ABSTRACT Introduction: Despite its survival benefits, bilateral internal thoracic artery (BITA) grafting is not commonly utilized due to concerns over deep sternal wound infection (DSWI). We observed the role of routine use of BITA and off-pump coronary artery bypass grafting (OPCABG) in the incidence of DSWI and associated risk factors. Methods: Between January 2010 and December 2020, 1,207 patients were treated with isolated coronary artery bypass grafting. In all cases, OPCABG was attempted, and BITA was used whenever there was a need for a second arterial graft for the left coronary artery. DSWI was defined as a wound infection requiring surgical intervention and/or the administration of antibiotics. Multiple linear regression analysis was employed to model the risk of DSWI. Results: The incidence of DSWI was 0.58%. Mortality rate was higher in DSWI group than in no-DSWI group (28.57% vs. 1.25%; P<0.001). No significant difference in DSWI incidence was observed when BITA (70.6%) or single internal thoracic artery (29.4%) were used (P=0.680). The prevalence of diabetes (100% vs. 40.7%; P=0.001), hyperlipidemia (100% vs. 85.9%; P=0.045), and obesity (71.4% vs. 26.8%; P-0.017) was significantly elevated in DSWI group, when compared with no-DSWI group. Diabetes (P=0.0001), unstable angina (P=0.0064), previous myocardial infarction > 30 days (P=0.0009), left ventricular ejection fraction < 50% (P=0.0074), and emergency surgery (P=0.0002) were independent risk factors. Conclusion: The results of routine use of skeletonized BITA after OPCABG were satisfactory regarding DSWI incidence and operative mortality in a single-center experience.

Objetivo: Analisar a perviedade da artéria torácica interna direita pediculada, anteroaórtica em anastomose para o ramo interventricular anterior na revascularização do miocárdio, em relação à artéria torácica interna esquerda, com o uso de angiotomografia coronária, no 6º mês de pós-operatório. Métodos: No período de dezembro de 2008 a dezembro de 2011, 100 pacientes foram selecionados, prospectivamente, para cirurgia de revascularização do miocárdio sem circulação extracorpórea. Foram agrupados em Grupo-1 (G-1) e Grupo-2 (G-2), com 50 pacientes cada, randomização por computador e conhecimento da técnica no início da cirurgia. No G-1, os pacientes receberam artéria torácica interna esquerda para o ramo interventricular anterior e complementação da revascularização do miocárdio com a artéria torácica interna direita livre para ramos da circunflexa. Os pacientes do G-2 receberam artéria torácica interna direita pediculada para o ramo interventricular anterior e complementação da revascularização do miocárdio com artéria torácica interna esquerda, pediculada, para ramos da circunflexa. Resultados: Os grupos eram semelhantes quanto aos dados clínicos de pré-operatório. Houve predominância do sexo masculino, 75,6% e 88% nos grupos 1 e 2 respectivamente. Cinco pacientes migraram do G-1 para o G-2 devido à doença ateromatosa na aorta ascendente. A média de anastomoses distais no G-1 foi de 3,48 (DP=0,72), e no G-2 foi de 3,20 (DP=0,76). Os resultados das angiotomografias coronarianas em 96 pacientes reestudados mostraram que todas as artérias torácicas internas, direita ou esquerda, utilizadas pediculadas para a região anterior do coração encontravam-se pérvias. Não houve óbitos em nenhum dos grupos. Conclusão: A cirurgia de revascularização do miocárdio com utilização da artéria torácica interna direita pediculada, anterógrada para o ramo interventricular anterior, apresenta resultado semelhante ao da artéria torácica interna esquerda utilizada para essa mesma coronária.

Objective: To assess the patency of the pedicled right internal thoracic artery with an anteroaortic course and compare it to the patency of the left internal thoracic artery , in anastomosis to the left anterior descending artery in coronary artery bypass grafting by using coronary CT angiography at 6 months postoperatively. Methods: Between December 2008 and December 2011, 100 patients were selected to undergo a prospective coronary artery bypass grafting procedure without cardiopulmonary bypass. The patients were randomly divided by a computer-generated list into Group-1 (G-1) and Group-2 (G-2), comprising 50 patients each, the technique used was known at the beginning of the surgery. In G-1, coronary artery bypass grafting was performed using the left internal thoracic artery for the left anterior descending and the free right internal thoracic artery for the circumflex, and in G-2, coronary artery bypass grafting was performed using the right internal thoracic artery pedicled to the left anterior descending and the left internal thoracic artery pedicled to the circumflex territory. Results: The groups were similar with regard to the preoperative clinical data. A male predominance of 75.6% and 88% was observed in G-1 and G-2, respectively. Five patients migrated from G-1 to G-2 because of atheromatous disease in the ascending aorta. The average number of distal anastomoses was 3.48 (SD=0.72) in G-1 and 3.20 (SD=0.76) in G-2. Coronary CT angiography in 96 re-evaluated patients showed that all ITAs, right or left, used in situ for the left anterior descending were patent. There were no deaths in either group. Conclusion: Coronary artery bypass grafting surgery involving anastomosis of the anteroaortic right internal thoracic artery to the left anterior descending artery has an outcome similar to that obtained using the left internal thoracic artery for the same coronary site.

