<p>The aim was to study pathophysiological mechanisms and risk factors for developing atrial fibrillation (AF) after coronary artery bypass grafting (CABG), and the effect of thoracic epidural anaesthesia (TEA).</p><p>The study comprised 141 patients undergoing CABG, including 45 patients randomised for TEA intra- and postoperatively. All patients underwent 24-hour Holter monitoring pre- and postoperatively for the analysis of arrhythmias and heart rate variability (HRV). Catecholamines and neuropeptides (reflecting sympathetic and parasympathetic activity), atrial peptides and echocardiographically assessed atrial arias were obtained pre- and postoperatively.</p><p>Logistic regression analysis identified body mass index (BMI), maximum supraventricular beats (SPB) per minute, and total amount of cardioplegia as independent predictors of postoperative AF. Patients developing AF showed limited diurnal variation of HRV preoperatively. All HRV parameters decreased significantly in all patients postoperatively. The significant postoperative increase in atrial areas and atrial peptides did not differ between patients developing AF and those who did not. TEA had no effect on the incidence of postoperative AF, but resulted in lower heart rate, less increase in adrenaline levels, and decreased neuropeptide levels (reflecting sympathetic and parasympathetic activity). AF was initiated by an SPB in 72.4% of non-TEA and 100% of TEA treated patients, whereas changes in heart rate only, before onset, were seen in 17.2% non-TEA patients.</p><p>The observed risk factors, SPB and cardioplegia, may both induce electrophysiological changes known to increase the susceptibility to AF. The observed postoperative atrial dilatation and autonomic imbalance, indicated by HRV and neuropeptide levels, may further favour the development of AF. The observation that a majority of postoperative AF was initiated by a premature atrial contraction supports our hypothesis that latent atrial foci may be a major trigger mechanism of postoperative AF.</p>

The aim was to study pathophysiological mechanisms and risk factors for developing atrial fibrillation (AF) after coronary artery bypass grafting (CABG), and the effect of thoracic epidural anaesthesia (TEA). The study comprised 141 patients undergoing CABG, including 45 patients randomised for TEA intra- and postoperatively. All patients underwent 24-hour Holter monitoring pre- and postoperatively for the analysis of arrhythmias and heart rate variability (HRV). Catecholamines and neuropeptides (reflecting sympathetic and parasympathetic activity), atrial peptides and echocardiographically assessed atrial arias were obtained pre- and postoperatively. Logistic regression analysis identified body mass index (BMI), maximum supraventricular beats (SPB) per minute, and total amount of cardioplegia as independent predictors of postoperative AF. Patients developing AF showed limited diurnal variation of HRV preoperatively. All HRV parameters decreased significantly in all patients postoperatively. The significant postoperative increase in atrial areas and atrial peptides did not differ between patients developing AF and those who did not. TEA had no effect on the incidence of postoperative AF, but resulted in lower heart rate, less increase in adrenaline levels, and decreased neuropeptide levels (reflecting sympathetic and parasympathetic activity). AF was initiated by an SPB in 72.4% of non-TEA and 100% of TEA treated patients, whereas changes in heart rate only, before onset, were seen in 17.2% non-TEA patients. The observed risk factors, SPB and cardioplegia, may both induce electrophysiological changes known to increase the susceptibility to AF. The observed postoperative atrial dilatation and autonomic imbalance, indicated by HRV and neuropeptide levels, may further favour the development of AF. The observation that a majority of postoperative AF was initiated by a premature atrial contraction supports our hypothesis that latent atrial foci may be a major trigger mechanism of postoperative AF.

