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[SciELO Preprints] - Guidelines on the Diagnosis and Treatment of Hypertrophic Cardiomyopathy – 2024
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Fernandes, Fabio Simões, Marcus V. Correia, Edileide de Barros Marcondes-Braga, Fabiana G. Coelho-Filho, Otavio Rizzi Mesquita, Cláudio Tinoco Mathias-Junior, Wilson Rochitte, Carlos Eduardo Ramires, Felix José Alvarez Alves, Silvia Marinho Martins Montera, Marcelo Westerlund Lopes, Renato Delascio Oliveira-Junior, Mucio Tavares Scolari, Fernando L. Avila, Walkiria Samuel Canesin, Manoel Fernandes Bacal, Fernando Bocchi, Edimar Alcides Moura, Lídia Ana Zytynski Saad, Eduardo Benchimol Scanavacca, Mauricio I. Valdigem, Bruno Pereira Cano , Manuel Nicolas Abizaid , Alexandre Ribeiro, Henrique Barbosa Lemos-Neto, Pedro Alves Ribeiro, Gustavo Calado de Aguiar Jatene, Fabio Biscegli Dias, Ricardo Ribeiro Beck-da-Silva, Luis Rohde, Luis Eduardo P. Bittencourt, Marcelo Imbroinise Pereira, Alexandre Krieger, José Eduardo Villacorta, Humberto Martins, Wolney de Andrade Figueiredo-Neto, José Albuquerque de Cardoso , Juliano Novaes Pastore, Carlos Alberto Jatene, Ieda Biscegli Tanaka, Ana Cristina Sayuri Hotta, Viviane Tiemi Romano, Minna Moreira Dias Albuquerque, Denilson Campos de Mourilhe-Rocha, Ricardo Hajjar, Ludhmila Abrahão Brito, Fabio Sandoli de Caramelli , Bruno Calderaro, Daniela Farsky, Pedro Silvio Colafranceschi , Alexandre Siciliano Pinto, Ibraim Masciarelli Vieira , Marcelo Luiz Campos Danzmann, Luiz Claudio Barberato , Silvio Henrique Mady, Charles Martinelli-Filho, Martino Torbey , Ana Flavia Malheiros Schwartzmann, Pedro Vellosa Macedo, Ariane Vieira Scarlatelli Ferreira , Silvia Moreira Ayub Schmidt, Andre Melo , Marcelo Dantas Tavares de Lima-Filho, Moysés Oliveira Sposito, Andrei C. Brito, Flavio de Souza Biolo, Andreia Madrini-Junior, Vagner Rizk, Stéphanie Itala Mesquita, Evandro Tinoco

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Publication date: 2024-04-08

Abstract: Pt Es En

A cardiomiopatia hipertrófica (CMH) é uma forma de doença do músculo cardíaco de causa genética, caracterizada pela hipertrofia das paredes ventriculares. O diagnóstico requer detecção por métodos de imagem (Ecocardiograma ou Ressonância Magnética Cardíaca) de qualquer segmento da parede do ventrículo esquerdo com espessura > 15 mm, sem outra causa provável. A análise genética permite identificar mutações de genes codificantes de diferentes estruturas do sarcômero responsáveis pelo desenvolvimento da CMH em cerca de 60% dos casos, permitindo o rastreio de familiares e aconselhamento genético, como parte importante do manejo dos pacientes e familiares. Vários conceitos sobre a CMH foram recentemente revistos, incluindo sua prevalência de 1 em 250 indivíduos, não sendo, portanto, uma doença rara, mas subdiagnosticada. A vasta maioria dos pacientes é assintomática. Naqueles sintomáticos, a obstrução do trato de saída do ventrículo esquerdo (OTSVE) é o principal distúrbio responsável pelos sintomas, devendo-se investigar a sua presença em todos os casos. Naqueles em que o ecocardiograma em repouso ou com Manobra de Valsalva não detecta gradiente intraventricular significativo (> 30 mmHg), devem ser submetidos à ecocardiografia com esforço físico para detecção da OTSVE.   Pacientes com sintomas limitantes e grave OTSVE, refratários ao uso de betabloqueadores e verapamil, devem receber terapias de redução septal ou uso de novas drogas inibidoras da miosina cardíaca. Por fim, os pacientes adequadamente identificados com risco aumentado de morta súbita podem receber medida profilática com implante de cardiodesfibrilador implantável (CDI).