Realizamos análise retrospectiva de todos os pacientes com idade igual ou superior a 70 anos, submetidos à operação de revascularização do miocárdio isolada, no período de janeiro de 1992 a dezembro de 1997, objetivando avaliar a morbimortalidade. Do total de 144 pacientes, 92 (63,9%) eram do sexo masculino, idade entre 70 e 84 anos, média de 73,51 anos e desvio padrão de 2,82. A grande maioria encontrava-se com angina classe funcional III ou IV (79,16%). Tiveram relação com a ocorrência de maior mortalidade, a presença no período pré-operatório de: obesidade (p = 0,004), insuficiência cardíaca congestiva (classe III/IV - p = 0,03) e/ou infarto agudo do miocárdio (< 21 dias - p = 0,01). Houve amplo predomínio de pacientes com lesões em três ou mais vasos, com média de 3,48 anastomoses/paciente. Utilizamos a artéria torácica interna pediculada em 126 (87,5%) pacientes; nos últimos 2 anos este índice atingiu 98,9%. As principais complicações presentes no período pós-operatório, mais relacionadas com o óbito, foram: insuficiência renal com diálise (p < 0,0001), infecção (p < 0,0001), com sepse, suporte respiratório prolongado (p < 0,0001), e baixo débito cardíaco (p = 0,003). Para a análise estatística utilizamos o teste T de Student, teste do Qui-quadrado e teste exato de Fisher. A mortalidade cirúrgica global, considerando-se os primeiros 30 dias do período pós-operatório, foi de 5,5% (8/144), caindo para 1,53% (1/65) nos últimos 2 anos. A operação de revascularização do miocárdio no idoso pode ser realizada com baixa morbimortalidade, avaliando-se cuidadosamente o paciente e seus sistemas orgânicos.

A retrospective analysis involving seventy-year-old patients as well as those over seventy who have undergone CABG as a single procedure, during Jannuary 1992 to December 1997, was carried out with the purpose of assessing their morbidity with mortality. Of the 144 patients, 92 (63.9%) were males, aged 70 to 84 (average age 73.51 and standard deviation 2.82). Most of those, 114 (79.16%), suffered from angina belonging to the functional class III or IV. The occurrence in the pre-operative period of obesity (p = 0.004), heart failure (III/IV class - p = 0.03) and/or acute myocardial infection (less than 21 days - p = 0.01) demonstrated a definite relationship with mortality. There were 120 (83.34%) patients with lesions in three or more vessels (average 3.48 anastomoses/patients).The pediculate internal mammary artery was employed in 126 patients (87.5%) and that rate increased to 98.9% in the last two years. The main complications in the post-operation period leading to death were either infections (p < 0.0001), prolonged ventilatory support (p < 0.0001), renal failure with dialysis (p < 0.0001) and/or low cardiac output (p = 0.003). As to statistical analysis the Student T test, the Chi-square test and Fisher's exact test were used. Surgical mortality totalling 5.5% (8/144) in the first thirty post-operative days decreased to 1.53% (1/65) in the last two years. Coronary artery bypass graft in the elderly can be a procedure with low morbidity and mortality if their body systems are carefully evaluated.

No período de 1984-1988, foram estudados 514 pacientes, 288 do sexo feminino e 226 do sexo masculino, com idade de 36,8 ± 16,5 anos, submetidos a cirurgia cardíaca valvar com implante de bioprótese porcina Labcor. As cirurgias realizadas foram, em 64%, relativas à valva mitral, 21,5% à aórtica e 2,1 % mitral-aórtica-tricúspide. No período pré-operatório, 1,6% apresentavam-se em classe funcional (NYHA) II, 63,7% classe III e 34,7% classe IV. Após a cirurgia, 77,2% apresentavam-se em classe I, 21,5% classe II, 0,3% classe III e 1,0% classe IV. O tamanho mais utilizado foi o de número 29 (33,3%), seguido do de número 27 (21,7%) e do de número 31 (15,2%); todos os demais apresentaram freqüências inferiores a 10%. Os débitos hospitalares foram da ordem de 7,6% e os tardios, de 3,2%, sendo a letalidade total igual a 10,1 %. O coeficiente de mortalidade foi de 6,3% pacientes/ano. Os sobreviventes foram acompanhados até 4 anos, ocorrendo 13 óbitos tardios, 34% relacionados à prótese. A incidência de complicações que levaram à reoperação para substituição da prótese foi de 17 (3,6%) casos, sendo 2 por endocardite, 1 por calcificação, 4 por vazamento paravalvular e os demais, por outras causas não relacionadas à prótese. Conclui-se que a bioprótese heteróloga Labcor apresentou, no período estudado, até 4 anos de acompanhamento, baixo índice de complicações diretamente relacionadas à válvula (5 de 475 pacientes que sobreviveram à cirurgia.

Between 1984 and 1988, we studied 514 patients who underwent surgery for valve replacement using Labcor's porcine bioprosthetic valve. Two hundred and eighty-eight patients were female and 226 were male with a mean age of 36.8 ± 16.5 years. There was 64% of mitral valve replacement; 21.6% of aortic valve replacement; 2.1 % of mitral-tricuspid replacement and 0.2 of mitral-aortic-tricuspid replacement. In the pre-operatory period 1.6% of the patients were in the functional class II (NYHA); 63.7% in class III and 34.7% in class IV. After surgery 77.2% of the patients were in functional class I; 21.5% in class II; 0.3% in class III and 1% in class IV. The sizes of the bioprosthetic valve more often used were in order of frequency: 29 (33.3%); 27 (21.7%) and 31 (15.2%). There was a 7.6% incidence of hospital deaths and 3.2% of late deaths. The overall mortality was 10.1%. The mortality rate was 6.3% patients-year. There was a 4 years follow-up with 13 late deaths, 34% of them related to the bioprosthetic porcine valve. A second replacement ocurred in 17 (3.6%) cases and was due to paravalvar leaking in 4 cases, infective endocarditis in 2 cases, calcification in 1 and in 10 cases was not related to the bioprosthetic valve. Thus, the Labcor's bioprosthetic porcine valve, during the 4 year follow-up, showed a low incidence of complications (5 of 475 patients who survived surgery).