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- Coronary artery bypass surgery in young adults: excellent perioperative results and long-term survivalPublication . Saraiva, J; Antunes, PE; Antunes, MJOBJECTIVES: To analyse perioperative results, long-term survival and freedom from complications after coronary artery bypass grafting (CABG) in young adults. METHODS: A total of 163 patients, 40 years old or younger, had isolated CABG from January 1989 to December 2010. Pre- and perioperative demographic and clinical data were retrieved from a prospectively organised database. Follow-up data were obtained by letter or telephone interviews. The mean age of the patients was 37.6 ± 2.9 years and 146 were men (90%). Fifty-three patients (32.5%) had angina class III/IV; 106 (65.0%), previous myocardial infarction; and 23 (14.1%), impaired left ventricular function (ejection fraction <40%). Indication for surgery was 3-vessel disease in 101 cases (62.0%), 2-vessel disease in 30 (18.4%) and single-vessel disease in 32 (19.6%). The left main stem was affected in 16 patients (9.8%). The mean EuroSCORE II was 0.92 ± 0.71. A total of 417 grafts were constructed (mean 2.6 grafts/patient), 247 of which (59.2%) were arterial. RESULTS: There were no in-hospital deaths. The mean hospital stay was 7.1 ± 4.0 days. Four patients (2.5%) were lost to follow-up, which extended from 3 to 25 years (mean 15.1 ± 5.5 years). There were 22 late deaths, 72.7% of cardiac or unknown origin. The 5-, 10- and 20-year survival rates were 98.7 ± 10.9, 95.2 ± 1.8 and 79.4 ± 4.4%, respectively. Twenty-six patients (18.1%) had non-fatal cardiac adverse complications (myocardial infarct, percutaneous re-revascularization or class III/IV angina), for 5-, 10- and 20-year freedom from complications of 97.9 ± 1.2, 91.9 ± 2.5 and 65.7 ± 7.1%, respectively. Twenty-two patients (17.5%) needed re-revascularization, for 5-, 10- and 20-year freedom from re-revascularization of 97.6 ± 1.4, 91.9 ± 2.6 and 69.5 ± 6.7%, respectively. CONCLUSIONS: Despite the aggressive nature of coronary artery disease in young patients, perioperative death and morbidity rates are low, with good long-term survival and low rates of re-revascularization.
- Coronary artery bypass surgery without cardioplegia: hospital results in 8515 patients†Publication . Antunes, PE; Ferrão de Oliveira, J; Prieto, D; Coutinho, GF; Correia, P; Branco, CF; Antunes, MJOBJECTIVES: Cardioplegic myocardial protection is used in most cardiac surgical procedures. However, other alternatives have proved useful. We analysed the perioperative results in a large series of patients undergoing coronary artery bypass (CABG) using cardiopulmonary bypass (CPB) and non-cardioplegic methods. METHODS: From January 1992 to October 2013, 8515 consecutive patients underwent isolated CABG with CPB without cardioplegia, under hypothermic ventricular fibrillation and/or an empty beating heart. The mean age was 61.9 ± 9.5 years, 12.4% were women, 26.3% diabetic, 64% hypertensive; and 9.6% had peripheral vascular disease, 7.8% cerebrovascular disease and 54.3% previous acute myocardial infarction (AMI). One-third of patients were in Canadian Cardiovascular Society Class III/IV. Three-vessel disease was present in 76.5% of the cases and 10.9% had moderate/severe left ventricle (LV) dysfunction (ejection fraction <40%). A multivariate analysis was made of risk factors associated to in-hospital mortality and three major morbidity complications [cerebrovascular accident, mediastinitis and acute kidney injury (AKI)], as well as for prolonged hospital stay. RESULTS: The mean CPB time was 58.2 ± 20.7 min. The mean number of grafts per patient was 2.7 ± 0.8 (arterial: 1.2 ± 0.5). The left internal thoracic artery (ITA) was used in 99.4% of patients and both ITAs in 23.1%. The in-hospital mortality rate was 0.7% (61 patients), inotropic support was required in 6.6% and mechanical support in 0.8, and 2.0% were re-explored for bleeding and 1.3% for sternal complications (mediastinitis, 0.8%). AKI, the majority transient, occurred in 1595 patients (18.9%). The incidence rates of stroke/transient ischemic attack (TIA) and acute myocardial infarction (AMI) were 2.6 and 2.5%, respectively, and atrial fibrillation/flutter occurred in 22.6% of cases. Age, LV dysfunction, non-elective surgery, previous cardiac surgery, peripheral vascular disease and CPB time were independent risk factors for mortality and major morbidity. The mean hospital stay was 7.2 ± 5.7 days. CONCLUSIONS: Isolated CABG with CPB using non-cardioplegic methods proved very safe, with low mortality and morbidity. These methods are simple and expeditious and remain as very useful alternative techniques of myocardial preservation.
