Made available in DSpace on 2016-06-02T20:19:11Z (GMT). No. of bitstreams: 1 2553.pdf: 1596497 bytes, checksum: 1c1b091ddb6a8fb9d0cc5e1b5bfd8201 (MD5) Previous issue date: 2009-06-26 / Universidade Federal de Minas Gerais / Noninvasive positive pressure ventilation (NIPPV) has been commonly applied in several clinical and postoperative conditions, especially after coronary artery bypass grafting (CABG) surgery and it can cause breathing pattern (BP) alterations and mechanical effects on cardiovascular system, with cardiac autonomic adjustments. However, it is not well established in the literature how these alterations occur in patients submitted to the CABG and if they can be related to the application of different positive airway pressure levels. In this context, we considered the development of two studies that could contribute with new information about these topics. The first study is entitled Acute application of bilevel positive airway pressure influence cardiac autonomic nervous system and its objective was to evaluate the changes in heart rate variability (HRV) during bilevel positive airway pressure (Bilevel) application in healthy young men. Twenty men underwent a 10-min register of R-R intervals (R-Ri) during sham ventilation, Bilevel 8-15cmH2O and Bilevel 13-20 cmH2O. HRV was analyzed in time and frequency-domain and with non-linear statistical measures. Physiological variables (blood pressure, breathing rate, end tidal carbon dioxide- ETCO2) were also collected. R-Ri mean, rMSSD, NN50, pNN50 and SD1 reduced during 13-20 cmH2O compared to sham ventilation, with reduction of the R-Ri mean compared to 8-15 cmH2O. R-Ri mean and high frequency band (HF) reduced and low frequency band (LF) increased during 8-15 cmH2O compared to sham ventilation. Delta of ETCO2 correlated positively with LF, HF, LF/HF, SDNN, rMSSD and SD1. In conclusion, acute application of Bilevel was able to alter cardiac autonomic nervous system, with parasympathetic activity reduction and sympathetic increase and higher level of positive airway pressure can cause a greater influence on the cardiovascular and respiratory system. The second study is entitled The effects of different levels of positive airway pressure on respiratory pattern and heart rate variability in patients submitted to coronary artery bypass grafting surgery and its objective was to access the effects of different levels of continuous positive airway pressure (CPAP) in BP and HRV in CABG postoperative (PO), as well as the impact of CABG in these variables. Eighteen patients underwent CABG was evaluated during spontaneous breathing (SB) and four different CPAP levels of CPAP, in a random order: (a) CPAP = sham (3 cmH2O), (b) 5 CPAP = cmH2O, (c) 8 CPAP= cmH2O, (d) 12 CPAP = cmH2O in PO. HRV was analysed in time and frequency domain and by non-linear methods (Poincaré plot e Detrended Fluctuation Analysis) and BP was analysed by inductive respiratory plethysmograph. There were significant alterations of HRV and BP in the PO of CRM, compared to pre-operative and alterations of DFAα1, DFAα2 e SD2 and respiratory variables during NIPPV, with higher influence observed during application of the two higher levels applied. Moreover, there was relationship between DFAα1 and inspiratory time of delta 12 cmH2O and SB, and 8 cmH2O and SB. In conclusion, acute CPAP application was able to alter the control of cardiac autonomic nervous system and BP of patients submitted to CABG and higher levels promoted better performance of pulmonary and cardiac autonomic function. / A ventilação não-invasiva por pressão positiva (VNIPP) tem sido comumente utilizada em diversas condições clínicas e pós-operatórias, principalmente na