nÃo hà / Enxertos compostos com artÃria torÃcica interna esquerda (ATIE) tem aumentado sua aplicabilidade na cirurgia de RevascularizaÃÃo MiocÃrdica (RM). A confirmaÃÃo de patÃncia do enxerto de ATIE à pedra fundamental na RM. O melhor parÃmetro de patÃncia calculado pelo ecoDopplercardiograma à a fraÃÃo diastÃlica (FD) &#8805; 0,5. O objetivo geral deste estudo foi estabelecer parÃmetros ecoDopplercardiogrÃficos de patÃncia do enxerto composto de ATIE, quando revasculariza a artÃria interventricular anterior (AIA) e outro ramo do sistema coronariano esquerdo. O especÃfico foi definir a sensibilidade e a especificidade de trÃs variÃveis: RelaÃÃo da velocidade-pico na diÃstole sobre a velocidade-pico na sÃstole (VPD/VPS), integral da velocidade-tempo na diÃstole (VTID) e FD quanto à patÃncia do enxerto composto utilizando FD &#8805; 0,5 como padrÃo de referÃncia. O estudo foi realizado segundo um desenho em duas fases, fase controle e fase estudo. Na fase controle, todos os pacientes tinham a patÃncia dos enxertos confirmadas por cineangiocoronariografia (CINE). Estes pacientes tinham registro das variÃveis VPD/VPS, VTID e FD. Foram entÃo estabelecidos pontos de cortes para essas variÃveis baseando-se nos cÃlculos de sensibilidade e especificidade atravÃs da curva ROC (ReceiverOperationCharacteristic) com o objetivo de diferenciar enxertos compostos de enxertos simples quando a ATIE somente revasculariza a AIA. Esses pontos de corte foram aplicados nos pacientes com enxerto composto da fase estudo. Foi construÃda uma tabela de contingÃncia 2x2 para o cÃlculo de sensibilidade e especificidade, tendo como indicador de patÃncia uma FD&#8805;0,5. Na fase controle, observou-se diferenÃas estatisticamente significativas na anÃlise das trÃs variÃveis em diferenciar o enxerto simples do composto. Os parÃmetros de patÃncia do enxerto composto estabelecidos pela fase estudo foram VPD/VPS &#8805; 0,71, VTId &#8805; 0,09 e FD &#8805; 0,58. A especificidade para todas essas variÃveis foi de 100%. A sensibilidade foi de 40% para VPD/VPS &#8805; 0,71, 36,4% para VTId &#8805; 0,09 e 68% para FD &#8805; 0,58. Conclui-se que valores maiores ou iguais aos estabelecidos para cada variÃvel representam um provÃvel indicador de patÃncia do enxerto composto. Valores abaixo do estabelecido apresentam grande proporÃÃo de falsos negativos, nÃo sendo conclusivo quanto à patÃncia. / Composite grafts with left internal thoraic artery (LITA) has incresed its applicability in Coronary Artery Bypass Surgery (CAGB). Confirmation of patency of the LITA graft is the cornerstone of Miocardial Revascularization. The best measure of patency calculated by Doppler echocardiogram (Doppler) is the diastolic fraction (DF) &#8805; 0.5. The aim of this study was to establish Doppler echocardiographic parameters which could suggest the presence of a composite graft of LITA, when it revascularizes the anterior interventricular artery (AIA) and another branch of the left coronary artery system. The endpoint of this study was to define sensitivity and specificity considering three variables: ratio of peak velocity in diastole over the systolic peak velocity (DPV / SPV), the mean velocity-time integral in diastole (VTID) and FD of the composite graft patency using FD &#8805; 0.5 as the reference standard. The study was conducted according to a design in two stages. It was defined a control group and study group. In the control group, all patients had graft patencies confirmed by coronary angiography (CINE) and the variables DPV / SPV,VTID and DF measured. So, we use this data to establish cutoff points for these variables , based on the calculation of sensitivity and specificity using the ROC curve (Receiverv Operation Characteristic) in order to differentiate composite from simple graft when ATIE only revascularizes the AIA. These cutoff points were applied in patients with composite graft group study. We built a 2x2 contingency table to calculate sensitivity and specificity, considering the indicator of patency a DF &#8805; 0.5. In the control group, we observed statistically significant differences in the analysis of the three variables in differentiating simple from composite grafts. The parameters of composite graft patency established by the study group were DPV / SPV &#8805; 0.71,VTID &#8805; 0.09 and FD &#8805; 0.58. The specificity for all these variables was 100%. The sensitivity was 40% for DPV / SPV &#8805; 0.71, &#8805; 36.4% for VTId&#8805; 0.09 and 68% for FD &#8805; 0.58. We conclude that values greater than or equal to those established for each variable represents a likely indicator of graft patency compound. Values below the established are not conclusive to exclude composite grafts due to a large proportion off alse negatives.

