A artéria radial (AR) constitui valiosa opção de enxerto na revascularização do miocárdio (RM), desde a retomada de seu uso, nos anos 1990. O objetivo deste estudo foi avaliar perviedade e remodelamento dos enxertos de AR e sua relação com lesão obstrutiva pré-operatória e parede miocárdica revascularizada, observando-se também os enxertos de artéria torácica interna (ATI). CASUÍSTICA E MÉTODO: Entre 1994 e 2007, 3.964 pacientes foram operados com uso da AR, no InCor/HCFMUSP. Foram selecionados os reestudos angiográficos (12 meses) de 100 pacientes, sendo 11 deles reestudados em duas épocas diferentes. Em 92 pacientes foi utilizada a ATI. Foram determinados os diâmetros médios de AR e ATI, através do software CASS-II®. RESULTADOS: O tempo médio de reestudo foi de 70,53 ±33,18 meses. Em 82 casos (82,0%), a AR revascularizou uma única coronária, mais freqüentemente (50,83%) os ramos marginal esquerdo (ME) ou ventricular posterior (VP/CX). As obstruções pré-operatórias entre 90 e 99% foram as mais prevalentes (39,0%). A perviedade observada foi de 80 casos para AR (80,0%) e 80 para ATIE (86,96%). Houve correlação entre as maiores obstruções pré-operatórias e maior perviedade da AR (p=0,024). Os diâmetros médios dos enxertos foram de 2,302mm ±0,479 (AR) e 2,262mm ±0,409 (ATI). Observaram-se AR maiores do que a média (>2,30mm) nas obstruções pré-operatórias de 100%, em comparação com as demais (p=0,017). As AR que revascularizaram a parede lateral apresentaram os maiores diâmetros, em comparação às demais (p=0,04). Nos 11 pacientes com 2 reestudos, os diâmetros médios das AR foram de: 2,482mm ±0,424 (primeiro reestudo) e 2,599mm ±0,532 (segundo reestudo)(p=n/s). Para as ATIE, observaram-se: 2,308mm ±0,459 (primeiro reestudo) e 2,326mm ±0,531 (segundo reestudo) (p=n/s). No segundo reestudo, observou-se maior número de AR com diâmetros maiores, relacionados às obstruções entre 90-100% (p=0,013). A parede miocárdica revascularizada não interferiu nos diâmetros dos enxertos. CONCLUSÕES: A obstrução pré-operatória interfere na perviedade e nos diâmetros dos enxertos de AR, especialmente nas obstruções de 90% ou mais. A parede miocárdica revascularizada não interfere na perviedade da AR, porém interfere nos diâmetros dos enxertos. Foi observado remodelamento dos enxertos de AR, estando as obstruções mais graves relacionadas aos maiores aumentos de diâmetros dos enxertos comportamento semelhante às ATI. / The radial artery (RA) is an invaluable option for coronary artery bypass grafting (CABG), since its re-introduction in the late 1990 s.The objective of this study was to assess patency and remodeling of RA grafts regarding the interference of pre-operative coronary obstruction and grafted myocardial wall, also observing the internal thoracic artery grafts (ITA). METHODS: Between 1994 and 2007, 3,964 patients were operated with RA grafts, at Heart Institute, University of São Paulo, Brazil. Post-operative coronary angiographies (12 months)of 100 patients were obtained, including 11 patients with two post-op exams, at different periods. In 92 patients the ITA was also used.The grafts medium diameters were obtained using the CASS-II® software. RESULTS: Mean time of post-op angiography was 70,53 ±33,18 months. In 82 cases (82,0%) the RA grafted a single coronary, more frequently (50,83%) the left marginal (LM) or posterior ventricular (PV) branches. Pre-op obstructions between 90 and 99% were more prevalent (39,0%). Patency was of 80 cases for the RA (80,0%) and 80 cases for the ATI grafts (86,96%). There was a correlation between more severe pre-op obstructions and greater patency of the RA grafts (p=0,024). The mean diameters were 2,302mm ±0,479 (RA) and 2,262mm ±0,409 (ITA). RA diameters were above the mean value (>2,30mm) in pre-op obstructions of 100%, compared to the rest (p=0,017). The RA grafting the lateral wall showed the larger diameters, compared to the rest (p=0,04). For the 11 patients with 2 post-op angiographies, mean diameters of RA grafts were: 2,482mm ±0,424 (first) and 2,599mm ±0,532 (second)(p=n/s). For ITA grafts, mean diameters were: 2,308mm ±0,459 (first) and 2,326mm ±0,531 (second)(p=n/s). For the second angiographies, RA grafts exhibited larger diameters, related to pre-op obstructions between 90 and 100% (p=0,013). The grafted myocardial wall showed no interference with graft diameter. CONCLUSIONS: Pre-op coronary obstruction interferes in patency and diameters of RA grafts, more evidently for obstructions of 90% or greater. The grafted myocardial wall does not interfere with RA patency, although it does interfere with graft diameter. Remodeling was observed in RA grafts, correlating greater pre-op coronary obstructions and more evident increase in graft diameter similarly to the ITA grafts.

