ABSTRACT Introduction: Along with cardiopulmonary bypass time, aortic cross-clamping time is directly related to the risk of complications after heart surgery. The influence of the time difference between cardiopulmonary bypass and cross-clamping times (TDC-C) remains poorly understood. Objective: To assess the impact of cardiopulmonary bypass time in relation to cross-clamping time on immediate results after coronary artery bypass grafting in the Registro Paulista de Cirurgia Cardiovascular (REPLICCAR) II. Methods: Analysis of 3,090 patients included in REPLICCAR II database was performed. The Society of Thoracic Surgeons outcomes were evaluated (mortality, kidney failure, deep wound infection, reoperation, cerebrovascular accident, and prolonged ventilation time). A cutoff point was adopted, from which the increase of this difference would affect each outcome. Results: After a cutoff point determination, all patients were divided into Group 1 (cardiopulmonary bypass time < 140 min., TDC-C < 30 min.), Group 2 (cardiopulmonary bypass time < 140 min., TDC-C > 30 min.), Group 3 (cardiopulmonary bypass time > 140 min., TDC-C < 30 min.), and Group 4 (cardiopulmonary bypass time > 140 min., TDC-C > 30 min.). After univariate logistic regression, Group 2 showed significant association with reoperation (odds ratio: 1.64, 95% confidence interval: 1.01-2.66), stroke (odds ratio: 3.85, 95% confidence interval: 1.99-7.63), kidney failure (odds ratio: 1.90, 95% confidence interval: 1.32-2.74), and in-hospital mortality (odds ratio: 2.17, 95% confidence interval: 1.30-3.60). Conclusion: TDC-C serves as a predictive factor for complications following coronary artery bypass grafting. We strongly recommend that future studies incorporate this metric to improve the prediction of complications. Introduction crossclamping cross clamping surgery TDCC TDC C (TDC-C understood Objective (REPLICCAR Methods 3090 090 3,09 performed mortality, (mortality infection accident time. . time) adopted outcome Results determination 14 min min. , min.) min.. regression odds ratio 164 64 1.64 95 interval 1.012.66, 101266 1.01 2.66 01 66 1.01-2.66) 385 85 3.85 1.997.63, 199763 1.99 7.63 99 7 63 1.99-7.63) 190 90 1.90 1.322.74, 132274 1.32 2.74 32 74 1.32-2.74) inhospital hospital 217 17 2.17 1.303.60. 130360 1.30 3.60 60 1.30-3.60) Conclusion 309 09 3,0 16 6 1.6 9 012 1.012.66 10126 101 1.0 266 2.6 0 1.01-2.66 38 8 3.8 997 1.997.63 19976 199 1.9 763 7.6 1.99-7.63 19 322 1.322.74 13227 132 1.3 274 2.7 1.32-2.74 21 2.1 303 1.303.60 13036 130 360 3.6 1.30-3.60 3, 1. 1.012.6 1012 10 26 2. 1.01-2.6 3. 1.997.6 1997 76 7. 1.99-7.6 1.322.7 1322 13 27 1.32-2.7 1.303.6 1303 36 1.30-3.6 1.012. 1.01-2. 1.997. 1.99-7. 1.322. 1.32-2. 1.303. 1.30-3. 1.012 1.01-2 1.997 1.99-7 1.322 1.32-2 1.303 1.30-3 1.01- 1.99- 1.32- 1.30-

OBJECTIVES: The aim of this study was to analyze mitral annulus (MA) dynamics using cardiac magnetic resonance (CMR) in patients with degenerative mitral insufficiency who underwent mitral valve repair (MVR). METHODS: Mitral valve imaging was performed by CMR in twenty-nine patients with degenerative mitral insufficiency who underwent MVR between July 2014 and August 2016, with quadrangular resection of the posterior leaflet without ring annuloplasty. They were prospectively followed up from the preoperative period up to 2 years postoperatively. RESULTS: We observed a significant reduction in all measurements of the MA after surgery. The mean systolic circumference of the MA was reduced from 13.28±1.95 cm to 11.50±1.59 cm, and the diastolic circumference was reduced from 12.51±2.01 cm to 10.66±2.09 cm in the immediate postoperative period, measures that remained stable 2 years after MVR (p<0.001). The mean maximum area of the MA was significantly reduced from 14.34±4.03 to 10.45±3.17 cm2 when comparing the immediate postoperative period and the 2 year follow-up (p<0.001). The same occurred with the mean minimum area of the MA, which was reduced from 12.53±3.68 cm2 to 9.23±2.84 cm2 in the same period, and this reduction was greater in the antero-posterior diameter than in the mid-lateral diameter. The mobility of the MA was preserved after surgery, ranging between 19.6% and 25.7% at 2-year follow-up. CONCLUSION: We observed a significant reduction in the MA size after MVR, with preservation of the MA mobility at the 2-year follow-up.