- The influence of educational nursing intervention on the eating habits and anthropometric values of people who have undergone coronary surgeryPublication . Ledo, D; Ferreira, PC; Silva, AMObjective: Educational nursing intervention is a strategy that can be useful for changing behaviours in a person’s health. Hospitalisation for coronary surgery is a valuable opportunity for the nurse to implement the knowledge which aims to promote healthy behaviours and secondarily, prevent coronary and cardiovascular disease, as these continue to be the main causes of death worldwide. The purpose of this study is to evaluate the influence of educational nursing intervention in the promotion of a healthy diet and in the anthropometric values (body mass index and waist perimeter) of people who have undergone coronary surgery. Methods: A quantitative and quasi-experimental study was conducted on a control group (20 participants in each group). The experimental group was submitted to a personalised structured educational intervention during hospitalisation, in the nursing follow-up visit (two to three weeks after surgery) and over the phone (two months after surgery). Each group went through two evaluations: the first before the surgery, and the second three months after the surgery. The instruments used to collect data included: the sociodemographic and clinical characterisation questionnaire and the Eating Habits Scale. Non-parametric tests were used. Results: The findings showed that 77.5% of the participants were male and 22.5% female. The participants’ average age was 67.35 ± 8.151. Results showed a significant improvement in the eating habits of both groups, with higher relevance in the experimental group and a reduction of the body mass index and waist perimeter exclusively in the experimental group. Conclusions: Regarding people who have undergone coronary surgery, personalised structured educational nursing intervention is a useful tool in obtaining health benefits and in secondary prevention of cardiovascular disease. More extensive and comprehensive studies are recommended to verify the results and enhance their success.
- Glucose uptake and lipid metabolism are impaired in epicardial adipose tissue from heart failure patients with or without diabetesPublication . Burgeiro, A; Fuhrmann, A; Cherian, S; Espinoza, D; Jarak, I; Carvalho, RA; Loureiro, M; Patrício, M; Antunes, MJ; Carvalho, EType 2 diabetes mellitus is a complex metabolic disease, and cardiovascular disease is a leading complication of diabetes. Epicardial adipose tissue surrounding the heart displays biochemical, thermogenic, and cardioprotective properties. However, the metabolic cross-talk between epicardial fat and the myocardium is largely unknown. This study sought to understand epicardial adipose tissue metabolism from heart failure patients with or without diabetes. We aimed to unravel possible differences in glucose and lipid metabolism between human epicardial and subcutaneous adipocytes and elucidate the potential underlying mechanisms involved in heart failure. Insulin-stimulated [(14)C]glucose uptake and isoproterenol-stimulated lipolysis were measured in isolated epicardial and subcutaneous adipocytes. The expression of genes involved in glucose and lipid metabolism was analyzed by reverse transcription-polymerase chain reaction in adipocytes. In addition, epicardial and subcutaneous fatty acid composition was analyzed by high-resolution proton nuclear magnetic resonance spectroscopy. The difference between basal and insulin conditions in glucose uptake was significantly decreased (P= 0.006) in epicardial compared with subcutaneous adipocytes. Moreover, a significant (P< 0.001) decrease in the isoproterenol-stimulated lipolysis was also observed when the two fat depots were compared, and it was strongly correlated with lipolysis, lipid storage, and inflammation-related gene expression. Moreover, the fatty acid composition of these tissues was significantly altered by diabetes. These results emphasize potential metabolic differences between both fat depots in the presence of heart failure and highlight epicardial fat as a possible therapeutic target in situ in the cardiac microenvironment.