cirurgia de revascularização do miocárdio (CRM) e pode causar alterações do padrão ventilatório (PV) e efeitos mecânicos sobre o sistema cardiovascular, com ajustes autonômicos cardíacos. Entretanto, ainda não é claro se estas alterações ocorrem em pacientes submetidos à CRM e se podem estar relacionadas a diferentes níveis pressóricos aplicados. Neste contexto, propusemos o desenvolvimento de dois estudos que poderiam contribuir com novas informações. O primeiro estudo, intitulado Aplicação aguda de pressão positiva por dois níveis pressóricos nas vias aéreas influencia o sistema nervoso autonômico cardíaco teve por objetivo avaliar as mudanças na variabilidade da frequência cardíaca (VFC) durante aplicação de pressão positiva por dois níveis pressóricos (Bilevel) em indivíduos jovens saudáveis. Vinte homens foram submetidos ao registro de 10 minutos dos intervalos R-R (iR-R) durante aplicação de ventilação sham, Bilevel 8- 15cmH2O e Bilevel 13-20 cmH2O. A VFC foi analisada no domínio do tempo e da freqüência e por métodos não-lineares. Variáveis fisiológicas (pressão arterial, frequência respiratória e fração de dióxido de carbono no final da expiração- ETCO2) também foram coletadas. Houve redução da média dos iR-R, e dos índices rMSSD, NN50, pNN50 e SD1 durante aplicação dos níveis 13-20 cmH2O de Bilevel comparado ao modo sham, ainda com redução da média dos iR-R quando comparados aos níveis 8-15cmH2O. Houve diminuição da média dos iR-R e da banda de alta freqüência (AF), com aumento da banda de baixa freqüência (BF) durante a aplicação de 8-15 cmH2O comparada à ventilação sham. O delta de ETCO2 correlacionou-se positivamente com BF, AF, BF/AF, SDNN, rMSSD e SD1. Em conclusão, a aplicação aguda de Bilevel foi capaz de alterar o sistema nervoso autonômico cardíaco, com redução da atividade parassimpática e aumento da atividade simpática e níveis mais elevados de pressão positiva podem causar maior influência nos sistemas cardiovascular e respiratório. O segundo estudo, intitulado Efeitos de diferentes níveis de pressão positiva nas vias aéreas sobre o padrão ventilatório e a variabilidade da freqüência cardíaca de pacientes submetidos à cirurgia de revascularização do miocárdio objetivou avaliar os efeitos da aplicação de diferentes níveis de pressão positiva contínua nas vias aéreas (CPAP) sobre o padrão ventilatório (PV) e a VFC no pós-operatório (PO) de CRM, bem como o impacto da CRM sobre estas variáveis. Foram avaliados 18 pacientes submetidos à CRM, durante RE (respiração espontânea) e aplicação de quatro níveis de CPAP, de forma randomizada: (a) CPAP = sham (3 cmH2O), (b) CPAP = 5 cmH2O, (c) CPAP= 8 cmH2O, (d) CPAP = 12 cmH2O no PO. A VFC foi analisada no domínio do tempo e da freqüência e por métodos não-lineares (Poincaré plot e Flutuações Depuradas de Tendência) e o PV foi analisado em diferentes variáveis, por meio da pletismografia respiratória por indutância. Houve alteração da VFC e do PV no PO de CRM, comparado ao período pré-operatório, bem como alterações dos índices DFAα1, DFAα2 e SD2, e de variáveis ventilatórias durante aplicação de VNIPP, com maior influência exercida pela aplicação dos dois níveis pressóricos mais elevados. Além disso, houve correlação entre o índice DFAα1 e tempo inspiratório para o delta de 12 cmH2O e RE, e 8 cmH2O e RE. Em conclusão, temos que a aplicação aguda de CPAP foi capaz de alterar o controle do sistema nervoso autonômico cardíaco e o PV de pacientes submetidos à CRM e os níveis mais elevados promoveram melhor desempenho da função pulmonar e autonômica cardíaca. Apoio Financeiro: FAPESP (07/53202-9).

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.

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.