背景與目的： 每一項疾病都有其潛在的風險，但要有效的降低死亡率及併發症發生率，必須找出關鍵性指標加以改善或預防。我們以心臟冠狀動脈繞道手術之患者為例，希望藉由統計分析的方式，找出造成死亡以及術後併發症最相關的因素，目的不只在預測，而在於防範。 研究對象與方法： 在我們的實驗設計上，風險因子分布在手術前、手術中、以及手術後三個階段，對象是某醫學中心接受心臟冠狀動脈繞道手術的220例患者。分析採用迴歸統計建立模型，其中羅吉斯迴歸中的依變數為死亡率與罹病率，線性迴歸的依變數為加護病房留置天數以及總住院日數。ROC curve亦將被建立，以判斷模型是否能區別病患是否罹病或死亡。所得資料亦計算EuroScore及其ROC曲線面積，並與歷史資料做比較。 結果： 所建立的死亡估計模型的有兩個，預測值都在97%以上，ROC曲線面積亦都超過0.96；併發症估計模型由六個變數所構成，預測率及ROC曲線面積分別為94%和0.984。加護病房留置天數及住院天數估計模型分別由八個及十三個因子來解釋，調整後的R square分別為0.527及0.6。EuroScore對死亡與併發症的預測率，分別為93.7%和82%，ROC曲線面積分別是0.864和0.797，均高於歷史文獻記錄，未來應該廣泛應用。 結論與建議： 經由適當的風險分級和危險因子分析，我們可以找出風險高低的標準和依據，了解影響死亡率與罹病率的關鍵因子是什麼，儘可能的做事前的防範與處置，希望能夠改善結果並提高手術的存活率。 EuroScore是個值得採用的預測工具，可以廣泛應用在死亡率與併發症發生率的估計，但是必須搭配風險因子的改善，才能發揮實際的功效。我們認為，體外循環時間與再次手術是最具有空間來降低死亡率與罹病率的兩個要素，有效率的控制時間、改善造成再手術的前因後果，除了死亡率與併發症發生率的下降外，還可以及早脫離對加護病房照顧的需求並減少留置的天數。

Coronary artery disease (CAD) is the leading cause of mortality worldwide and atrial fibrillation (AF) is a prevalent arrhythmia associated with increased risk of mortality and morbidity. Despite improved outcome in both diseases, there is a need to further describe the prevalence, outcome and management of CAD in patients with concomitant AF. AF was a common finding among patients with MI, with 16% having new-onset, paroxysmal or chronic AF. Patients post-MI with concomitant AF, regardless of subtype, were at increased risk of composite cardiovascular outcome of mortality, MI or ischemic stroke, including mortality and ischemic stroke alone. No major difference in outcome was observed between AF subtypes. At discharge, an oral anticoagulant was prescribed to 27% of the patients with MI and AF undergoing percutaneous coronary intervention (PCI). Aspirin or clopidogrel plus warfarin versus dual antiplatelet therapy with aspirin plus clopidogrel were associated with similar 0-90-day and lower 91-365-day risk of cardiovascular outcome, without increased risk of major bleeding events. Triple therapy with aspirin, clopidogrel plus warfarin versus dual antiplatelet therapy was associated with non-significant lower risk of cardiovascular outcome, but with increased risk of bleeding events. Treatment with renin-angiotensin system (RAS) inhibitors post-MI was associated with lower risk of all-cause and cardiovascular mortality in patients with and without congestive heart failure and/or AF. However, RAS inhibition in patients without AF was not associated with lower risk of new-onset AF. Approximately 1 in 3 patients undergoing isolated coronary artery bypass grafting (CABG) had pre- or postoperative AF. Patients with AF, regardless of subtype, were at higher risk of all-cause mortality, cardiovascular mortality and congestive heart failure. Furthermore, postoperative AF was associated with higher risk of recurrent AF. In conclusion, AF was a common finding in the setting of MI and CABG. AF, irrespectively if in the setting of MI or CABG was associated with higher risk of ischemic events and mortality. Also, postoperative AF was associated with recurrent AF. Oral anticoagulants post-MI and PCI in patients with AF was underutilized, however, optimal antithrombotic therapy is still unknown. RAS inhibition post-MI seems beneficial, however, it was not associated with lower incidence of new-onset AF.