La miocardiopatía hipertrófica (MCH) es una forma de enfermedad cardíaca de origen genético, caracterizada por el engrosamiento de las paredes ventriculares. El diagnóstico requiere la detección mediante métodos de imagen (Ecocardiograma o Resonancia Magnética Cardíaca) que muestren algún segmento de la pared ventricular izquierda con un grosor > 15 mm, sin otra causa probable. El análisis genético permite identificar mutaciones en genes que codifican diferentes estructuras del sarcómero responsables del desarrollo de la MCH en aproximadamente el 60% de los casos, lo que permite el tamizaje de familiares y el asesoramiento genético, como parte importante del manejo de pacientes y familiares. Varios conceptos sobre la MCH han sido revisados recientemente, incluida su prevalencia de 1 entre 250 individuos, por lo tanto, no es una enfermedad rara, sino subdiagnosticada. La gran mayoría de los pacientes son asintomáticos. En los casos sintomáticos, la obstrucción del tracto de salida ventricular izquierdo (TSVI) es el trastorno principal responsable de los síntomas, y su presencia debe investigarse en todos los casos. En aquellos en los que el ecocardiograma en reposo o la maniobra de Valsalva no detecta un gradiente intraventricular significativo (> 30 mmHg), deben someterse a ecocardiografía de esfuerzo para detectar la obstrucción del TSVI. Los pacientes con síntomas limitantes y obstrucción grave del TSVI, refractarios al uso de betabloqueantes y verapamilo, deben recibir terapias de reducción septal o usar nuevos medicamentos inhibidores de la miosina cardíaca. Finalmente, los pacientes adecuadamente identificados con un riesgo aumentado de muerte súbita pueden recibir medidas profilácticas con el implante de un cardioversor-desfibrilador implantable (CDI).

Hypertrophic cardiomyopathy (HCM) is a form of genetically caused heart muscle disease, characterized by the thickening of the ventricular walls. Diagnosis requires detection through imaging methods (Echocardiogram or Cardiac Magnetic Resonance) showing any segment of the left ventricular wall with a thickness > 15 mm, without any other probable cause. Genetic analysis allows the identification of mutations in genes encoding different structures of the sarcomere responsible for the development of HCM in about 60% of cases, enabling screening of family members and genetic counseling, as an important part of patient and family management. Several concepts about HCM have recently been reviewed, including its prevalence of 1 in 250 individuals, hence not a rare but rather underdiagnosed disease. The vast majority of patients are asymptomatic. In symptomatic cases, obstruction of the left ventricular outflow tract (LVOT) is the primary disorder responsible for symptoms, and its presence should be investigated in all cases. In those where resting echocardiogram or Valsalva maneuver does not detect significant intraventricular gradient (> 30 mmHg), they should undergo stress echocardiography to detect LVOT obstruction. Patients with limiting symptoms and severe LVOT obstruction, refractory to beta-blockers and verapamil, should receive septal reduction therapies or use new drugs inhibiting cardiac myosin. Finally, appropriately identified patients at increased risk of sudden death may receive prophylactic measure with implantable cardioverter-defibrillator (ICD) implantation.

https://doi.org/10.1590/SciELOPreprints.8394

Rare association between giant-cell aortitis and giant-cell aortic valvulitis
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Luzuriaga, Georgina del Cisne Jadán

; Dias, Ricardo Ribeiro

; Santiago, José Augusto Duncan

; Madrini Junior, Vagner

; Ishikawa, Walther Yoshiharu

; Fernandes, Fabio

; Aiello, Vera Demarchi

Autopsy and Case Reports

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2023, Volume 13 elocation e2023449

Abstract: En | Text: En | PDF: En

ABSTRACT Giant cell arteritis (GCA) is a type of chronic vasculitis that affects medium and large-caliber arteries, frequently related to aortic involvement and, consequently, to aneurysm formation. However, associated valvulitis with giant cells is uncommon. We describe the case of a 50-year-old female patient with aortic aneurysm and valvular insufficiency, whose anatomopathological examination revealed giant-cell aortic valvulitis associated with giant cell aortitis.

https://doi.org/10.4322/acr.2023.449

Nonatherosclerotic Giant Right Coronary Artery Aneurysm
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Cardoso, Lucas Figueredo

; Dias, Ricardo Ribeiro

; Demarchi, Lea Maria Macruz Ferreira

; Silveira, Lucas Molinari Veloso da

; Mady, Charles

; Jatene, Fabio B

Brazilian Journal of Cardiovascular Surgery

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apr 2022, Volume 37 N. 2 Pages 271 - 272

Abstract: En | Text: En | PDF: En

Abstract We present an unusual case of a 67-year-old woman with an incidental finding of a cardiac mass on a chest computed tomography. Coronary angiotomography confirmed the diagnosis of right coronary artery aneurysm, with 5.7×5.7 cm. The patient underwent aneurysm resection and coronary bypass surgery, with subsequent histologic study suggestive of arteritis sequelae. Giant coronary artery aneurysms have a high risk of complications and aneurysm exclusion must be beneficial. This is a rare condition that can also be part of a systemic inflammatory disease.

https://doi.org/10.21470/1678-9741-2020-0649

Impacto da Primeira Onda da Pandemia de COVID-19 na Cirurgia Cardiovascular no Brasil: Análise de um Centro Terciário de Referência
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Lisboa, Luiz Augusto

; Mejia, Omar Asdrúbal Vilca

; Arita, Elisandra Trevisan

; Guerreiro, Gustavo Pampolha

; Silveira, Lucas Molinari Veloso da

; Brandão, Carlos Manuel de Almeida

; Dias, Ricardo Ribeiro

; Dallan, Luís Roberto Palma

; Miana, Leonardo

; Caneo, Luiz F.