Abstract Coronary artery disease (CAD) is the leading cause of death in developed countries. In patients with complex CAD, coronary artery bypass grafting (CABG) remains the preferred treatment as it can provide long-lasting results. However, CABG carries a significant risk of excessive perioperative bleeding and other complications, which may deteriorate the prognosis. Transfusion of blood products is generally used to compensate blood loss. However, both bleeding and blood transfusions have been shown to be associated with an adverse outcome. This cohort study aimed to clarify the impact of perioperative bleeding and the use of different blood products in the development of perioperative complications in 2,764 patients undergoing isolated CABG. The universal definition of perioperative bleeding classification (UDPB) was employed to stratify the severity of bleeding. Additionally, the impact of storage time of transfused red blood cells (RBCs) on the outcome was investigated. Increased UDPB classes, particularly classes 3 and 4, were associated with significantly poorer immediate and late outcome. RBC transfusion in patients who underwent elective off-pump CABG was independently associated with increased troponin I release indicating myocardial injury. Prolonged storage duration of transfused RBCs did not affect immediate and late outcome of patients with moderate bleeding. The most remarkable risk factors for stroke after off-pump CABG were any degree of atherosclerosis of the ascending aorta as well as transfusion of platelets and/or solvent/detergent-treated plasma. The UDPB classification appears to be a promising research tool to stratify the severity of perioperative bleeding and to assess its prognostic impact after coronary surgery. Prevention of major bleeding that leads to blood transfusion may protect from myocardial injury and stroke and possibly result in better early and late outcomes. Patients with a diseased ascending aorta could be considered at high risk of stroke because of their risk of generalized atherosclerosis. In case of mildly diseased aorta, the “no-touch” aorta policy should be considered with the intention of preventing postoperative stroke. / Tiivistelmä Sepelvaltimotauti on yleisin kuolinsyy kehittyneissä maissa. Potilailla, joilla on vaikea monen suonen tai vasemman sepelvaltimon päärungon tauti, sepelvaltimoiden ohitusleikkaus on edelleen paras hoitovaihtoehto, koska sillä pystytään saavuttamaan pitkäkestoisia tuloksia. Kuitenkin ohitusleikkaukseen liittyy suuri riski leikkauksen aikaiselle tai jälkeiselle verenvuodolle ja muille haittatapahtumille, jotka osaltaan huonontavat potilaan ennustetta. Vuodon hoitona käytetään yleisesti verensiirtoa. Kuitenkin on osoitettu, että sekä verenvuoto että verituotteiden anto lisäävät riskiä komplikaatioille. Tämän kohorttitutkimuksen tavoitteena oli selvittää tarkemmin leikkauksen yhteydessä ilmenevän vuodon ja siihen liittyvän verensiirron vaikutuksia leikkauksen jälkeisten haittatapahtumien kehittymiseen 2764 ohitusleikatulla potilaalla. Universal Definition of Perioperative Bleeding (UDPB) -luokitusta käytettiin vuodon vaikeusasteen luokittelemiseen. Lisäksi tutkittiin siirrettyjen punasolujen varastointiajan vaikutusta potilaan ennusteeseen. Korkeammat UDPB-luokat, erityisesti luokat 3 ja 4, liittyivät merkittävästi huonompaan lyhyen ja pitkän aikavälin ennusteeseen. Potilailla, joille oli tehty kiireetön ohitusleikkaus ilman sydän-keuhkokoneen käyttöä, punasolujen anto oli itsenäinen riskitekijä suurentuneelle troponiini I -päästölle eli sydänlihasvauriolle. Pidentynyt punasolujen varastointiaika ei ollut yhteydessä lyhyen tai pitkän aikavälin ennusteeseen potilailla, jotka olivat vuotaneet kohtalaisesti. Merkittävimmät riskitekijät ilman sydän-keuhkokonetta tehdyn leikkauksen jälkeiselle aivoinfarktille olivat minkä tahansa asteinen nousevan aortan ateroskleroosi sekä verihiutaleiden ja/tai jääplasman anto. UDPB-luokitus vaikuttaa lupaavalta tutkimustyökalulta verenvuodon vaikeusasteen luokitteluun. Lisäksi sitä voidaan käyttää vuodon ennusteellisen vaikutuksen arvioimiseen ohitusleikkauksen jälkeen. Runsaan verenvuodon ja siihen liittyvän verensiirron ehkäiseminen saattaa suojata potilasta sydänlihasvauriolta ja aivoinfarktilta ja mahdollisesti johtaa parempaan lyhyen ja pitkän aikavälin ennusteeseen. Potilaita, joilla on nousevan aortan ateroskleroosi, voisi pitää suuressa aivoinfarktiriskissä yleisen ateroskleroosiriskin vuoksi. Potilailla, joilla on lieväkin nousevan aortan ateroskleroosi, tulisi harkita aortan jättämistä pihdittämättä aivoinfarktin ehkäisemiseksi.