Durante a cirurgia de revascularização do miocárdio com circulação extracorpórea e hipotermia (CEC-H) ocorre alteração na efetividade do propofol e na sua farmacocinética realizada a partir das concentrações plasmáticas do propofol total no decurso do tempo. A ligação do propofol à proteína plasmática parece estar alterada em consequência de diversos fatores incluindo a hemodiluição e a heparinização que ocorre no início da circulação extracorpórea, uma vez que se reportou anteriormente que a concentração plasmática do propofol livre aumentou durante a realização da circulação extracorpórea normotérmica. Por outro lado, a infusão alvo controlada é recomendada para manter a concentração plasmática do propofol equivalente ao alvo de 2 &#181g/mL durante a intervenção cirúrgica com CEC-H. Se alterações significativas na hipnose do propofol ocorrem nesses pacientes, então o efeito aumentado desse agente hipnótico poderia estar relacionado à redução na extensão da ligação do fármaco as proteínas plasmáticas; entretanto, o assunto ainda permanece em discussão e necessita de investigações adicionais. Assim, o objetivo do estudo foi investigar as concentrações plasmáticas de propofol livre em pacientes durante a revascularização do miocárdio com e sem o procedimento de CEC-H através da abordagem PK-PD. Dezenove pacientes foram alocados e estratificados para realização de cirurgia de revascularização do miocárdio com circulação extracorpórea (CEC-H, n=10) ou sem circulação extracorpórea (NCEC, n=9). Os pacientes foram anestesiados com sufentanil e propofol alvo de 2 &#181g/mL. Realizou-se coleta seriada de sangue para estudo farmacocinético e o efeito foi monitorado através do índice bispectral (BIS) para medida da profundidade da hipnose no período desde a indução da anestesia até 12 horas após o término da infusão de propofol, em intervalos de tempo pré-determinados no protocolo de estudo. As concentrações plasmáticas foram determinadas através de método bioanalítico pela técnica de cromatografia líquida de alta eficiência. A farmacocinética foi investigada a partir da aplicação do modelo aberto de dois compartimentos, PK Solutions v. 2. A análise PK-PD foi realizada no Graph Pad Prisma v.5.0 após a escolha do modelo do efeito máximo (EMAX sigmóide, slope variável). Os dados foram analisados utilizando o Prisma v. 5.0, p<0,05, significância estatística. As concentrações plasmáticas de propofol total foram comparáveis nos dois grupos (CEC-H e NCEC); entretanto o grupo CEC-H evidenciou aumento na concentração do propofol livre de 2 a 5 vezes em função da redução na ligação do fármaco às proteínas plasmáticas. A farmacocinética do propofol livre mostrou diferença significativa entre os grupos no processo de distribuição pelo prolongamento da meia vida e aumento do volume aparente, e no processo de eliminação em função do aumento na depuração plasmática e redução na meia vida biológica no grupo CEC-H. A escolha do modelo EMAX sigmóide, slope variável foi adequada uma vez que se evidenciou alta correlação entre os valores do índice bispectral e as concentrações plasmáticas do propofol livre (r2>0.90, P<0.001) para os pacientes investigados. / During coronary artery bypass grafting (CABG) surgery with cardiopulmonary bypass (CPB) profound changes occur on propofol effect and on kinetic disposition related to total drug plasma measurements in these patients. It was reported that drug plasma binding could be altered as a consequence of hemodilution and heparinization before starts CPB since free propofol plasma levels was increased by twice under normothermic procedure. In addition, the target controlled infusion (TCI) is recommended to maintain propofol plasma concentration (2 &#181g/mL) during CABG CPB-H intervention. However, whether significant changes that occur in propofol hypnosis in these patients could be related to the reduction on the extension of drug plasma binding remain unclear and under discussion until now. Then, the objective of this study was to investigate propofol free plasma levels in patients undergoing CABG with and without CPB by a pharmacokinetics-pharmacodynamics (PK-PD) approach. Nineteen patients were scheduled for on-pump coronary artery bypass grafting (CABG-CPB, n=10) or off-pump coronary artery bypass grafting (OPCABG, n=9) were anesthetized with sufentanil and propofol TCI (2 &#181g/mL). Blood samples were collected for drug plasma measurements and BIS were applied to access the depth of hypnosis from the induction of anesthesia up to 12 hours after the end of propofol infusion, at predetermined intervals. Plasma drug concentrations were measured using high-performance liquid chromatography, followed by a propofol pharmacokinetic analysis based on two compartment open model, PK Solutions v.2; PK-PD analysis was performed by applying EMAX model, sigmoid shape-variable slope and data were analyzed using Prisma v. 5.0, considering p<0.05 as significant difference between groups. The total propofol plasma concentrations were comparable in both groups during CABG; however it was shown in CPB-group significant increases in propofol free plasma concentration by twice to fivefold occur as a consequence of drug plasma protein binding reduced in these patients. Pharmacokinetics of free propofol in CPB-H group compared to OPCAB group based on two compartment open model was significantly different by the prolongation of distribution half-life, increases on plasma clearance, and biological half-life shortened. In addition, the kinetic disposition of propofol changes in a different manner considering free drug levels in the CPB-H group against OPCAB group as follows: prolongation of distribution half-life and increases on volume of distribution, remaining unchanged biological half-life in spite of plasma clearance increased. BIS values showed a strong correlation with free drug levels (r2>0.90, P<0.001) in CPB-H group and also in OPCAB group by the chosen EMAX model sigmoid shape-variable slope analyzed by GraphPad Prisma v.5.0.