; Jatene, Marcelo Biscegli

; Dallan, Luís Alberto Oliveira

; Jatene, Fabio Biscegli

Arquivos Brasileiros de Cardiologia

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mar 2022, Volume 118 N. 3 Pages 663 - 666

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

https://doi.org/10.36660/abc.20210235

Pericardial Effusion and Cardiac Tamponade: Etiology and Evolution in the Contemporary Era
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Queiroz, Claudio Martins de

; Cardoso, Juliano

; Ramires, Felix

; Ianni, Barbara

; Hotta, Viviane Tiemi

; Mady, Charles

; Buck, Paula de Cassia

; Dias, Ricardo Ribeiro

; Nastari, Luciano

; Fernandes, Fábio

International Journal of Cardiovascular Sciences

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nov 2021, Volume 34 N. 5 Pages 24 - 31

Abstract: En | Text: En | PDF: En

Abstract Background: Pericardial effusion is a relatively common finding and can progress to cardiac tamponade; etiological diagnosis is important for guiding treatment decisions. With advances in medicine and improvement in the social context, the most frequent etiological causes have changed. Objectives: To evaluate the clinical and laboratory characteristics, etiology, and clinical course of patients with pericardial effusion and cardiac tamponade. Materials and methods: Patients with pericardial effusion classified as small (< 10 mm), moderate (between 10-20 mm), or severe (> 20 mm) were included. Data from the clinical history, physical examination, laboratory tests, and complementary tests were evaluated in patients with pericardial effusion and cardiac tamponade. The significance level was set at 5%. Results: A total of 254 patients with a mean age of 53.09 ± 17.9 years were evaluated, 51.2% of whom were female. A total of 40.4% had significant pericardial effusion (> 20 mm). Pericardial tamponade occurred in 44.1% of patients. Among pericardial effusion patients without tamponade, the most frequent etiologies were: idiopathic (44.4%) and postsurgical (17.6%), while among those with tamponade, the most frequent etiologies were postsurgical (21.4%) and postprocedural (19.6%). The mean follow-up time was 2.2 years. Mortality was 42% and 23.2 in those with and without tamponade, respectively (p=0.001). Conclusions: There is an etiological difference between pericardial effusion patients with and without cardiac tamponade. An idiopathic etiology is more common among those without tamponade, while postinterventional/postsurgical is more common among those with tamponade. The tamponade group had a higher mortality rate.

https://doi.org/10.36660/ijcs.20200247 20 downloads

Brazilian Single-Center Experience with Aortic Root Replacement in 448 Patients: What Is the Best Technique?
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Dinato, Fabrício José

; Dias, Ricardo Ribeiro

; Duncan, José Augusto

; Fernandes, Fábio

; Ramirez, Felix José Alvares

; Mady, Charles

; Jatene, Fabio B

Brazilian Journal of Cardiovascular Surgery

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dec 2020, Volume 35 N. 6 Pages 869 - 877

Abstract: En | Text: En | PDF: En

Abstract Introduction: The objective of this study was to evaluate whether a surgery with the use of valved conduit is capable of leading to better immediate and late results than those obtained by the valve-sparing aortic root reconstruction technique. Methods: Between January 2002 and June 2016, 448 patients underwent aortic root reconstruction. These were divided into three groups according to the technique used: 319 (71.2%) patients received mechanical valved conduits, 49 (10.9%) received biological valved conduits, and 80 (17.9%) underwent the valve-sparing aortic root reconstruction technique. The results were examined by univariate and multivariate analyses of Cox proportional hazards models with multiple logistic regression. Results: The hospital mortality rate was 7.5%. The mortality rates were 8.2%, 12%, and 2.5% in the mechanical valved conduit, biological valved conduit, and aortic valve-sparing groups, respectively, with no significant difference between groups (P=0.1). Thromboembolic complications and reoperation-free survival were also similar (P=0.169 and P=0.688). However, valve-sparing aortic root replacement was superior in terms of long-term survival (P<0.001), hemorrhagic-free survival (P<0.001), and endocarditis-free survival (P=0.048). Multivariate analysis showed that the following aspects had an impact on mortality: age > 70 years (P<0.001; hazard ratio [HR] 1.05), preoperative acute kidney injury (P<0.0042; HR 2.9), diagnosis of dissection (P<0.01; HR 2.0), previous cardiac surgery (P<0.027; HR 2.3), associated coronary artery bypass grafting (P<0.038; HR 1.8), reoperation for postoperative tamponade (P<0.004; HR 2.2) and postoperative acute kidney injury (P<0.02; HR 3.35). Conclusion: Valve-sparing technique seems to be the operation of choice, whenever possible, for aortic root reconstruction.

https://doi.org/10.21470/1678-9741-2020-0043 255 downloads

Galectina-3 em Pacientes com Pericardite Constritiva Crônica
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Fernandes, Fábio

