ABSTRACT Objective: This study aims to investigate the ability of the six-minute walk distance (6MWD) as a prognostic marker for midterm clinical outcomes three months after coronary artery bypass grafting (CABG), to identify possible predictors of fall in 6MWD in the early postoperative period, and to establish the percentage fall in early postoperative 6MWD, considering the preoperative baseline as 100%. Methods: A prospective cohort of patients undergoing elective CABG were included. The percentage fall in 6MWD was assessed by the difference between preoperative and postoperative day (POD) five. Clinical outcomes were evaluated three months after hospital discharge. Results: There was a significant decrease in 6MWD on POD5 compared with preoperative baseline values (percentage fall of 32.5±16.5%, P<0.0001). Linear regression analysis showed an independent association of the percentage fall of 6MWD with cardiopulmonary bypass (CPB) and preoperative inspiratory muscle strength. Receiver operating characteristic curve analysis revealed that the best cutoff value of percentage fall in 6MWD to predict poorer clinical outcomes at three months was 34.6% (area under the curve = 0.82, sensitivity = 78.95%, specificity = 76.19%, P=0.0001). Conclusion: This study indicates that a cutoff value of 34.6% in percentage fall of 6MWD on POD5 was able to predict poorer clinical outcomes at three months of follow-up after CABG. Use of CPB and preoperative inspiratory muscle strength were independent predictors of percentage fall of 6MWD in the postoperative period. These findings further support the clinical application of 6MWD and propose an inpatient preventive strategy to guide clinical management over time.

ABSTRACT Objective: This study aims to investigate the ability of the six-minute walk distance (6MWD) as a prognostic marker for midterm clinical outcomes three months after coronary artery bypass grafting (CABG), to identify possible predictors of fall in 6MWD in the early postoperative period, and to establish the percentage fall in early postoperative 6MWD, considering the preoperative baseline as 100%. Methods: A prospective cohort of patients undergoing elective CABG were included. The percentage fall in 6MWD was assessed by the difference between preoperative and postoperative day (POD) five. Clinical outcomes were evaluated three months after hospital discharge. Results: There was a significant decrease in 6MWD on POD5 compared with preoperative baseline values (percentage fall of 32.5±16.5%, P<0.0001). Linear regression analysis showed an independent association of the percentage fall of 6MWD with cardiopulmonary bypass (CPB) and preoperative inspiratory muscle strength. Receiver operating characteristic curve analysis revealed that the best cutoff value of percentage fall in 6MWD to predict poorer clinical outcomes at three months was 34.6% (area under the curve = 0.82, sensitivity = 78.95%, specificity = 76.19%, P=0.0001). Conclusion: This study indicates that a cutoff value of 34.6% in percentage fall of 6MWD on POD5 was able to predict poorer clinical outcomes at three months of follow-up after CABG. Use of CPB and preoperative inspiratory muscle strength were independent predictors of percentage fall of 6MWD in the postoperative period. These findings further support the clinical application of 6MWD and propose an inpatient preventive strategy to guide clinical management over time. Objective sixminute six minute MWD (6MWD CABG, , (CABG) period 100 100% Methods included POD (POD five discharge Results 325165 32 5 16 32.5±16.5% P<0.0001. P00001 P P<0.0001 . 0 0001 P<0.0001) (CPB 346 34 6 34.6 area 082 82 0.82 7895 78 95 78.95% 7619 76 19 76.19% P=0.0001. P=0.0001 P=0.0001) Conclusion followup follow up time (CABG 10 32516 3 1 32.5±16.5 P0000 P<0.000 000 34. 08 8 0.8 789 7 9 78.95 761 76.19 P=0.000 3251 32.5±16. P000 P<0.00 00 0. 78.9 76.1 P=0.00 325 32.5±16 P00 P<0.0 78. 76. P=0.0 32.5±1 P0 P<0. P=0. 32.5± P<0 P=0 32.5 P< P= 32.