INTRODUÇÃO: Complicações pulmonares são frequentes no pós-operatório da cirurgia de revascularização do miocárdio (RM) e a ventilação não-invasiva (VNI) tem sido utilizada nos cuidados pós-operatórios de forma profilática e terapêutica. A manobra de recrutamento alveolar (MRA) consiste no aumento sustentado de pressão na via aérea utilizando um alto nível de pressão expiratória final positiva (PEEP) em indivíduos hipoxêmicos, garantindo uma ventilação pulmonar homogênea e, com isso melhorando a oxigenação arterial. O objetivo desse estudo foi de avaliar se o uso da VNI associada à MRA pode melhorar a oxigenação e se pode ser aplicada de forma segura nos pacientes pós-operatório de RM. MÉTODOS: Foram incluídos 34 pacientes internados na unidade de terapia intensiva (UTI) ventilados mecanicamente após RM com relação Pa02/Fi02 < 300 e escore radiológico de atelectasia ;:: 2. Os pacientes foram randomizados 16 para o grupo controle (GC) e 18 para o grupo recrutamento (GR), após a extubação a VNI foi aplicada por 30 minutos três vezes ao dia de acordo com a rotina da UTI. No GC a VNI era realizada com PEEP de 8 cm H20 e no GR foi aplicada PEEP de 15 cm H20 e 20 cm H20 durante 2 minutos cada e depois ficava com PEEP de 8 cm H20. Analisamos a Pa02 pela gasometria arterial em ar ambiente e o escore radiológico de atelectasia, estabilidade hemodinâmica e evento adverso até a alta da UTI. RESULTADOS: Aumento de Pa02 12,6 ± 6,8% GC e 23,3 ± 8,5% GR com p < 0,001, o escore radiológico de atelectasia apresentou resolução completa em 94,4% GR, enquanto que no GC, 87,5% apresentou algum grau de atelectasia, p < 0,001. Não houve eventos adversos relacionados. CONCLUSÃO: o uso por 30 minutos da VNI associada à MRA foi seguro, melhorou a oxigenação e reduziu a atelectasia / BACKGROUND: Postoperative pulmonary impairment is common in the early period after coronary artery bypass grafting (CABG) and noninvasive ventilation (NIV) has been used in postoperative care to prevent and treatment. Recruitment maneuver (RM) consists in a sustained raise of airway pressure with high levei of positive end-expiratory pressure (PEEP) in hypoxemic subjects, insuring a homogeneous pulmonary ventilation and enhancing oxygenation. The aims of this study were to evaluate if the use of NIV associated with RM could improve oxygenation and if it could be safely applied in CABG postoperative patients. METHODS: Were included 34 patients admitled to the intensive care unit (ICU) mechanically ventilated after CABG with Pa02/Fi02 ratio < 300 and radiological atelectasis score (RAS) ~ 2. Patients were randomized 16 to the control group (CG) and 18 to the recruitment group (RG), after extubation NIV was applied for 30 minutes three times a day according to ICU routine. In the CG, NIV was performed with PEEP 8 cm H20 and in the RG, was applied PEEP 15 cm H20 and 20 cm H20 for 2 minutes each and then was with PEEP 8 cm H20. We analyzed Pa02 from arterial blood gas at room air and RAS, hemodynamic stability and adverse event until discharged from the ICU. RESUL TS: Increased of Pa02 12.6±6.8% CG and 23.3±8.5% RG p < 0,001, RAS presented complete improvement for 94.4% RG, whereas in the CG, 87.5% presented some degree of atelectasis, p < 0,001. There was no adverse event related. CONCLUSION: The use of 30 minutes of NIV associated with RM was safe, improved oxygenation and reduced atelectasis

Duas técnicas invasivas para o tratamento da doença aterosclerótica coronariana oclusiva firmaram-se ao longo dos anos: revascularização cirúrgica do miocárdio e angioplastia transcutânea com stents metálicos. O estudo visa comparar as alterações histopatológicas causadas por stents metálicos coronarianos fabricados com a superliga de composição química em porcentagem em peso cromo 20%, tungstênio 15%, níquel 10% e cobalto restante, designada ASTM F.90, revestidos, ou não, com carbeto de silício pelo processo de asperção térmica originando uma superfície hidrofílica. Stents com espessura das hastes entre 80 a 90 nm, área das células entre 1,4 a 2,1 mm² e relação metal-artéria de 13 a 19%, em pacientes reestenosantes que sofreram posteriormente revascularização cirúrgica do miocárdio, com aqueles não submetidos à angioplastia prévia. Foram determinados dois grupos: grupo I ou grupo controle, pacientes que sofreram revascularização cirúrgica do miocárdio sem angioplastia prévia de qualquer natureza; grupo II pacientes submetidos à revascularização cirúrgica do miocárdio, após reestenose intra-stent coronariana. Pacientes de ambos os grupos foram avaliados rotineiramente quanto à indicação e risco cirúrgico e durante o procedimento convencional da revascularização cirúrgica do miocárdio utilizando circulação extracorpórea, antes de realizar a anastomose do enxerto vascular na coronária, amostras contendo pequenos fragmentos de endotélio foram retiradas juntamente com fragmentos dos stents, enviadas para análise histopatológica e produção de laminas coradas com H-E. Observou-se a presença de arterite crônica caracterizada por infiltrado mononuclear em conjunto com fenômeno de proliferação fibroblástica e de musculatura lisa naqueles pacientes que