; Melo, Dirceu Thiago Pessoa de

; Ramires, Felix José Alvarez

; Sabino, Ester Cerdeira

; Moreira, Carlos Henrique Valente

; Benvenutti, Luiz Alberto

; Hotta, Viviane Tiemi

; Sayegh, Ana Luiza Carrari

; Souza, Francis Ribeiro de

; Dias, Ricardo Ribeiro

; Mady, Charles

Arquivos Brasileiros de Cardiologia

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apr 2020, Volume 114 N. 4 Pages 683 - 689

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

Resumo Fundamento A galectina-3 (Gal-3) é uma molécula pró-inflamatória e pró-fibrótica, envolvida na patogênese da insuficiência cardíaca. O papel da Gal-3 em pacientes com pericardite constritiva crônica (PCC) não está claro. Objetivo O objetivo deste estudo foi avaliar os níveis de Gal-3 em pacientes com PCC e correlacioná-los com parâmetros clínicos, funcionais e histológicos. Métodos Nós avaliamos prospectivamente 25 pacientes sintomáticos com PCC agendados à pericardiectomia e 21 controles sadios. Os pacientes foram submetidos à avaliação clínica, medidas de Gal-3 e peptídeo natriurético do tipo B (BNP), ecocardiografia, ressonância magnética cardíaca e teste cardiopulmonar de exercício (TCPE) no período basal. Seis meses após a pericardiectomia, repetiu-se o TCPE. Um erro alfa < 5% foi considerado estatisticamente significativo, com um intervalo de confiança de 95%. Resultados Foram incluídos 25 pacientes com idade mediana de 45 anos. A etiologia foi principalmente idiopática (n = 19, 76%), e 14 (56%) apresentaram classe funcional New York Heart Association (NYHA) III/IV. Os valores medianos de BNP e Gal-3 foram 143 (89-209) pg/dL e 14,8 (9,7-17,2) ng/mL, respectivamente. Os níveis de Gal-3 não foram estatisticamente maiores nos pacientes com PCC que em controles (p = 0,22). Não foram encontradas correlações significativas da Gal-3 com BNP, medidas ecocardiográficas e de ressonância magnética cardíaca, e achados histológicos. Após a pericardiectomia, encontrou-se uma correlação estatisticamente significativa entre Gal-3 e medidas do TCPE – duração do teste (r = –0,79; p < 0,001) e tempo de exercício (r = –0,79; p < 0,001). Conclusões Pacientes com PCC apresentaram níveis normais de Gal-3, quando comparados aos indivíduos controles. A Gal-3 não se correlacionou com medidas morfológicas e funcionais antes da pericardiectomia. No entanto, associações entre Gal-3 e intolerância ao exercício após pericardiectomia pode sugerir um papel da Gal-3 na predição de prognóstico após a pericardiectomia. (Arq Bras Cardiol. 2020; 114(4):683-689)

Abstract Background Galectin-3 (Gal-3) is a proinflammatory, profibrotic molecule implicated in the pathogenesis of heart failure. The role of Gal-3 in patients with chronic constrictive pericarditis (CCP) is not clear. Objective The aim of this study was to assess plasma Gal-3 in patients with CCP and correlate it with clinical, functional and histologic parameters. Methods We prospectively evaluated 25 symptomatic patients with CCP referred for pericardiectomy and 21 healthy controls. Patients underwent clinical assessment, Gal-3 and B-type natriuretic peptide (BNP) measurements, echocardiography, cardiac magnetic resonance imaging and cardiopulmonary exercise test (CPET) at baseline. Six months after pericardiectomy CPET was repeated. An alpha error < 5% was considered statistically significant, with a confidence interval of 95%. Results Twenty-five patients with a median age of 45 years were included. Etiology was mainly idiopathic (n = 19, 76%); and 14 (56%) patients had NYHA functional class III/IV. Median BNP and Gal-3 were 143 (89-209) pg/dL and 14.8 (9.7-17.2) ng/mL, respectively. Gal-3 levels were not significantly higher in CCP patients than in control (p = 0.22). There were no significant correlations of Gal-3 with BNP, echocardiographic and cardiac magnetic resonance measures and histological findings. After pericardiectomy, it was found a statistically significant correlation between Gal-3 and the CPTE measures test duration (r = –0.79; p < 0.001) and exercise time (r = –0.79; p < 0.001). Conclusions Patients with CCP had normal levels of Gal-3 as compared to the controls. Gal-3 did not correlate with morphological and functional measures before pericardiectomy. However, the associations between Gal-3 and exercise intolerance after pericardiectomy may suggest a role of Gal-3 in prognosis prediction after pericardiectomy. (Arq Bras Cardiol. 2020; 114(4):683-689)

https://doi.org/10.36660/abc.20190152 775 downloads

Analysis of >100,000 Cardiovascular Surgeries Performed at the Heart Institute and a New Era of Outcomes
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Mejia, Omar A.V.