Resumo Fundamento: A revascularização cirúrgica do miocárdio é o melhor tratamento para o paciente dialítico com doença coronariana multiarterial. Contudo, o procedimento ainda apresenta elevada morbimortalidade. O uso da circulação extracorpórea (CEC) pode impactar de maneira negativa na evolução intra-hospitalar desses pacientes. Objetivos: Avaliar a diferença entre as técnicas com ou sem CEC na evolução intra-hospitalar de pacientes dialíticos submetidos a cirurgia de revascularização do miocárdio. Métodos: Estudo unicêntrico de 102 pacientes dialíticos consecutivos e não selecionados, submetidos à revascularização cirúrgica do miocárdio em um hospital terciário universitário no período de 2007 a 2014. Resultados: 63 pacientes foram operados com CEC e 39 sem o uso de CEC. Foi observada alta prevalência de fatores de risco cardiovascular em ambos grupos, porém sem diferença estatisticamente significante entre eles. O grupo "com CEC" apresentou maior número de coronárias revascularizadas (2,4 vs 1,7; p <0,0001), maior necessidade de hemocomponentes (77,7% vs 25,6%; p <0,0001) e apoio inotrópico (82,5% vs 35,8%; p <0,0001). Na evolução pós-operatória, o grupo "sem CEC" apresentou menor necessidade de drogas vasoativas (61,5% vs 82,5%; p = 0,0340), maior taxa de extubação em sala cirúrgica (58,9% vs 23,8%, p = 0,0006), menor tempo de ventilação mecânica (13,0 horas vs 36,3 horas, p = 0,0217), menor taxa de infecções (7,6% vs 28,5%; p = 0,0120) e menor tempo de internação em UTI (5,2 dias vs 8,1 dias; p = 0,0054) em comparação ao grupo "com CEC". Não houve diferença de mortalidade entre os grupos. Conclusão: O uso da CEC na revascularização do miocárdio em pacientes dialíticos resultou em maior morbidade no período perioperatório em comparação ao procedimento realizado sem CEC, contudo, sem diferença de mortalidade.

Abstract Background: Myocardial revascularization surgery is the best treatment for dyalitic patients with multivessel coronary disease. However, the procedure still has high morbidity and mortality. The use of extracorporeal circulation (ECC) can have a negative impact on the in-hospital outcomes of these patients. Objectives: To evaluate the differences between the techniques with ECC and without ECC during the in-hospital course of dialytic patients who underwent surgical myocardial revascularization. Methods: Unicentric study on 102 consecutive, unselected dialytic patients, who underwent myocardial revascularization surgery in a tertiary university hospital from 2007 to 2014. Results: Sixty-three patients underwent surgery with ECC and 39 without ECC. A high prevalence of cardiovascular risk factors was found in both groups, without statistically significant difference between them. The group "without ECC" had greater number of revascularizations (2.4 vs. 1.7; p <0.0001) and increased need for blood components (77.7% vs. 25.6%; p <0.0001) and inotropic support (82.5% vs 35.8%; p <0.0001). In the postoperative course, the group "without ECC" required less vasoactive drugs, (61.5% vs. 82.5%; p = 0.0340) and shorter time of mechanical ventilation (13.0 hours vs. 36,3 hours, p = 0.0217), had higher extubation rates in the operating room (58.9% vs. 23.8%, p = 0.0006), lower infection rates (7.6% vs. 28.5%; p = 0.0120), and shorter ICU stay (5.2 days vs. 8.1 days; p = 0.0054) as compared with the group with ECC surgery. No difference in mortality was found between the groups. Conclusion: Myocardial revascularization with ECC in patients on dialysis resulted in higher morbidity in the perioperative period in comparison with the procedure without ECC, with no difference in mortality though.