apresentavam reestenose intra-stent, sendo mais intenso no local do stent. A visualização das superfícies dos stents em escala nanometrica (MFA) é de suma importância para análise estrutural das próteses, avaliando irregularidades nas superfícies recobertas das hastes dos stents. A persistência de arterite crônica coronariana avaliada por infiltrado linfomononuclear e proliferação de fibrocolágeno foi constatada em pacientes reestenosantes. / Two invasive techniques for the treatment of occlusive coronary atherosclerosis disease were signed over the years: coronary artery bypass surgery and transcutaneous angioplasty with bare metal stent. The study attempts to compare the histopathological abnormality caused in patients with implantation of bare metal stent in coronary made with: Chromium 20%, Tungsten 15%, Nickel 10% and Cobalt remainder, ASTM F.90 alloy for surgical implant applications, and covered with a thin layer of amorphous silicon carbide, or not, and its total or partial obstruction, after undergoing coronary artery bypass grafting, with those who had coronary artery bypass surgery with no previous angioplasty. Two groups were studied: group I, or control group, patients who underwent coronary artery bypass grafting without previous angioplasty of any kind; group II of patients undergoing coronary artery bypass surgery after coronary-stent restenosis. Patients in both groups were evaluated for the indication and surgical risk; was done routinely during the procedure of conventional coronary artery bypass grafting with cardiopulmonary bypass. Before performing the anastomosis in coronary vascular graft, a small fragment of the endothelium was removed along whit a fragment of the stent, and sent for analysis with hematoxilin-eosin. The presence of chronic inflammatory coronary reaction was detected, mediated by mononuclear cells with phenomenon of fibroblast and smooth muscle proliferation in patients presenting in-stent restenosis. It w coronary reaction as also observed that the inflammatory and proliferative process is more intense at the site of stent implantation. The analysis of surface of the stents used atomic force microscopy proved to be an important method for the surface analysis for stents, and showed on nanometric scale an irregular coverage of silicon carbide. In conclusion, in the patients with restenosis in-stent occurs persistence of chronic inflammation with mononuclear cells and process of fibroblast proliferation.

Aims: Coronary Revascularization (CR) has increased patients' survival rate globally. However, the lack of a consensus definition of Health Related Quality of Life (HRQoL) and the different methodological and conceptual approaches adopted by researchers in the cardio-revascularization field create an incomplete picture of the influence of CR on individuals' HRQoL. By using mixed methodology, the current research aimed to explore Greek CHD patients' perspectives of their HRQoL after CR (Coronary Artery Bypass Grafting (CABG) or Percutaneous Coronary Interventions (PCI)), as well as detect and explain individual disparities. Method: Two studies were conducted with a total sample of 487 individuals: (1) The translation and validation of the Coronary Revascularization Outcome Questionnaire (CROQ) into Greek and (2) The longitudinal mixed methods study, the main study of the thesis, following a sequential explanatory design with two research components: a) the longitudinal quantitative component aimed to detect changes in patients' HRQoL (both overall and its subdomains) following CR over a 12-month period based on individuals' subjective evaluation as captured by the CROQ, detect the influence of CR type on the outcome and to explore potential predictors (individuals' demographic, clinical and behavioural features). Data were analysed using multilevel modelling; b) the qualitative component aimed to capture individuals' lived experience, their view and understanding of themselves and their life approximately 12 months after treatment using Interpretive Phenomenological Analysis (IPA). Results/findings: Based on participants' subjective evaluations as captured by the validated Greek version of the CROQ, one year after CR Greek Coronary Heart Disease (CHD) patients experience an increase in their HRQoL level compared to prior to CR. The pattern of change though is not constant; initially HRQoL increases with time, and then decreases again, however, remaining much greater compared to prior to CR one year after CR. Regarding the influence of the CR type of treatment on patients' HRQoL level, a year after CR mixed findings are revealed. In the symptoms and physical functioning subdomain, patients treated with CABG demonstrate a greater increase compared to patients treated with PCI. In the psychosocial functioning subdomain no difference is found. In the cognitive functioning subdomain, patients treated with CABG demonstrate a decline compared to their cognitive functioning prior to the CR. Various demographic, clinical and behavioural features are demonstrated to be predictors of the outcome though not consistent for all subdomains. The main predictors associated