; Lisboa, Luiz Augusto Ferreira

; Caneo, Luiz Fernando

; Arita, Elisandra Trevisan

; Brandão, Carlos Manuel de Almeida

; Dias, Ricardo Ribeiro

; Costa, Roberto

; Jatene, Marcelo Biscegli

; Pomerantzeff, Pablo Maria Alberto

; Dallan, Luís Alberto Oliveira

; Jatene, Fabio Biscegli

Arquivos Brasileiros de Cardiologia

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apr 2020, Volume 114 N. 4 Pages 603 - 612

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

Resumo Fundamento: O desafio atual da cirurgia cardiovascular (CCV) é melhorar resultados em pacientes cada vez mais graves. Nesse sentido, Programas de Melhoria Contínua da Qualidade (PMCQ) tem impactado os resultados. Objetivo: Avaliar a evolução da incidência e mortalidade das CCV, assim como os resultados atuais do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor). Métodos: Análise dos resultados das CCV realizadas no InCor entre jan-1984 e jun-2019. Foram observadas as tendências dos volumes cirúrgicos e da mortalidade em 5 períodos 1º (1984-1989), 2º (1990-1999), 3º (2000-2007), 4º (2008-2015) e 5º (2016-2019). O PMCQ foi estabelecido entre 2015-2016. A análise incluiu o total de cirurgias e a evolução dos procedimentos mais frequentes. Resultados: Foram realizadas 105.599 CCV, com uma média anual de 2.964 procedimentos e mortalidade de 5,63%. Comparando o 4º com o 5º período, o volume global médio de cirurgias foi de 2.943 para 3.139 (p = 0,368), cirurgias de revascularização miocárdica (CRM) de 638 para 597 (p = 0,214), valvas cardíacas de 372 para 465 (p = 0,201) e cardiopatias congênitas de 530 para 615 (p = 0,125). A mortalidade média global passou de 7,8% para 5% (p < 0,0001), nas cirurgias de revascularização miocárdica de 5,8% para 3,1% (p < 0,0001), nas cirurgias valvares de 14% para 7,5% (p < 0,0001) e nas cirurgias de cardiopatias congênitas de 12,1% para 9,6% (p < 0,0001). Conclusão: Embora haja uma tendência recente ao aumento dos volumes cirúrgicos, houve uma diminuição significativa da mortalidade cirúrgica nos grupos analisados. Após o estabelecimento do PMCQ, as taxas de mortalidade se aproximaram a dos padrões internacionais.

Abstract Background: The current challenge of cardiovascular surgery (CVS) is to improve the outcomes in increasingly severe patients. In this respect, continuous quality improvement (CQI) programs have had an impact on outcomes. Objective: To assess the evolution of the incidence and mortality due to CVS, as well as the current outcomes of the Hospital das Clínicas Heart Institute of the University of São Paulo Medical School (InCor-HCFMUSP). Methods: An outcome analysis of CVSs performed at the InCor, between January 1984 and June 2019. We observed the surgical volume and mortality rates in 5 time periods: 1st (1984-1989), 2nd (1990-1999), 3rd (2000-2007), 4th (2008-2015) and 5th (2016-2019). The CQI program was implemented between 2015 and 2016. The analysis included the total number of surgeries and the evolution of the most frequent procedures. Results: A total of 105,599 CCVs were performed, with an annual mean of 2,964 procedures and mortality of 5,63%. When comparing the 4th and the 5th periods, the average global volume of surgeries was increased from 2,943 to 3,139 (p = 0.368), bypass graft (CABG), from 638 to 597 (p = 0.214), heart valve surgery, from 372 to 465 (p = 0.201), and congenital heart disease surgery, from 530 to 615 (p = 0.125). The average global mortality went from 7.8% to 5% (p < 0.0001); in CABG surgery, from 5.8% to 3.1% (p < 0.0001); in heart valve surgery, from 14% to 7.5% (p < 0.0001) and in congenital heart disease surgery, from 12.1% to 9.6% (p < 0.0001). Conclusion: In spite of a recent trend towards increased surgical volume, there was a significant decrease in operative mortality in the groups studied. After the implementation of the CQI program, the mortality rates were closer to international standards.

https://doi.org/10.36660/abc.20190736 938 downloads

Perioperative Management of the Diabetic Patient Referred to Cardiac Surgery
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Arthur, Camila Perez de Souza

; Mejía, Omar Asdrúbal Vilca

; Lapenna, Gisele Aparecida

; Brandão, Carlos Manuel de Almeida

; Lisboa, Luiz Augusto Ferreira

; Dias, Ricardo Ribeiro

; Dallan, Luís Alberto Oliveira

; Pomerantzeff, Pablo Maria Alberto

; Jatene, Fabio B.