Resumo Objetivo: O melhor tratamento atual para os pacientes dialíticos com acometimento coronariano multiarterial é a revascularização cirúrgica do miocárdio. Dentre as complicações pós-operatórias, a síndrome vasoplégica de etiopatogenia inflamatória torna-se importante pelo impacto altamente negativo no prognóstico. Considerando que esses pacientes possuem uma exacerbação intrínseca da resposta inflamatória, nosso objetivo foi avaliar a incidência e a mortalidade da síndrome vasoplégica no pós-operatório de revascularização miocárdica nesse grupo. Métodos: Estudo retrospectivo, unicêntrico, de 50 pacientes dialíticos consecutivos e não selecionados, submetidos à revascularização miocárdica, em um hospital terciário universitário, no período de 2007 a 2012. Esses pacientes foram divididos em 2 grupos, de acordo com o emprego ou não da circulação extracorpórea. A incidência e a mortalidade da vasoplegia foram analisadas nos grupos. Após a identificação dos pacientes quanto à presença de vasoplegia, este subgrupo foi estudado separadamente. Resultados: Não houve diferenças demográficas pré-operatórias entre os grupos com circulação extracorpórea (n=20) e sem circulação extracorpórea (n=30). Dados intraoperatórios demonstraram maior número de artérias coronárias revascularizadas (2,8 vs. 1,8; P<0,0001) e maior necessidade de transfusão (65% vs. 23%; P=0,008) no grupo circulação extracorpórea. A incidência de vasoplegia foi estatisticamente maior (P=0,0124) no grupo circulação extracorpórea (30%) em comparação ao grupo sem circulação extracorpórea (3%). A mortalidade dos pacientes com vasoplegia foi 50% no grupo circulação extracorpórea e 0% no grupo sem circulação extracorpórea. A análise do subgrupo vasoplégico não demonstrou diferenças clínicas estatisticamente significantes. Conclusão: O emprego da circulação extracorpórea na revascularização cirúrgica do miocárdio em pacientes com insuficiência renal crônica dialítica aumentou o risco para desenvolvimento de síndrome vasoplégica pós-operatória.

Abstract Objective: Coronary artery bypass grafting is currently the best treatment for dialysis patients with multivessel coronary artery involvement. Vasoplegic syndrome of inflammatory etiology constitutes an important postoperative complication, with highly negative impact on prognosis. Considering that these patients have an intrinsic inflammatory response exacerbation, our goal was to evaluate the incidence and mortality of vasoplegic syndrome after myocardial revascularization in this group. Methods: A retrospective, single-center study of 50 consecutive and non-selected dialysis patients who underwent myocardial revascularization in a tertiary university hospital, from 2007 to 2012. The patients were divided into 2 groups, according to the use of cardiopulmonary bypass or not (off-pump coronary artery bypass). The incidence and mortality of vasoplegic syndrome were analyzed. The subgroup of vasoplegic patients was studied separately. Results: There were no preoperative demographic differences between the cardiopulmonary bypass (n=20) and off-pump coronary artery bypass (n=30) group. Intraoperative data showed a greater number of distal coronary arteries anastomosis (2.8 vs. 1.8, P<0.0001) and higher transfusion rates (65% vs. 23%, P=0.008) in the cardiopulmonary bypass group. Vasoplegia incidence was statistically higher (P=0.0124) in the cardiopulmonary bypass group (30%) compared to the off-pump coronary artery bypass group (3%). Vasoplegia mortality was 50% in the cardiopulmonary bypass group and 0% in the off-pump coronary artery bypass group. The vasoplegic subgroup analysis showed no statistically significant clinical differences. Conclusion: Cardiopulmonary bypass increased the risk for developing postoperative vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure.

Fundamentos: Atualmente, a revascularização cirúrgica do miocárdio é o melhor tratamento para o paciente dialítico com lesão coronariana multiarterial, contudo a mortalidade e a morbidade hospitalar do procedimento ainda permanecem altas. Objetivos: Avaliar os resultados e a evolução intra-hospitalar da revascularização cirúrgica do miocárdio isolada em pacientes dialíticos. Métodos: Estudo retrospectivo unicêntrico de 50 pacientes dialíticos consecutivos e não selecionados, submetidos à revascularização cirúrgica do miocárdio em um hospital terciário universitário no período de 2007 a 2012. Resultados: A casuística apresentou alta prevalência de fatores de risco cardiovasculares (100% hipertensos, 68% diabéticos e 40% dislipidêmicos). Não houve óbito intraoperatório, e 60% dos procedimentos foram feitos sem circulação extracorpórea. Houve sete (14%) óbitos intra-hospitalares. Infecção pós-operatória, insuficiência cardíaca prévia, uso de circulação extracorpórea, função ventricular anormal e reexploração cirúrgica foram os fatores associados a maior mortalidade. Conclusão: A revascularização cirúrgica do miocárdio é um procedimento factível para essa classe de pacientes, contudo com alta morbidade e mortalidade intra-hospitalar. É necessário melhor entendimento das particularidades metabólicas desses pacientes para o planejamento adequado das condutas.