- Histomorphometric analysis of the human internal thoracic artery and relationship with cardiovascular risk factorsPublication . Fonseca, DA; Antunes, PE; Antunes, MJ; Cotrim, MDIn this study, we aimed at performing a histomorphometric analysis of human left internal thoracic artery (ITA) samples as well as at correlating the histomorphometric findings with the clinical profile, including risk factors and medication. Distal segments of ITA were obtained from 54 patients undergoing coronary artery bypass grafting. Histological observation was performed in paraffin-embedded transverse sections of ITA through four staining protocols: hematoxylin-eosin, van Gieson, Masson's trichrome and von Kossa. Morphometric analysis included the intimal width (IW), medial width (MW) and intima/media ratio (IMR). No overt atherosclerotic lesions were observed. Mild calcifications were observed across the vascular wall layers in almost all samples. Multivariable linear regression analysis showed associations between IW and IMR and the following clinical variables: age, gender, kidney function expressed as eGFR and myocardial infarction history. Age (odds ratio = 1.16, P = 0.004), female gender (odds ratio = 11.34, P = 0.011), eGFR (odds ratio = 1.03, P = 0.059) and myocardial infarction history (odds ratio = 4.81, P = 0.040) were identified as the main clinical predictors for intimal hyperplasia. Preatherosclerotic lesions in ITA samples from patients undergoing coronary revascularization were associated not only with classical cardiovascular risk factors such as age and gender, but also with other clinical variables, namely kidney function and myocardial infarction history.
- Vascular effects of a polyphenolic fraction from Oxalis pes-caprae L.: role of α-adrenergic receptors Sub-typesPublication . Fonseca, DA; Ferreira, M; Campos, MG; Antunes, PE; Antunes, MJ; Cotrim, MDOxalis pes-caprae L. is a plant of the Oxalidaceae family, from which several compounds have been previously identified. Recently, we showed that an Oxalis pes-caprae L. extract inhibits the vasopressor effect of noradrenaline. In this work we aimed to explore the mechanisms involved in this effect. The results confirmed that the flavonoid fraction present in the extract inhibits noradrenaline-induced contractions and that this effect is concentration-dependent. Also, a parallel shift to the right in the noradrenaline concentration-response curve was observed, suggesting a decrease in efficacy and also in potency. Together these results support the assumption that the extract could exert a non-competitive antagonism on the α-adrenergic receptors. However, experiments in the presence of competitive antagonists for α-adrenergic receptor sub-types (i.e. prazosin, yohimbine and phentolamine) showed that the effect may not be directly mediated by α-adrenergic receptors. Thus, the interaction of this extract with the adrenergic system remains to be confirmed.
- Challenges in rheumatic valvular disease: Surgical strategies for mitral valve preservationPublication . Antunes, MJIn developing countries, rheumatic fever and carditis still constitutes a major public health problem. Patients have special characteristics that differ from those with rheumatic mitral valve disease we still see in developed countries. They are usually young, poor, uneducated, and have low compliance to prophylaxis / therapy. In addition, they usually have great difficulty in accessing medical care. In these situations, the rate of complications associated to valve replacement is significantly increased. Alternatively, mitral valve repair is now known to achieve better long-term results in this pathology, but this was not widely recognized three or four decades ago, when first reports showed worse results after repair of rheumatic regurgitation than with degenerative valves. This has been reported by several groups in developing countries in different continents, with high incidence of repairs and excellent long term results. It is, therefore, becoming increasingly clear that, although, the results may not compare to those obtained with degenerative pathology, repair of rheumatic valves, when feasible, is the procedure of choice, especially in these underprivileged populations.
