEC anastomosis were similar (37.3 x 40.8 N, respectively, P=0.17). Conclusion: Telescoped proximal anastomosis by the technique of VORTEC is feasible. After 30 days the tensile strength of the both anastomosis were similar. <![CDATA[Impact of Surgeon Experience During Carotid Endarterectomy Operation and Effects on Perioperative Outcomes]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-76382016000600444&lng=es&nrm=iso&tlng=es Abstract Objective: We evaluated the effect of surgeon experience on complication and mortality rates of carotid endarterectomy operation. Methods: Fifty-nine consecutive patients who underwent carotid endarterectomy between January 2013 and February 2016 were divided into two groups. Patients who had been operated by surgeons performing carotid endarterectomy for more than 10 years were allocated to group 1 (experienced surgeons; n=34). Group 2 (younger surgeons; n=25) consisted of patients operated by surgeons independently performing carotid endarterectomy for less than 2 years. Both groups were compared in respect of operative results and postoperative complications. Results: No intergroup difference was found for laterality of the lesion or concomitant coronary artery disease. In group 1, signs of local nerve damage (n=2; 5.9%) were detected, whereas in group 2 no evidence of local nerve damage was observed. Surgeons in group 1 used local and general anesthesia in 3 (8.8%) and 31 (91.2%) patients, respectively, while surgeons in group 2 preferred to use local and general anesthesia in 1 (4%) and 24 (96%) patients, respectively. Postoperative stroke was observed in group 1 (n=2; 5.9%) and group 2 (n=2; 5.8%). Conclusion: Younger surgeons perform carotid endarterectomy with similar techniques and have similar results compared to experienced surgeons. Younger surgeons rarely prefer using shunt during carotid endarterectomy. The experience and the skills gained by these surgeons during their training, under the supervision of experienced surgeons, will enable them to perform successful carotid endarterectomy operations independently after completion of their training period. <![CDATA[Low Cost Simulator for Heart Surgery Training]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-76382016000600449&lng=es&nrm=iso&tlng=es Abstract Objective: Introduce the low-cost and easy to purchase simulator without biological material so that any institution may promote extensive cardiovascular surgery training both in a hospital setting and at home without large budgets. Methods: A transparent plastic box is placed in a wooden frame, which is held by the edges using elastic bands, with the bottom turned upwards, where an oval opening is made, "simulating" a thoracotomy. For basic exercises in the aorta, the model presented by our service in the 2015 Brazilian Congress of Cardiovascular Surgery: a silicone ice tray, where one can train to make aortic purse-string suture, aortotomy, aortorrhaphy and proximal and distal anastomoses. Simulators for the training of valve replacement and valvoplasty, atrial septal defect repair and aortic diseases were added. These simulators are based on sewage pipes obtained in construction material stores and the silicone trays and ethyl vinyl acetate tissue were obtained in utility stores, all of them at a very low cost. Results: The models were manufactured using inert materials easily found in regular stores and do not present contamination risk. They may be used in any environment and maybe stored without any difficulties. This training enabled young surgeons to familiarize and train different surgical techniques, including procedures for aortic diseases. In a subjective assessment, these surgeons reported that the training period led to improved surgical techniques in the surgical field. Conclusion: The model described in this protocol is effective and low-cost when compared to existing simulators, enabling a large array of cardiovascular surgery training. <![CDATA[Quadricuspid Aortic Valve: A Comprehensive Review]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-76382016000600454&lng=es&nrm=iso&tlng=es Abstract Quadricuspid aortic valve (QAV) is a rare congenital heart disease. The functional status of QAV is predominantly a pure aortic regurgitation. Clinical manifestations of patients with a QAV depend on the functional status of the QAV and the associated disorders. Significant valvular regurgitation and (or) stenosis is often present with subsequent operation performed at the fifth to sixth decade of life. The functional status of QAV is predominantly regurgitant; whereas pure stenotic QAV can be as few as in only 0.7% of the patients. QAV is usually an isolated anomaly, but other congenital heart defects can be present in 18-32% of the patients. About one-fifth of them require a surgical operation. Tricuspidalization is a preferred technique for QAV repair. As not all the patients with a QAV necessarily warrant a surgical operation, decision-making in patient selection and surgical procedure of choice are crucial. Antibiotic prophylaxis against infective endocarditis is necessary in the QAV patients with unequal-sized cusps. <![CDATA[Endoscopic or No-Touch Vein Harvesting for CABG: What is Best for the Patient?]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-76382016000600461&lng=es&nrm=iso&tlng=es Abstract Quadricuspid aortic valve (QAV) is a rare congenital heart disease. The functional status of QAV is predominantly a pure aortic regurgitation. Clinical manifestations of patients with a QAV depend on the functional status of the QAV and the associated disorders. Significant valvular regurgitation and (or) stenosis is often present with subsequent operation performed at the fifth to sixth decade of life. The functional status of QAV is predominantly regurgitant; whereas pure stenotic QAV can be as few as in only 0.7% of the patients. QAV is usually an isolated anomaly, but other congenital heart defects can be present in 18-32% of the patients. About one-fifth of them require a surgical operation. Tricuspidalization is a preferred technique for QAV repair. As not all the patients with a QAV necessarily warrant a surgical operation, decision-making in patient selection and surgical procedure of choice are crucial. Antibiotic prophylaxis against infective endocarditis is necessary in the QAV patients with unequal-sized cusps. <![CDATA[Development of a Multifunctional Needle for Percutaneous Heart Biopsy and Cell Therapy. A Technical Note]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-76382016000600465&lng=es&nrm=iso&tlng=es Abstract Validation of transendocardial injection as a method for delivering therapeutic agents to the diseased heart is increasing. Puncture heart biopsies should re-emerge as a possible alternative method to allow access to the myocardium and implantable biomaterial for cell therapy. Therefore, this work aims to present a percutaneous puncture device for biopsy and intramyocardial biomaterial injection, standardize the technique and attest to the safety of the method. The adaptation consists of creating myocardial microlesions that allow for better fixation of stem cells. The objective of this technical note covers only the development of the needle and the histological quality of the biopsies. It has not been used in humans yet. <![CDATA[PetCO<sub>2</sub>, VCO<sub>2</sub> and CorPP Values in the Successful Prediction of the Return of Spontaneous Circulation: An Experimental Study on Unassisted Induced Cardiopulmonary Arrest]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-76382016000600468&lng=es&nrm=iso&tlng=es Abstract Validation of transendocardial injection as a method for delivering therapeutic agents to the diseased heart is increasing. Puncture heart biopsies should re-emerge as a possible alternative method to allow access to the myocardium and implantable biomaterial for cell therapy. Therefore, this work aims to present a percutaneous puncture device for biopsy and intramyocardial biomaterial injection, standardize the technique and attest to the safety of the method. The adaptation consists of creating myocardial microlesions that allow for better fixation of stem cells. The objective of this technical note covers only the development of the needle and the histological quality of the biopsies. It has not been used in humans yet.