Background: Coronary artery bypass grafting currently is the best treatment for dialytic patients with multivessel coronary disease, but hospital morbidity and mortality related to procedure is still high. Objective: Evaluate results and in-hospital outcomes of coronary artery bypass grafting in dialytic patients. Methods: Retrospective unicentric study including 50 consecutive and not selected dialytic patients, who underwent coronary artery bypass grafting in a tertiary university hospital from 2007 to 2012. Results: High prevalence of cardiovascular risk factors was observed (100% hypertensive, 68% diabetic and 40% dyslipidemic). There was no intra-operative death and 60% of the procedures were performed off-pump. There were seven (14%) in-hospital deaths. Postoperative infection, previous heart failure, cardiopulmonary bypass, abnormal ventricular function and surgical re-exploration were associated with increased mortality. Conclusion: Coronary artery bypass grafting is feasible to dialytic patients although high in-hospital morbidity and mortality. It is necessary better understanding about metabolic aspects to plan adequate interventions.

OBJETIVO: Apresentar os resultados imediatos e avaliar o desempenho clínico e hemodinâmico das biopróteses sem suporte de pericárdio bovino (stentless) em posição aórtica. MÉTODOS: Foram operados 20 pacientes com indicação de troca valvar aórtica por bioprótese, sendo 11 homens, 16 com estenose aórtica; a média de idade foi 66,3 ± 8,8 anos. A técnica operatória utilizada foi o implante subcoronariano. Cinco pacientes receberam procedimentos associados. No pós-operatório, a morbidade-mortalidade e o desempenho hemodinâmico foram avaliados por meio de ecocardiograma transtorácico. RESULTADOS: Os tempos médios de circulação extracorpórea e anóxia foram, respectivamente, 136,5 ± 24,41 min e 105,2 ± 21,62 min. A mortalidade hospitalar foi 5% (um paciente). A permanência na UTI foi, em média, 3,65 ± 3,23 dias. A média dos gradientes transvalvares no pós-operatório foi 25,39 ± 7,82 mmHg. A fração de ejeção do ventrículo esquerdo no pré-operatório era 67 ± 13,49% e, no pós-operatório, foi 63,24 ± 16,06% (p = 0,45). Onze pacientes não apresentaram nenhum grau de refluxo valvar, 8 apresentaram refluxo leve, e um, refluxo leve a moderado. CONCLUSÃO: As próteses stentless podem ser utilizadas no tratamento cirúrgico das valvopatias aórticas, com morbidade e mortalidade na fase hospitalar semelhante à descrita na literatura para procedimentos semelhantes, e apresentam desempenho hemodinâmico satisfatório.

OBJECTIVE: To present the immediate results and assess the clinical and hemodynamic performance of stentless bovine pericardial bioprostheses in aortic position. METHODS: Twenty patients were operated who were indicated for surgery for valve replacement with biological prostesis. Eleven patients were male; sixteen had aortic stenosis; four, insufficiency; the mean age was 66.3 ± 8.8 years. The surgical technique used was subcoronary implant. Associated procedures were performed in five patients. Postoperative morbidity,mortality and hemodynamic performance were assessed on transthoracic echocardiogram. RESULTS: Mean time of cardiopulmonary bypass was 136.5 ± 24.41 minutes and mean anoxic time was 105.2 ± 21.62 minutes. Hospital mortality was 5% (one patient). Mean time of intensive care unit stay was 3.65 ± 3.23 days. Mean postoperatively transvalvular gradient was was 25.39 ± 7.82 mmHg. Left ventricle ejection fraction was 67 ± 13.49% preoperatively and 63.24 ± 16.06% postoperatively (p = 0.45). Eleven patients did not present any degree of valve regurgitation, eight presented mild regurgitation and one ,mild to moderate regurgitation. CONCLUSION: Stentless prostheses can be used for the surgical tratment of aortic valve diseases, with in hospital mortality and morbidity similar to the mortality and morbidity described in the literature for similar procedures, with satisfactory hemodynamic performance.