OBJECTIVE: To determine long-term survival, identify preoperative factors predictive of a favorable outcome, and assess functional improvement after coronary artery bypass grafting in patients with advanced left ventricular dysfunction. METHODS: Between 1995 and 2001, 244 patients who underwent coronary artery bypass grafting and had a preoperative left ventricular ejection fraction less than or equal to 35% were included. left ventricular ejection fraction was determined by uniplanar or biplanar ventriculography during left heart catheterization. Indication for surgery was predominance of tissue viability. Functional improvement was evaluated through echocardiography and gated scintigraphy at exercise/ rest. Survival was determined by Kaplan-Meier analysis. RESULTS: Mean left ventricular ejection fraction was 29±4% (ranged from 9% to 35%). An average of 3.01 coronary bypass grafts per patient were performed. In-hospital mortality was 3.7% (9 patients). The 4-year survival rate was 89.7%. Multivariate correlates of favorable short- and long-term outcome were preoperative New York Heart Association Funcional classification for congestive heart failure class I/II, lower PAsP, higher left ventricular ejection fraction and gated left ventricular ejection fraction Ex/Rest ratio >5%. Left ventricular ejection fraction rise from 32±5% to 39±5%, p <0.001. Gated left ventricular ejection fraction at exercise/ rest increased markedly after surgery: from 27±8%/ 23±7% to 37±5%/ 31±6%, p <0.001. CONCLUSIONS: In selected patients with severe ischemic left ventricular dysfunction and predominance of tissue viability, coronary artery bypass grafting may be capable of implement preoperative clinical/ functional parameters in predicting outcome as left ventricular ejection fraction and gated left ventricular ejection fraction at exercise/ rest.

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.

INTRODUCTION: In elderly patients with acute myocardial infarction, very little is known about the role of surgical myocardial revascularization and percutaneous coronary intervention (invasive therapies - IT), especially in the context of long-term outcomes after hospital discharge. METHODS: We analyzed 1588 patients with MI who had been included prospectively in a databank and followed for up to 7.5 years. In this population, 548 patients were >70 years old (elderly group - EG), and 1040 were <70 years of age (younger group - YG); 1088 underwent IT during hospitalization, and the remaining 500 were treated medically (conservative therapy - CT). Patients were monitored either by visit or by phone at least once a year. A standard questionnaire was administered to all patients. The impact of IT was analyzed with both non-adjusted and adjusted models. RESULTS: By the end of the follow-up period, the survival rates for the IT and CT groups were, respectively, 71.9% versus 47.2% in the global population (hazard ratio=0.55, P<0.001), 81.5% versus 66.6% in the YG (hazard ratio=0.68, P=0.018) and 48.8% versus 20.3% in the EG (hazard ratio=0.58, P<0.001). In the adjusted models, the hazard ratios were 0.62 (P<0.001) in the global population, 0.74 in the YG (P=0.073) and 0.64 (P=0.001) in the EG. CONCLUSION: Long-term follow-up of patients with myocardial infarction revealed that IT during the in-hospital phase was at least as effective in elderly patients as in younger patients.

Descrevemos um caso de pseudoaneurisma de ventrículo esquerdo associado a grave regurgitação mitral, complicando um infarto ínfero-látero-dorsal. A lesão foi descoberta em ecocardiograma de rotina durante o seguimento ambulatorial. Destacam-se a estratégia cirúrgica bem sucedida, e a boa evolução clínica da paciente.