Brazilian Journal of Cardiovascular Surgery

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dec 2018, Volume 33 N. 6 Pages 618 - 625

Abstract: En | Text: En | PDF: En

Abstract Currently there is a progressive increase in the prevalence of diabetes in a referred for cardiovascular surgery. Benefits of glycemic management (< 180 mg/dL) in diabetic patients compared to patients without diabetes in perioperative cardiac surgery. The purpose of this study is to present recommendations based on international evidence and adapted to our clinical practice for the perioperative management of hyperglycemia in adult patients with and without diabetes undergoing cardiovascular surgery. This update is based on the latest current literature derived from articles and guidelines regarding perioperative management of diabetic patients to cardiovascular surgery.

https://doi.org/10.21470/1678-9741-2018-0147 759 downloads

10.

Use of 3D Printing in Preoperative Planning and Training for Aortic Endovascular Repair and Aortic Valve Disease
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Gomes, Eduardo Nascimento

; Dias, Ricardo Ribeiro

; Rocha, Bruno Aragão

; Santiago, José Augusto Duncan

; Dinato, Fabrício José de Souza

; Saadi, Eduardo Keller

; Gomes, Walter J.

; Jatene, Fabio B.

Brazilian Journal of Cardiovascular Surgery

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oct 2018, Volume 33 N. 5 Pages 490 - 495

Abstract: En | Text: En | PDF: En

Abstract Introduction: Three-dimensional (3D) printing has become an affordable tool for assisting heart surgeons in the aorta endovascular field, both in surgical planning, education and training of residents and students. This technique permits the construction of physical prototypes from conventional medical images by converting the anatomical information into computer aided design (CAD) files. Objective: To present the 3D printing feature on developing prototypes leading to improved aortic endovascular surgical planning, as well as transcatheter aortic valve implantation, and mainly enabling training of the surgical procedure to be performed on patient's specific condition. Methods: Six 3D printed real scale prototypes were built representing different aortic diseases, taken from real patients, to simulate the correction of the disease with endoprosthesis deployment. Results: In the hybrid room, the 3D prototypes were examined under fluoroscopy, making it possible to obtain images that clearly delimited the walls of the aorta and its details. The endovascular simulation was then able to be performed, by correctly positioning the endoprosthesis, followed by its deployment. Conclusion: The 3D printing allowed the construction of aortic diseases realistic prototypes, offering a 3D view from the two-dimensional image of computed tomography (CT) angiography, allowing better surgical planning and surgeon training in the specific case beforehand.

https://doi.org/10.21470/1678-9741-2018-0101 1446 downloads

11.

Importance of Clinical and Laboratory Findings in the Diagnosis and Surgical Prognosis of Patients with Constrictive Pericarditis
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Fernandes, Fábio

; Melo, Dirceu Thiago Pessoa de

; Ramires, Felix José Alvarez

; Dias, Ricardo Ribeiro

; Tonini, Marcio

; Fernandes, Vinicius dos Santos

; Rochitte, Carlos Eduardo

; Moreira, Carlos Henrique Valente

; Mady, Charles

Arquivos Brasileiros de Cardiologia

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nov 2017, Volume 109 N. 5 Pages 457 - 465

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

Resumo Fundamento: Estudos internacionais têm relatado o valor de perfil clínico e exames de imagem no diagnóstico e prognóstico da pericardite constritiva. Entretanto, dados da população brasileira são escassos. Objetivo: Avaliar as características clínicas, sensibilidade de exames de imagem e fatores relacionados ao óbito em uma série de casos de pericardite constritiva submetidos à pericardiectomia. Métodos: Pacientes com pericardite constritiva confirmada por cirurgia foram avaliados retrospectivamente quanto a variáveis clínicas e laboratoriais. Dois métodos diagnósticos foram utilizados: ecocardiograma transtorácico e ressonância cardíaca. Preditores de mortalidade foram determinados por análise univariada usando metodologia das proporções de Cox e hazard ratio. Todos os testes foram considerados bicaudais e um erro alfa ≤ 5% foi considerado como significante. Resultados: Foram estudados 84 pacientes com idade média de 44 ± 17,9 anos, sendo 67% do sexo masculino. Sinais e sintomas de insuficiência cardíaca (IC) predominantemente direita estiveram presentes com estase jugular, edema e ascite em 89%, 89% e 62% dos casos, respectivamente. Etiologia idiopática foi observada em 69% dos casos, seguida por tuberculose em 21%. Apesar do grau de IC, encontramos baixos níveis de BNP (mediana de 157 pg/mL). As sensibilidades diagnósticas para constrição do ecocardiograma e da ressonância foram 53,6% e 95,9%, respectivamente. Durante a evolução clínica, houve 9 óbitos (10,7%) e os fatores de risco foram: anemia, elevações de BNP, PCR, hipertensão pulmonar > 55 mmHg e fibrilação atrial. Conclusões: Pericardite constritiva manifesta-se com sinais e sintomas de IC biventricular com predomínio à direita e baixos níveis de BNP. A ressonância magnética apresenta melhor sensibilidade para diagnóstico. Marcadores clínicos, laboratoriais e de imagem estiveram associados ao óbito.