with larger positive changes following CR seem to be sex, BMI and smoking; females with low BMI that do not smoke tend to demonstrate a greater increase in HRQoL after CR. According to individuals' lived experience, participants, reflecting on their experience one year after treatment, perceive CR as a simple process and their negative experience is mostly related to medical care. Many participants with no symptoms or adverse effects tend to misperceive CHD, viewing their health condition as an acute disease treated with CR. Trying to understand disease causality they tend to adopt medical discourse especially in relation to stress as a factor that can be controlled by themselves and reflect on their own responsibility as a causal factor. Feeling grateful for being alive, sensing a different body, a 'revitalized body' as many participants suggest, as well as a fear of re-occurrence or disease progression motivate individuals to work on aspects of the self related to the CHD development in an effort to regain control over their life which has been reduced after the CHD diagnosis. In effect a dramatic change in how the self and life are viewed is reported, highlighting a positive growth; a greater appreciation of life, a personal growth and effort to build more meaningful relationships. Challenges that participants face in modification of their lifestyle are attributed to both external and internal factors. Concerning smoking participants' accounts point to a lack of knowledge regarding the relationship between smoking and CHD, a lack of support (by experts or family members) and conscious denial as a way to cope with every day anxiety and stress, but also a pleasure in everyday life. The findings provide a complementary insight into perceptions of individuals with CHD about their quality of life one year after CR, suggesting that other factors beyond CR may influence their perspectives. Conclusions/implications: This study highlights the benefits of using a mixed methods longitudinal design in exploring HRQoL. Both the quantitative and qualitative findings support the notion that HRQoL is a multidimensional, continuously changing concept, providing support for the Wold Health Organization's definition. Also, the findings suggest that CR has a positive influence on individuals' HRQoL. The effect of the CR type needs further investigation as mixed findings are observed in the present thesis. Moreover, it seems difficult to investigate the pure effect of CR on individuals' HRQoL without taking into consideration individuals' adjustment processes and positive growth triggered by the CR. The self regulation model (SRM) might be considered a useful theoretical framework for developing theory-based interventions aiming to alter patients' false beliefs since individuals' making-meaning process seems to be aligned with it. Finally, the complementary insights concerning smoking may help health care providers to develop smoking cessation interventions tailored to cardiac patients.

INTRODUÇÃO: Complicações pulmonares são frequentes no pós-operatório da cirurgia de revascularização do miocárdio (RM) e a ventilação não-invasiva (VNI) tem sido utilizada nos cuidados pós-operatórios de forma profilática e terapêutica. A manobra de recrutamento alveolar (MRA) consiste no aumento sustentado de pressão na via aérea utilizando um alto nível de pressão expiratória final positiva (PEEP) em indivíduos hipoxêmicos, garantindo uma ventilação pulmonar homogênea e, com isso melhorando a oxigenação arterial. O objetivo desse estudo foi de avaliar se o uso da VNI associada à MRA pode melhorar a oxigenação e se pode ser aplicada de forma segura nos pacientes pós-operatório de RM. MÉTODOS: Foram incluídos 34 pacientes internados na unidade de terapia intensiva (UTI) ventilados mecanicamente após RM com relação Pa02/Fi02 < 300 e escore radiológico de atelectasia ;:: 2. Os pacientes foram randomizados 16 para o grupo controle (GC) e 18 para o grupo recrutamento (GR), após a extubação a VNI foi aplicada por 30 minutos três vezes ao dia de acordo com a rotina da UTI. No GC a VNI era realizada com PEEP de 8 cm H20 e no GR foi aplicada PEEP de 15 cm H20 e 20 cm H20 durante 2 minutos cada e depois ficava com PEEP de 8 cm H20. Analisamos a Pa02 pela gasometria arterial em ar ambiente e o escore radiológico de atelectasia, estabilidade hemodinâmica e evento adverso até a alta da UTI. RESULTADOS: Aumento de Pa02 12,6 ± 6,8% GC e 23,3 ± 8,5% GR com p < 0,001, o escore radiológico de atelectasia apresentou resolução completa em 94,4% GR, enquanto que no GC, 87,5% apresentou algum grau de atelectasia, p < 0,001. Não houve eventos adversos relacionados. CONCLUSÃO: o uso por 30 minutos da VNI associada à MRA foi seguro, melhorou a oxigenação e reduziu a atelectasia / BACKGROUND: Postoperative pulmonary impairment is common in the early period after coronary artery bypass grafting (CABG) and noninvasive ventilation (NIV) has been used in postoperative care to prevent and treatment. Recruitment maneuver (RM) consists in a sustained raise of airway pressure with high levei of positive end-expiratory pressure (PEEP) in hypoxemic