We described a case of left ventricular pseudoaneurysm associated to a severe mitral regurgitation, complicating a inferolaterodorsal acute myocardial infarction. The lesion was found in a routine echocardiogram during the in-hospital follow-up. The well-succeeded surgical strategy and the good clinical evolution of the patient were distinguished.

OBJETIVO: Comparando a revascularização do miocárdio (RM) com e sem circulação extracorpórea (CEC), com o sangramento no pós-operatório e a necessidade de transfusão de sangue e hemoderivados. MÉTODOS: De novembro/2001 a fevereiro/2002, foram analisados 186 pacientes submetidos a revascularização miocárdica, excluindo-se procedimentos associados, divididos em grupo A de 116 pacientes submetidos a RM com CEC e grupo B de 69 pacientes a RM sem CEC. Os dois grupos foram comparáveis em relação a características pré e intra-operatórias, exceto pelo maior número de anastomoses distais (p=0,0004) no grupo A, e maior atividade de protrombina (p=0,04) e RNI (p=0,03) no grupo B. Para evitar discrepâncias entre os grupos, foram selecionados 140 pacientes com características estatisticamente similares. RESULTADOS: Estudando os grupos pareados, tanto o volume total de sangramento em 24h (p=0,001), quanto aquele indexado para a superfície corpórea (p=0,004) foram respectivamente maiores no grupo A (609,6 ± 395,8 ml; 331,8 ± 225,8 ml/m²) em relação ao grupo B (437,2 ± 315 ml; 241 ± 173,9 ml/m²). Embora a necessidade de transfusão não fosse significativamente diferente entre os grupos (p=0,1), a quantidade transfundida de concentrado de hemáceas foi maior no grupo A (p=0,01). Não houve diferença estatística em relação à transfusão dos outros hemocomponentes e à necessidade de revisão cirúrgica de hemostasia. CONCLUSÃO: A RM sem CEC apresentou vantagens sobre a RM com CEC, em relação ao menor sangramento no pós-operatório e menor transfusão de concentrado de hemáceas. As repercussões deste achado podem ser inúmeras, principalmente em relação a minimização de fatores mórbidos e de custos hospitalares.

OBJECTIVE: To compare myocardial revascularization (MR) with and without extracorporeal circulation (ECC) in regard to postoperative bleeding and the need for blood and hemoderivate transfusion. METHODS: From November 2001 to February 2002, 186 patients undergoing myocardial revascularization were assessed, excluding those who underwent associated procedures. The patients were divided into 2 groups as follows: group A - comprising 116 patients undergoing MR with ECC; and group B - comprising 69 patients undergoing MR without ECC. Both groups were comparable in regard to pre- and intraoperative characteristics, except for the greater number of distal anastomoses (P=0.0004) in group A, and greater prothrombin activity (P=0.04) and INR (P=0.03) in group B. To avoid discrepancies between the groups, 140 patients with statistically similar characteristics were selected. RESULTS: Studying the paired groups, both the total bleeding volume in 24 hours (P=0.001) and the bleeding volume indexed for body surface (P=0.004) were greater in group A (609.6 ± 395.8 mL; 331.8 ± 225.8 mL/m², respectively) than in group B (437.2 ± 315 mL; 241 ± 173.9 mL/m², respectively). Although the need for transfusion was not significantly different between the groups (P=0.1), the amount of erythrocyte concentrate transfused was greater in group A (P=0.01). No statistical difference was observed in regard to transfusion of other hemocomponents and the need for surgical review of hemostasis. CONCLUSION: Myocardial revascularization without ECC was more advantageous than MR with ECC in regard to smaller postoperative blood loss and a lesser need for transfusion of erythrocyte concentrate. The repercussions of this finding may be innumerable, particularly in regard to minimization of morbid factors and hospital costs.

In children, chylothorax occurs mainly after cardiac and thoracic surgeries. One of the recommended postsurgery treatments is ligation of the thoracic tract, when all other conservative treatments have failed. We report 4 cases of chylothorax in patients who were successfully treated with this approach, which resulted in a decrease in pleural drainage without recurrent chylothorax.