Abstract Cardiovascular diseases are the leading cause of death worldwide, and coronary artery disease accounts for the majority of them. The treatment of choice for complex coronary artery disease is coronary artery bypass grafting. However, as surgery in general, cardiac surgery is associated with an increased risk of perioperative bleeding and utilization of blood products. The present study aimed to investigate the impact of preoperative anemia, perioperative bleeding and retained blood syndrome as well as blood transfusion on the outcomes after isolated coronary surgery. The severity of perioperative bleeding was assessed mainly using the E-CABG and UDPB stratification criteria. Our analyses showed that severe bleeding is associated with a significantly increased risk of stroke. Furthermore, severe bleeding increased the risk of several adverse events even in low-risk patients. Retained blood syndrome was observed to be a common complication after coronary surgery and was associated with an increased risk of postoperative complications. Preoperative anemia seems to have no significant impact on patient early and late survival. Instead, the frequent exposure to blood products may be the determinant of poorer survival observed among anemic patients. Perioperative blood loss and exposure to allogeneic blood has been shown to increase adverse events. Therefore, prevention of bleeding and measures to optimize patient blood management could improve patient outcomes after cardiac surgery. / Tiivistelmä Sydän ja verisuonitaudit ovat maailmanlaajuisesti yleisin kuoleman aiheuttaja, joista sepelvaltimotaudilla on suurin vaikutus. Sepelvaltimoiden ohitusleikkaus on käypä hoito vakavassa sepelvaltimotaudissa. Kuten kirurgiassa yleisestikin, erityisesti sydänkirurgia on yhdistetty suurentuneeseen verenevuodon ja verituotteiden saannin riskiin. Tutkimukseni tavoitteena oli selvittää preoperatiivisen anemian, perioperatiivisen verenvuodon, verituotteiden annon, sekä leikkausalueelle jääneen veren itsenäisiä vaikutuksia potilaiden lopputulemiin sepelvaltimoiden ohitusleikkauksen jälkeen. Verituotteiden ja perioperatiivisen verenvuodon määrää arvioitiin pääsääntöisesti käyttäen E-CABG ja UDPB verenvuotoluokituksia. Tuloksenamme oli, että vakava verenvuoto lisää merkitsevästi aivoinfarktin riskiä. Lisäksi vakava perioperatiivinen verenvuoto on yhteydessä useisiin komplikaatioihin myös matalan leikkausriskin potilailla. Leikkausalueelle jääneen veren huomattiin olevan yleinen ongelma sepelvaltimoiden ohitusleikkauksen jälkeen, minkä lisäksi se lisäsi riskiä useille haitta-tapahtumille. Preoperatiivisella anemialla ei ollut tilastollisesti merkitsevää vaikutusta potilaiden lyhyen ja pitkän aikavälin ennusteisiin. Sen sijaan, aneemisille potilaille annetut verensiirrot saattaisivat aiheuttaa näillä potilailla huomatun alentuneen elinajan ennusteen. Perioperatiivisen verenvuodon ja altistumisen verituotteille on osoitettu lisäävän haittatapahtumia. Siispä verenvuodon vähentäminen ja verituotteiden säästäminen voisi parantaa potilaiden ennustetta sydänkirurgiassa.

No description available.