- Surgical Treatment of Posterior Mitral Valve Prolapse: Towards 100% RepairPublication . Correia, PM; Coutinho, GF; Branco, C; Garcia, A; Antunes, MJBACKGROUND: The study aim was to evaluate the immediate and long-term results of surgical treatment of isolated posterior mitral valve leaflet prolapse (PLP), focusing on survival and freedom from recurrent mitral regurgitation (MR). METHODS: Between January 1998 and December 2012, a total of 492 consecutive patients (375 males, 117 females; mean age 61.8 ± 12.1 years; range: 13-86 years) with isolated PLP [304 (61.8%) with myxomatous degeneration; 188 (38.2%) with fibroelastic deficiency] were treated at the authors' institution. Of these patients, 202 (41.1%) were in NYHA class III-IV, and atrial fibrillation was present in 104 (21.1%). Mitral valve repair was achieved in 484 patients (98.4%), resection was performed in 419 (85.2%), and prosthetic ring annuloplasty was used in 436 (88.6%). Concomitant procedures were performed in 153 patients (31.1%), including tricuspid valve repair in 50 (10.2%), aortic valve surgery in 34 (6.9%), and coronary artery bypass grafting (CABG) in 64 (13%). RESULTS: The hospital mortality rate was 0.2%, and the mean follow up was 7.1 ± 3.9 years. There were 71 late deaths (14.4%), and overall survival at five, 10 and 15 years was 91.7 ± 1.3%, 82.1 ± 2.3% and 64.7 ± 6.1%, respectively. There was no significant difference in long-term survival compared with the age- and gender-matched general population (p = 0.146). Multivariate Cox-proportional hazard analysis showed older age (HR 1.03 per annum), left ventricular dysfunction (HR 2.44), atrial fibrillation (HR 1.96), left ventricular end-diastolic dimension (HR 1.05 per mm) and non-use of prosthetic ring (HR 3.03) as significant predictors of late mortality. Recurrence of moderate or severe MR occurred in 31 patients, six of whom underwent mitral valve reoperation. Predictors of late recurrence of MR were fibroelastic deficiency (HR 2.38), mitral calcification (HR 5.26), posterior leaflet plication (HR 3.58), absence of complete ring annuloplasty (HR 3.84) and systolic pulmonary artery pressure at discharge (HR 1.10 per mmHg). Freedom from mitral valve reoperation at 15 years was 97.4 ± 1.1% CONCLUSIONS: Mitral valve repair in isolated PLP can be achieved in virtually all cases with a very low operative risk and a high durability of repair. Atrial fibrillation or large left ventricles are associated with a poor prognosis. Failure to use a complete ring annuloplasty carries a risk not only for the return of MR but also for survival.
- Long-term follow-up of asymptomatic or mildly symptomatic patients with severe degenerative mitral regurgitation and preserved left ventricular functionPublication . Coutinho, GF; Garcia, AL; Correia, PM; Branco, C; Antunes, MJOBJECTIVES: The timing for mitral valve surgery in asymptomatic patients with severe mitral regurgitation and preserved left ventricular function remains controversial. We analyzed the immediate and long-term outcomes of these patients after surgery. METHODS: From January 1992 to December 2012, 382 consecutive patients with severe chronic degenerative mitral regurgitation, with no or mild symptoms, and preserved left ventricular function (ejection fraction ≥ 60%) were submitted to surgery and followed for up to 22 years (3209 patient-years). Patients with associated surgeries, other than tricuspid valve repair, were excluded. Cox proportional-hazard survival analysis was performed to determine predictors of late mortality and mitral reoperation. Subgroup analysis involved patients with atrial fibrillation or pulmonary hypertension. RESULTS: Mitral valvuloplasty was performed in 98.2% of cases. Thirty-day mortality was 0.8%. Overall survival at 5, 10, and 20 years was 96.3% ± 1.0%, 89.7% ± 2.0%, and 72.4% ± 5.8%, respectively, and similar to the expected age- and gender-adjusted general population. Patients with atrial fibrillation/pulmonary hypertension had a 2-fold risk of late mortality compared with the remaining patients (hazard ratio, 2.54; 95% confidence interval, 1.17-4.80; P = .018). Benefit was age-dependent only in younger patients (<65 years; P = .016). Patients with atrial fibrillation/pulmonary hypertension (hazard ratio, 4.20, confidence interval, 1.10-11.20; P = .037) and patients with chordal shortening were at increased risk for reoperation, whereas patients with P2 prolapse (hazard ratio, 0.06; confidence interval, 0.008-0.51; P = .037) and patients with myxomatous valves (hazard ratio, 0.072; confidence interval, 0.008-0.624; P = .017) were at decreased risk. CONCLUSIONS: Mitral valve repair can be achieved in the majority of patients with low mortality (<1%) and excellent long-term survival. Patients with atrial fibrillation/pulmonary hypertension had compromised long-term survival, particularly younger patients (aged <65 years), and are at increased risk of mitral reoperation.
- Rupture of expanded polytetrafluoroethylene neochordae used for mitral valve repair: does size matter?Publication . Antunes, MJ; Coutinho, GF