After Thirty Years, We Still Cannot Understand Why Methylene Blue is not a Reference to Treat Vasoplegic Syndrome in Cardiac Surgery.

Vasoplegic syndrome (VS) comprises a constellation of concurrent signs and symptoms: hypotension, high cardiac index, low systemic vascular resistance, low filling pressures, the tendency to occur diffuse bleeding, and sustained hypotension. All of these parameters may persist even despite the use of high doses of vasoconstrictor amines. VS arises from vasoplegic endothelial dysfunction with excessive release of nitric oxide by polymorphonuclear leukocytes mediated by the nitric oxide synthase's inducible form and is associated with systemic inflammatory reaction and high morbimortality.

Right Atrium Tumor Extension Through the Inferior Vena Cava. Considerations About Nine Cases Operated Under Cardiopulmonary Bypass.

Introduction: Adrenocortical and renal cell carcinomas rarely invade the right atrium (RA). These neoplasms need surgical treatment, are very aggressive and have poor prognostic and surgical outcomes.

Case Series: We present a retrospective cohort of nine cases of RA invasion through the inferior vena cava (four adrenocortical carcinomas and five renal cell carcinomas).

Twenty years of vasoplegic syndrome treatment in heart surgery. Methylene blue revised.

Objective: This study was conducted to reassess the concepts established over the past 20 years, in particular in the last 5 years, about the use of methylene blue in the treatment of vasoplegic syndrome in cardiac surgery.

Methods: A wide literature review was carried out using the data extracted from: MEDLINE, SCOPUS and ISI WEB OF SCIENCE.

Results: The reassessed and reaffirmed concepts were 1) MB is safe in the recommended doses (the lethal dose is 40 mg/kg); 2) MB does not cause endothelial dysfunction; 3) The MB effect appears in cases of NO up-regulation; 4) MB is not a vasoconstrictor, by blocking the cGMP pathway it releases the cAMP pathway, facilitating the norepinephrine vasoconstrictor effect; 5) The most used dosage is 2 mg/kg as IV bolus, followed by the same continuous infusion because plasma concentrations sharply decrease in the first 40 minutes; and 6) There is a possible "window of opportunity" for MB's effectiveness.

A variant technique for the surgical treatment of left ventricular aneurysms.

Objective: To present a surgical variant technique to repair left ventricular aneurysms.

Methods: After anesthesia, cardiopulmonary bypass, and myocardial protection with hyperkalemic tepic blood cardioplegia: 1) The left ventricle is opened through the infarct and an endocardial encircling suture is placed at the transitional zone between the scarred and normal tissue; 2) Next, the scar tissue is circumferentially plicated with deep stitches using the same suture thread, taking care to eliminate the entire septal scar; 3) Then, a second encircling suture is placed, completing the occlusion of the aneurysm, and; 4) Finally, the remaining scar tissue is oversewn with an invaginating suture, to ensure hemostasis. Myocardium revascularization is performed after correction of the left ventricle aneurysm.

Pressure support-ventilation versus spontaneous breathing with "T-Tube" for interrupting the ventilation after cardiac operations.

Objective: To compare pressure-support ventilation with spontaneous breathing through a T-tube for interrupting invasive mechanical ventilation in patients undergoing cardiac surgery with cardiopulmonary bypass.

Methods: Adults of both genders were randomly allocated to 30 minutes of either pressure-support ventilation or spontaneous ventilation with "T-tube" before extubation. Manovacuometry, ventilometry and clinical evaluation were performed before the operation, immediately before and after extubation, 1h and 12h after extubation.

A variant "no-patch" technique for surgery of left ventricular aneurysms.

A variant "no-patch" technique for the surgical treatment of left ventricular aneurysms is described. The entire operation is performed using a single suture tied after the 2 encircling stitch adjustments and at the final external suture. Before the second encircling pursestring stitch, scar tissue circular plication is carried out.

Exhaled nitrite/nitrate levels as a marker of respiratory complications after heart valve surgery.