Ziel: Die Ergebnisse nach aortokoronarer Bypassoperation (CABG) unterscheiden sich bei Patienten mit schlechter linksventrikulärer Pumpfunktion deutlich von denen bei Patienten ohne Einschränkungen derselben. Das Ziel dieser Studie war die Untersuchung des Einflusses einer reduzierten linksventrikulären Ejektionsfraktion (LVEF), eines vergrößerten linksventrikulären enddiastolischen Volumenindexes (LVEDVI) und eines erhöhten linksventrikulären enddiastolischen Druckes (LVEDP) auf das postoperative "outcome". Material und Methodik: Im Rahmen dieser retrospektiven Studie wurden 148 Patienten mit einer koronaren Herzkrankheit (KHK) und eingeschränkter Ejektionsfraktion (EF / Aim: Results of coronary artery bypass grafting (CABG) in patients with poor left ventricular ejection fraction (LVEF) differ from those in patients with normal LVEF. The aim of the study was a investigation into the influence of reduced LVEF, augmented left ventricular enddiastolic volume index (LVEDVI) and elevated left ventricular enddiastolic pressure (LVEDP) on the outcome of CABG. Methods: 148 Patients with LVEF < 50% underwent CABG. Exercise tolerance and LVEF were determined pre- and postoperatively. Three subgroups were built to distinguish the influence of reduced LVEF on postoperative outcome. Group I: LVEF < 30%, group II: 30% < LVEF < 40%, group III: 40% < LVEF < 50%. Results: Exercise tolerance rised from a preoperatively mean of 70 Watt to 97 Watt postoperatively. Mean NYHA class was 2,7 pre- and 1,7 postoperatively. There were no significant differences in the results of the three subgroups. Perioperative mortality in group I was 6,3%. Actuarial 1 and 2 years survival in this group is at 81 and 70% respectively. These results differ clearly from those of group II and III. Perioperativ mortality was 2,2% in group II and 1,4% in group III. Actuarial 1 and 2 years survival is at 93 and 84% in group II and at 95 and 83% in group III. There was no difference in postoperative outcome of patients with LVEDP > 12mmHg in comparison to patients with LVEDP < 12mmHg. Patients with LVEDVI > 100 ml/m2 had a sifnificant higher peri- and postoperative mortality than patients with LVEDVI < 100 ml/m2. Mean LVEDVI of those patients, whose LVEF increased postoperatively, was 84 ml/m2. Patients with no change in LVEF had a mean LVEDVI of 122 ml/m2. Conclusion: CABG in patients with reduced LVEF improves exercise tolerance and quality of life. Poor LVEF (< 30%) and augmented LVEDVI are predicting higher peri- and postopertive mortality. Postoperative increase of LVEF is unlikely in patients with enlarged left ventricels.

Endotelio funkcijos sutrikimas (disfunkcija) - būklė, apibūdinama padidėjusia adhezijos molekulių ekspresija, padidėjusia prouždegiminių veiksnių ir protrombotinių faktorių sinteze bei sutrikusia kraujagyslių tono reguliacija - yra mirties dėl kardiovaskulinės patologijos, miokardo infarkto bei poreikio revaskuliarizacijos procedūroms išsivystymo rizikos veiksnys. Darbo tikslas buvo nustatyti endotelio pažeidimą atspindinčių žymenų, hs-CRP, sVCAM-1 ir sICAM-1 reikšmę, nuspėjant kardiovaskulines komplikacijas po aortos vainikinių jungčių suformavimo operacijos, atliktos dirbtinės kraujo apytakos sąlygomis. Nustatėme, kad didesnės priešoperacinės hs-CRP ir sVCAM-1 koncentracijos buvo nepriklausomi didesnės kardiovaskulinių komplikacijų po aortos vainikinių jungčių suformavimo operacijų rizikos žymenys. Po aortos vainikinių jungčių suformavimo operacijos nustatyta reikšmingai didesnė hs-CRP, sVCAM-1 ir sICAM-1 koncentracija, palyginus su priešoperaciniu koncentracijos lygiu. Patikimos žymenų koreliacijos su aortos užspaudimo, dirbtinės kraujo apytakos bei operacijos trukme neradome. Pacientams po aortos vainikinių jungčių suformavimo operacijos koreliacijos tarp pooperacinio sICAM-1, sVCAM-1 bei hs-CRP koncentracijos lygio