Abstract Background: International studies have reported the value of the clinical profile and laboratory findings in the diagnosis of constrictive pericarditis. However, Brazilian population data are scarce. Objective: To assess the clinical characteristics, sensitivity of imaging tests and factors related to the death of patients with constrictive pericarditis undergoing pericardiectomy. Methods: Patients with constrictive pericarditis surgically confirmed were retrospectively assessed regarding their clinical and laboratory variables. Two methods were used: transthoracic echocardiography and cardiac magnetic resonance imaging. Mortality predictors were determined by use of univariate analysis with Cox proportional hazards model and hazard ratio. All tests were two-tailed, and an alpha error ≤ 5% was considered statically significant. Results: We studied 84 patients (mean age, 44 ± 17.9 years; 67% male). Signs and symptoms of predominantly right heart failure were present with jugular venous distention, edema and ascites in 89%, 89% and 62% of the cases, respectively. Idiopathic etiology was present in 69.1%, followed by tuberculosis (21%). Despite the advanced heart failure degree, low BNP levels (median, 157 pg/mL) were found. The diagnostic sensitivities for constriction of echocardiography and magnetic resonance imaging were 53.6% and 95.9%, respectively. There were 9 deaths (10.7%), and the risk factors were: anemia, BNP and C reactive protein levels, pulmonary hypertension >55 mm Hg, and atrial fibrillation. Conclusions: Magnetic resonance imaging had better diagnostic sensitivity. Clinical, laboratory and imaging markers were associated with death.

https://doi.org/10.5935/abc.20170147 1502 downloads

12.

Hybrid Approach of Aortic Diseases: Zone 1 Delivery and Volumetric Analysis on the Descending Aorta
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Duncan, José Augusto

; Dias, Ricardo Ribeiro

; Dinato, Fabrício José

; Fernandes, Fábio

; Ramirez, Félix José Álvares

; Mady, Charles

; Jatene, Fabio Biscegli

Brazilian Journal of Cardiovascular Surgery

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oct 2017, Volume 32 N. 5 Pages 361 - 366

Abstract: En | Text: En | PDF: En

Abstract Introduction: Conventional techniques of surgical correction of arch and descending aortic diseases remains as high-risk procedures. Endovascular treatments of abdominal and descending thoracic aorta have lower surgical risk. Evolution of both techniques - open debranching of the arch and endovascular approach of the descending aorta - may extend a less invasive endovascular treatment for a more extensive disease with necessity of proximal landing zone in the arch. Objective: To evaluate descending thoracic aortic remodeling by means of volumetric analysis after hybrid approach of aortic arch debranching and stenting the descending aorta. Methods: Retrospective review of seven consecutive patients treated between September 2014 and August 2016 for diseases of proximal descending aorta (aneurysms and dissections) by hybrid approach to deliver the endograft at zone 1. Computed tomography angiography were analyzed using a specific software to calculate descending thoracic aorta volumes pre- and postoperatively. Results: Follow-up was done in 100% of patients with a median time of 321 days (range, 41-625 days). No deaths or permanent neurological complications were observed. There were no endoleaks or stent migrations. Freedom from reintervention was 100% at 300 days and 66% at 600 days. Median volume reduction was of 45.5 cm3, representing a median volume shrinkage by 9.3%. Conclusion: Hybrid approach of arch and descending thoracic aorta diseases is feasible and leads to a favorable aortic remodeling with significant volume reduction.

https://doi.org/10.21470/1678-9741-2017-0040 550 downloads

13.

Does aortic valve repair in valve-sparing aortic root reconstruction compromise the longevity of the procedure?
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Dias, Ricardo Ribeiro

; Duncan, José Augusto

; de Souza Dinato, Fabrício José

; Araújo, Lucas Lacerda

; Issa, Hugo Monteiro Neder

; Fernandes, Fábio

; Mady, Charles

; Jatene, Fábio Biscegli

Clinics

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apr 2017, Volume 72 N. 4 Pages 207 - 212

Abstract: En | Text: En | PDF: En

OBJECTIVES: The effect of performing aortic valve repair in combination with valve-sparing operation on the length of time for which patients are free from reoperation is unclear. The objective of this study was to determine if the performance of aortic valve repair during valve-sparing operation modified the freedom from reoperation time. METHODS: From January 2003 to July 2014, 78 patients with a mean age of 49±15 years underwent valve-sparing operation. Sixty-eight percent of these patients were male. Twenty-two (28%) aortic valve repair procedures were performed in this patient population. In the aortic valve repair + valve-sparing operation group, 77.3% of patients had moderate/severe aortic insufficiency, while in the valve-sparing operation group, 58.6% of patients had moderate/severe aortic insufficiency (ns = not significant). Additionally, 13.6% of patients in the aortic valve repair + valve-sparing operation group had functional class III/IV, while 14.2% of patients in the valve-sparing operation group had functional class III/IV (ns). RESULTS: The in-hospital and late mortality rates, for the aortic valve repair + valve-sparing operation and valve-sparing operation groups were similar, as they were 4.5% and 3.6%; and 0% and 1.8%, respectively. In the aortic valve repair + valve-sparing operation group, 0% of patients presented moderate/severe aortic insufficiency during late follow-up, while in the valve-sparing operation group, 14.2% of patients presented with moderate/severe aortic insufficiency during this period (ns). In the aortic valve repair + valve-sparing operation group, 5.3% of patients presented with functional class III/IV, while in the valve-sparing operation group, 4.2% of patients presented with functional class III/IV (ns). In the aortic valve repair + valve-sparing operation group, 0% of patients required reoperation, while in the valve-sparing operation group, 3.6% of patients required reoperation over a mean follow-up period of 1621±1156 days (75 patients). CONCLUSION: Valve-sparing operation is a safe and long-lasting procedure and performance of aortic valve repair when necessary does not increase risk of reoperation on the aortic valve.