Purpose: The purposes of this study are to measure the nitric oxide metabolites nitrite and nitrate (NOx) in the exhaled breath condensates (EBCs) of patients submitted to heart valve surgery and to assess the correlation between NOx levels and postoperative respiratory complications.

Materials And Methods: Exhaled breath condensate and blood samples were collected from each patient during spontaneous breathing preoperatively, during invasive mechanical ventilation in the fourth hour after surgery and 12, 24, 48, and 72 hours after the operation. Nitrite and nitrate levels in the EBC and serum were measured by chemiluminescence.

Effects of elevated perfusion pressure and pulsatile flow on human saphenous veins isolated from diabetic and non-diabetic patients.

Objective: This study was carried out to determine high pressure and pulsatile flow perfusion effects on human saphenous vein (HSV) segments obtained from diabetic and non-diabetic patients.

Methods: The veins were perfused with oxygenated Krebs solution for 3 h, with a pulsatile flow rate of 100 mL/min and pressures of 250 × 200 or 300 × 250 mmHg. After perfusion, veins were studied by light microscopy; nitric oxide synthase (NOS) isoforms, CD34 and nitrotyrosine immunohistochemistry and tissue nitrite/nitrate (NO(x)) and malondialdehyde (MDA) quantification.

Reflections on the 24 years durability of an isolate tricuspid bovine pericardium IMC/Braile bioprosthesis.

We were challenged by the experience of one patient reoperation for a bioprosthetic bovine pericardium degenerative stenosis, 24 years after implantation. This bioprosthesis was implanted due to tricuspid valve bacterial staphylococcal endocarditis after septic abortion.

Preoperative respiratory muscle dysfunction is a predictor of prolonged invasive mechanical ventilation in cardiorespiratory complications after heart valve surgery.

Objective: To verify whether preoperative respiratory muscle strength and ventilometric parameters, among other clinically relevant factors, are associated with the need for prolonged invasive mechanical ventilation (PIMV) due to cardiorespiratory complications following heart valve surgery.

Methods: Demographics, preoperative ventilometric and manometric data, and the hospital course of 171 patients, who had undergone heart valve surgery at Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, were prospectively collected and subjected to univariate analysis for identifying the risk factors for PIMV.

Results: The hospital mortality was 7%.

Mitral insufficiency surgery to treat advanced heart failure.

Dilated cardiomyopathy is characterized by severe, progressive myocardial dysfunction that is, irreversible. That syndrome leads to cardiac remodeling with augmentation of left ventricle volume and sphericity, dilation of the mitral annulus and dislocation of papillary muscles that pulls up the mitral cords thereby restraining leaflet excursion. These biomechanical modifications generate functional mitral valve regurgitation, a dismal prognostic sign.

Risk factors for acute renal failure after heart surgery.

Objective: The aim of the present study was to identify risk factors for acute renal failure in patients with normal levels of serum creatinine who had undergone coronary artery bypass graft (CABG) surgery and/or valve surgery.

Methods: Data from a cohort of 769 patients were assessed using bivariate analyses and binary logistic regression modeling.

Results: Three hundred eighty one patients underwent CABG, 339 valve surgery and 49 had undergone both simultaneously.

Methylene blue for vasoplegic syndrome treatment in heart surgery: fifteen years of questions, answers, doubts and certainties.

Objective: There is strong evidence that methylene blue (MB), an inhibitor of guanylate cyclase, is an excellent therapeutic option for vasoplegic syndrome (VS) treatment in heart surgery. The aim of this article is to review the MB's therapeutic function in the vasoplegic syndrome treatment.

Methods: Fifteen years of literature review.

Isolated mitral and aortic valve replacement with the St. Jude Medical valve: a midterm follow-up.

Background: In our country, the biological valvular prostheses predominate, considering the difficulties related to anticoagulation, even in young patients, in spite of the need for repeated operations due to the degeneration of the bioprostheses.

Objectives: To report our consecutive series of recipients of isolated St Jude Medical mechanical valve prosthesis in the mitral (MVR) or aortic (AVR) position.