subjects, insuring a homogeneous pulmonary ventilation and enhancing oxygenation. The aims of this study were to evaluate if the use of NIV associated with RM could improve oxygenation and if it could be safely applied in CABG postoperative patients. METHODS: Were included 34 patients admitled to the intensive care unit (ICU) mechanically ventilated after CABG with Pa02/Fi02 ratio < 300 and radiological atelectasis score (RAS) ~ 2. Patients were randomized 16 to the control group (CG) and 18 to the recruitment group (RG), after extubation NIV was applied for 30 minutes three times a day according to ICU routine. In the CG, NIV was performed with PEEP 8 cm H20 and in the RG, was applied PEEP 15 cm H20 and 20 cm H20 for 2 minutes each and then was with PEEP 8 cm H20. We analyzed Pa02 from arterial blood gas at room air and RAS, hemodynamic stability and adverse event until discharged from the ICU. RESUL TS: Increased of Pa02 12.6±6.8% CG and 23.3±8.5% RG p < 0,001, RAS presented complete improvement for 94.4% RG, whereas in the CG, 87.5% presented some degree of atelectasis, p < 0,001. There was no adverse event related. CONCLUSION: The use of 30 minutes of NIV associated with RM was safe, improved oxygenation and reduced atelectasis

Des éléments contributifs à plusieurs facettes de la chirurgie cardiaque ont été étudiés dans la présente thèse. Le premier manuscrit adresse la problématique de l’accident cérébro-vasculaire (ACV) post-opératoire. Nous avons analysé de façon rétrospective la médication prise en pré-opératoire de 6813 patients nécessitant une chirurgie de revascularisation coronarienne. Le but étant d’établir si la présence d’une médication précise (aspirine, inhibiteur de l’enzyme de conversion de l’angiotensine, statine, bêta-bloqueur) peut agir en pré-opératoire pour diminuer le risque d’ACV. En analyse multivariée, la combinaison de la prise de bêta-bloqueurs avec une statine a produit un ratio de cote de 0,37, suggérant un effet protecteur très important. Dans le deuxième manuscrit, je présente une étude ciblant les patients avec insuffisance mitrale ischémique modérée. Trente et un patients furent randomisés entre un traitement par pontages seuls vs pontages et annuloplastie mitrale restrictive. L’insuffisance mitrale a disparu en post-opératoire immédiat en présence de l’annuloplastie alors qu’aucun effet immédiat de la revascularisation coronarienne n’était noté sur l’insuffisance mitrale. Un an suivant la chirurgie, une insuffisance mitrale légère est réapparue chez le groupe ayant subi l’annuloplastie alors que les patients du groupe pontages seuls ont remodelé leur ventricule gauche et diminué l’importance de leur insuffisance mitrale au même niveau que le groupe annuloplastie. Aucun des marqueurs d’évolution clinique, tant au niveau symptomatique qu’au niveau de la survie ne diffère entre les groupes. La troisième étude est un suivi sur 20 ans des patients ayant eu des remplacements valvulaires mitraux ou aortiques avec une prothèse mécanique Carbomedics. Cette étude démontre une excellente survie avec un taux de complications valvulaires hémorragiques, thrombotiques, thrombo-emboliques, et d’endocardite favorable comparé aux autres types de prothèse et une absence de bris mécanique. / Many aspects of heart surgery have been carefully studied in the present thesis. The first manuscript touches the important problematic of post-operative stroke. We have analysed in a retrospective fashion the prescription drugs taken pre-operatively in 6,813 patients requiring coronary artery bypass surgery. The aim was to analyse the effect of taking any of the following medications pre-operatively on the risk of post-operative stroke: aspirin, agiotension converting enzyme (ACE) inhibitors, statins, beta-blockers. The combination of taking a beta-blocker and a statin yielded an odd ratio of 0.37 in multivariable analysis, suggesting a strong protective effect. In the second manuscript, I present a study addressing the problematic of moderate ischemic mitral regurgitation. We randomized 31 patients to be treated either by coronary bypass grafts alone or by a combination of coronary bypass grafting and restrictive mitral annuloplasty. Mitral valve regurgitation disappeared immediately following surgery in the annuloplasty group while no impact of coronary artery bypass graft (CABG) alone was noted on mitral insufficiency at the same time point. After one year of follow-up, mild mitral insufficiency was noted to recur in the annuloplasty group while the patients from the CABG alone group remodelled their left ventricle and secondarily decreased their mitral insufficiency grade to the same level as the annuloplasty group. None of the different measurements of clinical evolution differed between the groups at one year. The third study is a 20-year follow-up of patients who had an isolated valvular replacement on the aortic or mitral position with the Carbomedics mechanical prosthesis. This study shows an excellent survival rate with low complications of hemorrhage, thrombosis, thrombo-embolism, reoperation and endocarditis. Noteworthy, a complete absence of structural failure at 20 years.