https://doi.org/10.6061/clinics/2017(04)03 565 downloads

14.

Surgery of the aortic root: should we go for the valve-sparing root reconstruction or the composite graft-valve replacement is still the first choice of treatment for these patients?
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Lamana, Fernando de Azevedo

; Dias, Ricardo Ribeiro

; Duncan, Jose Augusto

; Faria, Leandro Batisti de

; Malbouisson, Luiz Marcelo Sa

; Borges, Luciano de Figueiredo

; Mady, Charles

; Jatene, Fábio Biscegli

Brazilian Journal of Cardiovascular Surgery

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sep 2015, Volume 30 N. 3 Pages 343 - 352

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

ResumoObjetivo:Analisar comparativamente os resultados da operação de preservação da valva aórtica e do tubo valvulado nas reconstruções da raiz da aorta.Métodos:No período de janeiro de 2002 a outubro de 2013, 324 pacientes foram submetidos à reconstrução da raiz da aorta. Foram 263 tubos valvulados e 61 preservações da valva aórtica (43 reimplantes e 18 remodelamentos). 26% dos pacientes estavam em classe funcional III e IV; 9,6% com síndrome de Marfan e 12% apresentavam valva aórtica bivalvulada. Houve predomínio dos aneurismas sobre as dissecções (81% contra 19%), sendo 7% de dissecções agudas. O seguimento completo de 100% dos pacientes foi realizado com tempo mediano de seguimento de 902 dias para pacientes submetidos à tubo valvulado e de 1492 para aqueles submetidos à preservação da valva aórtica.Resultados:A mortalidade hospitalar foi de 6,7% contra 4,9% respectivamente para tubo valvulado e preservação da valva aórtica (ns). No seguimento tardio, a insuficiência aórtica importante foi de 0% e 5,8%, e a insuficiência cardíaca crônica, classe funcional I e II de 89,4% e 94%, respectivamente, para tubo valvulado e preservação da valva aórtica (ns). A reconstrução da raiz da aorta com a preservação da valva aórtica apresentou menor mortalidade tardia (P=0,001) e menos complicações hemorrágicas (P=0,006). Não houve diferença para tromboembolismo, endocardite ou necessidade de reoperação.Conclusão:A reconstrução da raiz da aorta com a preservação valvar deve ser a operação a ser realizada por apresentar menor mortalidade e sobrevida livre de eventos hemorrágicos.

AbstractObjective:To compare the results of the root reconstruction with the aortic valve-sparing operation versus composite graftvalve replacement.Methods:From January 2002 to October 2013, 324 patients underwent aortic root reconstruction. They were 263 composite graft-valve replacement and 61 aortic valve-sparing operation (43 reimplantation and 18 remodeling). Twenty-six percent of the patients were NYHA functional class III and IV; 9.6% had Marfan syndrome, and 12% had bicuspid aortic valve. There was a predominance of aneurysms over dissections (81% vs. 19%), with 7% being acute dissections. The complete follow-up of 100% of the patients was performed with median follow-up time of 902 days for patients undergoing composite graft-valve replacement and 1492 for those undergoing aortic valve-sparing operation.Results:In-hospital mortality was 6.7% and 4.9%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). During the late follow-up period, there was 0% moderate and 15.4% severe aortic regurgitation, and NYHA functional class I and II were 89.4% and 94%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). Root reconstruction with aortic valve-sparing operation showed lower late mortality (P=0.001) and lower bleeding complications (P=0.006). There was no difference for thromboembolism, endocarditis, and need of reoperation.Conclusion:The aortic root reconstruction with preservation of the valve should be the operation being performed for presenting lower late mortality and survival free of bleeding events.

https://doi.org/10.5935/1678-9741.20150028 1598 downloads

15.

Answer to “Key points of reducing neurologic complications in frozen elephant trunk technique”
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Dias, Ricardo Ribeiro

; Duncan, Jose Augusto

Brazilian Journal of Cardiovascular Surgery

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aug 2015, Volume 30 N. 4 Pages 506 - 506

Abstract: En | Text: En | PDF: En

https://doi.org/10.5935/1678-9741.20150057 698 downloads

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