Methods: Data from patients operated between January 1995 and December 2003 were revised in order to determine patient survival and prosthesis-related events up to December 2006.

Blood cardioplegia with N-acetylcysteine may reduce coronary endothelial activation and myocardial oxidative stress.

Objectives: The aim of this prospective study was to compare the efficacy of intermittent antegrade blood cardioplegia with or without n-acetylcysteine (NAC) in reducing myocardial oxidative stress and coronary endothelial activation.

Methods: Twenty patients undergoing elective isolated coronary artery bypass graft surgery were randomly assigned to receive intermittent antegrade blood cardioplegia (32 degrees C-34 degrees C) with (NAC group) or without (control group) 300 mg of NAC. For these 2 groups we compared clinical outcome, hemodynamic evolution, systemic plasmatic levels of troponin I, and plasma concentrations of malondialdehyde (MDA) and soluble vascular adhesion molecule 1 (sVCAM-1) from coronary sinus blood samples.

Plasma nitrate/nitrite (NOx) is not a useful biomarker to predict inherent cardiopulmonary bypass inflammatory response.

Background And Aim: There were strong evidences that nitric oxide has capital importance in the progressive vasodilatation associated with varied circulatory shock forms, including systemic inflammatory response syndrome (SIRS), in patients undergoing cardiac surgeries for cardiopulmonary bypass (CPB). If CPB procedures, per se, are the inciting stimulus for inflammation, plasma nitrate/nitrite (NOx) excretion would be expected to be higher in these patients rather than in patients operated without CPB. In consequence, we hypothesized that increased levels of NOx would be predictive for vasoplegic syndrome.

Endothelium dysfunction caused by acute pressure distension of human saphenous vein used for myocardial revascularization.

Objective: To study morphofunctional alterations induced by brief pressure increases in human saphenous veins utilized in coronary artery bypass grafting.

Method: Saphenous veins of 20 patients undergoing coronary artery bypass grafting, were distributed into four experimental groups, control, 100 mmHg, 200 mmHg and 300 mmHg, and submitted to pressure distention over 15 seconds using Krebs solution. The evaluation included CD34 immunohistochemistry and an In vitro vascular reactivity study in organ chambers.

Efficacy and safety of aprotinin use for reoperative valvular surgery.

Background: Preservation of the hemostatic system during cardiac surgery is a main concern, primarily after repeated cardiac operations.

Methods: We compared the outcomes of adult patients undergoing isolated reoperative valvular surgery receiving full-dose of aprotinin (redo group, n = 70) with patients experiencing primary isolated valvular surgery not receiving aprotinin (primary group, n = 135).

Results: The mean age was lower in the redo group (45 +/- 14 years vs 50 +/- 17 years, p = 0.

Surgical correction of total anomalous pulmonary venous drainage in an adult.

Total anomalous pulmonary venous drainage (TAPVD) is rarely seen in adults, because this congenital heart disease almost always requires surgical treatment in the neonatal period, often on an emergency basis. We report a patient that, despite being diagnosed during childhood, underwent surgical repair at age 25, about one year after his clinical condition worsened.

Anomalous origin of the left coronary artery from the pulmonary artery in an adult with systemic collateral circulation to the left coronary artery.

A case of anomalous origin of the left coronary artery from the pulmonary artery in an adult with collateral circulation between the left coronary artery and systemic extracardiac vessels is reported. After evaluating the surgical options, my colleagues and I conclude that ligation of the left coronary artery and a left internal thoracic artery graft to the left anterior descending coronary artery is the preferable option for treating such patients.

Dorsal minithoracotomy for ductus arteriosus clip closure in premature neonates.

We present a new surgical technique for patent ductus arteriosus (PDA) occlusion in premature neonates (PN). Through a dorsal minithoracotomy the PDA is dissected extrapleurally with q-tips and clipped. The short surgical time, avoidance of pleural drainage, and prevention of late breast deformity are the operation highlights.