Made available in DSpace on 2016-06-02T20:19:06Z (GMT). No. of bitstreams: 1 1696.pdf: 3646825 bytes, checksum: e027c9b9c12baae91d504600ec364c3c (MD5) Previous issue date: 2008-02-28 / Universidade Federal de Sao Carlos / It is well-known that cardiac autonomic and pulmonary function are impaired after coronary artery bypass surgery (CABG). Strategies resulting in beneficial cardiorespiratory responses as soon as possible after surgery are clinically important in these patients. However, information on the differences in cardiorespiratory responses of these patients to inpatient cardiac rehabilitation (CR) with distinct left ventricular (LVF) is still scant. Therefore, the purpose of this study was to assess the cardiorespiratory responses to a short-term inpatient CR programme in patients with LVF normal and reduced. Twenty three patients were studied and divided into LVF normal group (LVFN, n=12) or reduced group (LVFR, n=11). Cardiac autonomic function was evaluated by heart rate variability (HRV) and the pulmonary function by spirometric and respiratory muscle strength (RMS) at (1) post-operative day 1 (PO1) and (2) day before discharge. Heart rate (HR) and R-R intervals (R-Ri) were recorded by telemetry system Polar S810i, at rest, in supine and sitting position. HRV was evaluated in time domain by mean R-R (mean R-R), square root of the mean squared differences of successive R-Ri (RMSSD) and standard deviation of all R-Ri (SDNN) indexes (ms) The spirometric data of vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1) and maximal voluntary ventilation (MVV) were obtained and the RMS was measured indirectly by maximal inspiratory (MIP) and expiratory (MEP) pressures. All patients initiated the CR on PO1 following a programme of progressive steps composed of whole body and breathing exercises previously established until discharge. Results: After inpatient CR, both groups presented improvement of mean R-R (ms) and RMSSD (ms) indexes at rest and beneficial response to postural change with lower RMSSD (ms) index in sitting position. Significant improvement of pulmonary function in both groups was observed to majority spirometric data as FVC, MVV and FEV1 and RMS only presented tend to improvement in response to CR programme Conclusions: These results indicate that patients undergoing CABG with preserved or depressed LVF presented beneficial cardiorespiratory responses to CR after surgery. We also assign slightly more favourable responses on autonomic function in those with depressed LVF without additional risks. Therefore, the inpatient whole CR should be strongly indicates as soon as possible post-CABG even in patients with cardiac dysfunction. Financial support: CNPq e FAPESP (05/59427-7). / É conhecido que a função autonômica cardíaca e pulmonar se encontram prejudicadas em pacientes submetidos à cirurgia de revascularização do miocárdio (CRM). Estratégias resultantes em respostas cardiorrespiratórias benéficas e implementadas tão cedo quanto possível no pós-CRM são clinicamente importantes a estes pacientes. No entanto, permanece escassa a informação sobre as possíveis diferenças nas respostas cardiorrespiratórias destes pacientes a reabilitação cardíaca (RC) hospitalar quando estes apresentam funções ventriculares distintas (normal ou reduzida). Portanto, o objetivo deste estudo foi avaliar as respostas cardiorrespiratórias a um programa de RC na fase hospitalar em pacientes com função ventricular esquerda (FVE) normal e reduzida. Foram estudados vinte e três pacientes divididos em: Grupo FVEN=12, composto de pacientes com FVE normal e Grupo FVER=11, composto de pacientes com FVE reduzida. A função autonômica cardíaca foi avaliada pela variabilidade da freqüência cardíaca (VFC) e a função pulmonar pelas variáveis espirométricas e medida de força muscular respiratória (FMR) no (1) primeiro dia pós-operatório (PO1) e (2) no dia anterior a alta hospitalar. A freqüência cardíaca (FC) e os intervalos R-R foram registrados pelo sistema de telemetria Polar S810i, em condições de repouso, nas posições supina e sentada. A VFC foi analisada no domínio do tempo pela média dos iR-R (média R-R), raiz quadrada da média do quadrado das diferenças entre intervalos RR normais adjacentes (RMSSD) e desvio-padrão da média de todos os intervalos R-R normais (SDNN) em milisegundos. Os dados espirométricos de capacidade vital (CV), capacidade vital forçada (CVF), volume expiratório forçado no 1º segundo (VEF1) e ventilação voluntária máxima (VVM) foram obtidos e a FMR foi medida indiretamente pelas pressões inspiratória (PImax) e expiratória (PEmax) máximas. Todos os pacientes iniciaram o programa de RC no PO1 seguindo um programa de etapas progressivas composto de exercícios globais e respiratórios previamente estabelecido até a alta hospitalar. Resultados: Após RC, ambos os grupos apresentaram melhora da média R-R (ms) e do índice RMSSD (ms) em repouso e respostas benéficas a mudança postural com menor valor do índice RMSSD (ms) na posição sentada. Foi encontrada melhora significativa da função pulmonar em ambos os grupos, observada para a maioria dos dados espirométricos como CVF, VVM e VEF1 e a FMR apresentou apenas tendência à melhora em reposta ao programa de RC. Conclusões: Estes resultados indicam que pacientes submetidos a CRM com FVE preservada ou reduzida apresentaram respostas cardiorrespiratórias benéficas a RC após a cirurgia. Atribuímos resposta mais favorável para função autonômica cardíaca para aqueles pacientes com FVE reduzida sem riscos adicionais. Portanto, um programa de RC global em ambiente hospitalar deve ser fortemente indicado tão o mais rapidamente possível pós-CRM mesmo em pacientes com disfunção cardíaca. Apoio financeiro: CNPq e FAPESP (05/59427-7).