Relatamos caso de um paciente submetido a transplante cardíaco ortotópico, onde se utilizou um doador marginal pela piora clínica do receptor, que apresentava choque cardiogênico por disfunção de ventrículo direito secundária a hipertensão pulmonar associado à vasoplegia. Obtivemos recuperação hemodinâmica do paciente, com redução da resistência vascular pulmonar, retirada de drogas vasoativas e recuperação da função do ventrículo direito após a introdução de sildenafil.

We report the case of a male patient who underwent orthotopic cardiac transplantation. A marginal donor was used, because the recipient's clinical condition was critical. He experienced cardiogenic shock due to right ventricular dysfunction secondary to pulmonary hypertension associated with vasoplegia. After the introduction of sildenafil, the patient recovered hemodynamically, his pulmonary vascular resistance decreased, the vasoactive drugs were withdrawn, and his right ventricular function improved.

OBJETIVO: Analisar os resultados imediatos, clínicos e ecocardiográficos, com o uso do homoenxerto aórtico criopreservado no tratamento cirúrgico da valva aórtica. MATERIAL: Dezoito pacientes com lesão na valva aórtica receberam homoenxerto aórtico criopreservado, sendo 15 homens, 10 com insuficiência aórtica e oito, estenose aórtica. A idade variou de 18 a 65 (média de 44,5 ± 18,14) anos. Quatro pacientes apresentavam endocardite bacteriana em atividade, 12 estavam em classe funcional II, seis em classe funcional III (NYHA). A função ventricular esquerda era normal em 15 pacientes. RESULTADOS: A mortalidade hospitalar foi de 5,5% (um paciente), por insuficiência respiratória, os demais receberam alta hospitalar entre o 5° e 8° dia de pós-operatório em classe funcional I. O gradiente transvalvar aórtico máximo, ao ecocardiograma, variou de zero a 30 mmhg, com média de 10,9 ± 9,2 mmhg. Cinco pacientes não apresentavam nenhum grau de refluxo pelo homoenxerto, 11 (61,1%) tinham refluxo mínimo e dois apresentavam refluxo leve. O tempo de circulação extracorpórea variou de 130 a 220 (média de 183,9 ± 36,7) minutos. O tempo de pinçamento da aorta variou de 102 a 168 (média de 139,14 ± 25,10) minutos. O sangramento no pós-operatório variou 210 a 1220 ml, com média de 511,4 ± 335,1 ml e não houve reoperações. O tempo de intubação orotraqueal variou de 2h e 50min a 17 h com média de 9,14 ± 3,6 h. CONCLUSÃO: O homoenxerto aórtico criopreservado pode ser utilizado rotineiramente com baixa morbi-mortalidade hospitalar.

OBJECTIVE: To assess immediate clinical and echocardiographic results of the use of cryopreserved aortic homografts for aortic valve replacement. METHODS: Eighteen patients with aortic valve disease underwent aortic valve replacement, receiving a cryopreserved aortic homograft, 15 were male, 10 had aortic regurgitation, and 8 had aortic stenosis. Age ranged from 18 to 65 years (mean, 44.5 ± 18.14 years). Four patients had infective endocarditis, 12 patients were in functional class II, and 6 patients were in functional class III (NYHA). Left ventricular function was normal in 15 patients. RESULTS: Hospital mortality was 5.5% (1 patient) due to respiratory distress; the other patients were discharged from the hospital between the fifth and eighth postoperative days in functional class I. Maximal aortic transvalvular gradient, on echocardiography, ranged from 0 to 30 mmHg, with a mean of 10.9 ± 9.2 mmHg. Five patients did not have any degree of regurgitation through the aortic homograft, 11 patients (61.1%) had minimal regurgitation, and 2 had mild regurgitation. Duration of extracorporeal circulation ranged from 130 to 220 minutes (mean, 183.9 ± 36.7 minutes). Duration of aortic clamping ranged from 102 to 168 minutes (mean, 139.14 ± 25.10 minutes). Bleeding in the postoperative period ranged from 210 to 1220 mL, with a mean of 511.4 ± 335.1 mL. Reoperations were not necessary. Duration of orotracheal intubation ranged from 2 hours 50 minutes to 17 hours with a mean of 9.14 ± 3.6 hours. CONCLUSION: Cryopreserved aortic homografts may be routinely used with low hospital morbidity and mortality.