ir kardiovaskulinių komplikacijų išsivystymo rizikos nebuvo nenustatyta. / The endothelial cell damage/dysfunction is associated with increased expression of adhesion molecules, synthesis of proinflammatory, prothrombotic factors and abnormal modulation of vascular tone. A growing body of evidence suggests that endothelial dysfunction is associated with future cardiovascular events including cardiac death, myocardial infarction and the need for revascularization procedures. The aim of the study was to evaluate the impact of markers of endothelial damage as predictors of cardiovascular events after on-pump coronary artery bypass grafting surgery. We found that higher concentrations preoperatively of hs-CRP and sVCAM-1 were independent markers for higher risk of cardiovascular events after coronary artery bypass grafting surgery. Concentration of hs-CRP, sVCAM-1 and sICAM-1 increased significantly after on-pump coronary artery bypass grafting surgery compared to preoperative level. However correlation between the duration of aortic cross-clamp, cardiopulmonary bypass or surgery and markers of endothelial damage was not found. Correlation between postoperative concentration of hs-CRP, sVCAM-1 and sICAM-1 and risk for cardiovascular events after coronary artery bypass grafting surgery was not found.

Endotelio funkcijos sutrikimas (disfunkcija) - būklė, apibūdinama padidėjusia adhezijos molekulių ekspresija, padidėjusia prouždegiminių veiksnių ir protrombotinių faktorių sinteze bei sutrikusia kraujagyslių tono reguliacija - yra mirties dėl kardiovaskulinės patologijos, miokardo infarkto bei poreikio revaskuliarizacijos procedūroms išsivystymo rizikos veiksnys. Darbo tikslas buvo nustatyti endotelio pažeidimą atspindinčių žymenų, hs-CRP, sVCAM-1 ir sICAM-1 reikšmę, nuspėjant kardiovaskulines komplikacijas po aortos vainikinių jungčių suformavimo operacijos, atliktos dirbtinės kraujo apytakos sąlygomis. Nustatėme, kad didesnės priešoperacinės hs-CRP ir sVCAM-1 koncentracijos buvo nepriklausomi didesnės kardiovaskulinių komplikacijų po aortos vainikinių jungčių suformavimo operacijų rizikos žymenys. Po aortos vainikinių jungčių suformavimo operacijos nustatyta reikšmingai didesnė hs-CRP, sVCAM-1 ir sICAM-1 koncentracija, palyginus su priešoperaciniu koncentracijos lygiu. Patikimos žymenų koreliacijos su aortos užspaudimo, dirbtinės kraujo apytakos bei operacijos trukme neradome. Pacientams po aortos vainikinių jungčių suformavimo operacijos koreliacijos tarp pooperacinio sICAM-1, sVCAM-1 bei hs-CRP koncentracijos lygio ir kardiovaskulinių komplikacijų išsivystymo rizikos nebuvo nenustatyta. / The endothelial cell damage/dysfunction is associated with increased expression of adhesion molecules, synthesis of proinflammatory, prothrombotic factors and abnormal modulation of vascular tone. A growing body of evidence suggests that endothelial dysfunction is associated with future cardiovascular events including cardiac death, myocardial infarction and the need for revascularization procedures. The aim of the study was to evaluate the impact of markers of endothelial damage as predictors of cardiovascular events after on-pump coronary artery bypass grafting surgery. We found that higher concentrations preoperatively of hs-CRP and sVCAM-1 were independent markers for higher risk of cardiovascular events after coronary artery bypass grafting surgery. Concentration of hs-CRP, sVCAM-1 and sICAM-1 increased significantly after on-pump coronary artery bypass grafting surgery compared to preoperative level. However correlation between the duration of aortic cross-clamp, cardiopulmonary bypass or surgery and markers of endothelial damage was not found. Correlation between postoperative concentration of hs-CRP, sVCAM-1 and sICAM-1 and risk for cardiovascular events after coronary artery bypass grafting surgery was not found.