Ependimomas são tumores raros de sistema nervoso central, sendo os de cauda eqüina mais freqüentes. Esses tumores raramente metastatizam. Descreve-se o caso de um homem de 35 anos que apresentou, nove anos após ressecção de ependimoma em região coccígea, queixa de dor pleurítica, dispnéia aos esforços, tosse e sudorese noturna. A radiografia pulmonar evidenciou derrame pleural e nódulos metastáticos nos pulmões. Os exames histopatológico e imuno-histoquímico de tecido obtido por biópsia pulmonar a céu aberto confirmaram o diagnóstico de ependimoma. Com quimioterapia o paciente tem boa evolução, com seguimento de 43 meses.

Ependymomas are rare tumors of the central nervous system that most often occur at the cauda equina. These tumors seldom metastasize. A 35 year-old man, nine years after the resection of an ependymoma of the coccygeal region developed pleuritic pain, dyspnea, cough and night sudoresis. Lung X-ray revealed pleural congestion and metastic nodes in both lungs. Histopathological and immunohistochemical examinations of the tissue obtained through open pulmonary biopsy confirmed the diagnosis of a pendymoma, chemotherapy was administered and after 43 months of follow up the patient's evolution has been good.

Objetivo: Estudar aspectos ainda não esclarecidos relacionados a parâmetros clínicos pré-operatórios de prognóstico, risco cirúrgico, benefício funcional e sobrevida a longo prazo. Métodos: Foram analisados 71 pacientes com diagnóstico de cardiomiopatia isquêmica, com fração de ejeção ventricular esquerda < 30% e perfusão miocárdica pela cintilografia TL-201 antes e após a revascularização do miocárdio no período hospitalar e após a alta, com seguimento médio de 48 meses. Resultados: A mortalidade imediata foi de 2,8% e a sobrevida tardia em seguimento de 5 anos foi de 62,8%. Analisando todos os pacientes em relação à curva de sobrevida, não se verificou correlação da presença ou ausência da onda Q no ECG, com a presença de isquemia na cintilografia Tl-201, com o grau de fração de ejeção do ventrículo esquerdo e com a intensidade de insuficiência cardíaca (ICC) ou de angina. Comparando-se os pacientes sobreviventes com os que faleceram, verificou-se diferença estatisticamente significante em relação à maior presença de ICC classe funcional IV e de bloqueio de ramo esquerdo nos pacientes que faleceram. Conclusão: As presenças de insuficiência cardíaca classe funcional IV e de bloqueio de ramo esquerdo relacionaram-se a pior prognóstico. Devido ao mecanismo de morte ser multifatorial e a miocardiopatia isquêmica apresentar padrão miocárdico e arterial heterogêneos, é difícil estabelecer índices pré-operatórios de prognóstico para a revascularização do miocárdio. Os resultados cirúrgicos obtidos a curto e longo prazos demonstram a segurança do procedimento cirúrgico e o seu benefício em aumentar a sobrevida e a qualidade de vida dos pacientes com cardiomiopatia isquêmica.

Purpose: To evaluate the prognosis value of preoperative parameters, surgical risk, functional benefits and long-term survival after myocardial revascularization. Methods: Seventy one patients with coronary artery disease and severe left ventricular dysfunction (left ventricular ejection fraction < 30%) and evaluated the myocardial perfusion by Tl-201 scintigraphy were studied before and after myocardial revascularization, during the hospitalar period and 48 months (avarage) of late follow up. Results: The early mortality observed was 2,8% and the survival in 5 years 62,8%. The statistical analysis related to the preoperative clinical parameters in all patients were not significant in: a) severity of congestive heart failure (CHF) or angina; b) presence of Q wave (EKG); c) presence of ischemia (Tl-201); d) left ventricular ejection fraction. The statistical analysis related to survivors and no survivors were significant: a) functional class IV of CHF; b) presence of left brunch bundle block (LBBB). Conclusion: Our results show that functional class IV of CHF and LBBB were related to bad prognosis and demonstrate the difficulty to establish preoperative clinical parameters of prognosis due to the presence of heterogeneous coronary and myocardial pattern of the ischemic cardiomyopathy. Our surgical results confirm that myocardial revascularization is a safe procedure, increases late survival and improves the quality of life of these patients with coronary artery disease and severe left ventricular dysfunction.