O enxerto de artéria torácica interna tem demonstrado capacidade de remodelamento devido a interação com o leito arterial coronariano. O objetivo deste estudo foi analisar a influência dos fatores clínicos e angiográficos no remodelamento dos enxertos, definido como variação no calibre vascular. Casuística e métodos: No período entre 1983 e 1999, 356 pacientes realizaram cirurgia de revascularização do miocárdio utilizando a artéria torácica interna esquerda para o ramo interventricular anterior e a artéria torácica interna direita para um ramo da circunflexa. Trinta e dois pacientes foram submetidos a cineangiocoronariografia pós-operatória, a qual foi posteriormente analisada com o aplicativo CASS II®. Este estudo observacional apresentou acompanhamento médio de 42 meses(6-204 meses). As variáveis angiográficas analisadas foram os diâmetros proximal e distal dos enxertos arteriais (variável dependente), área coronariana, pontuação de fluxo TIMI, diâmetro de estenose proximal, fluxo dominante distal e ramos patentes. Fatores de risco cardiovascular também foram incluídos. Resultados: O modelo de regressão linear múltiplo demonstrou um R2ajustado=0,69 (p=0,0001) para o modelo a direita e R2ajustado=0,46 (p=0,002) para a esquerda. Os enxertos apresentaram diâmetros proximal e distal de 2,67mm ±0,085 e 2,232mm ±0,085 à esquerda; 2,458mm ±0,088 e 2,010mm ± 0,091 (média±EP) à direita, respectivamente (p>0,05). Nenhuma variável clínica obteve correlação significante estatisticamente. A área coronariana apresentou coeficiente de beta=0,42 (0,14-0,6/IC-95%) e diâmetro de estenose proximal de 0,55 (0,40-0,65/IC-95%) para o remodelamento do lado direito. A área coronariana demonstrou coeficiente de beta=0,54 (0,3- 0,68/IC-95%) para o remodelamento do lado esquerdo. Conclusões: A artéria torácica interna não demonstrou diferença de calibre em relação a lateralidade (esquerda vs direita). O diâmetro de estenose proximal da artéria coronária revascularizada demonstrou correlação positiva com o remodelamento dos enxertos do lado direito. A área da artéria coronária revascularizada foi a única variável de influência para o remodelamento bilateral dos enxertos / Internal thoracic artery grafts has demonstrated capacity for remodeling due to interaction with the coronary artery bed. The goal was to analysis the influence of clinical and angiographic factors in this remodeling as defined as grafts caliber variation. Methods: In a period from 1983 to 1999, 356 patients underwent to coronary artery bypass surgery using the left internal thoracic artery anastomosed to interventricular anterior branch and the right internal thoracic artery to circumflex branches. Thirty two patients were submitted to postoperative coronary angiography which was further analysed by CASS II® software. The mean follow-up of this observational study was 42 months(6- 204 months). Angiographic variables analyzed was proximal and distal diameters of arterial grafts(dependent variable), coronary area, TIMI flow grade, proximal stenosis diameter, dominant distal flow and patent branches. Cardiovascular risk factors were included indeed. Results: The multiple regression model demonstrated R2adjusted=0.69 (p=0.0001) for right side and R2adjusted=0.46 (p=0.002) for left side. The grafts presented proximal and distal diameters of 2.67mm ±0.085 and 2.232mm ±0.085 from left side; 2.458mm ±0.088 and 2.010mm ±0.091 (mean±SE) from right side respectively (p > 0,05). None of the clinical variables had statistical significant correlation. The coronary area presented as a beta coefficient=0.42 (0.14-0.6/CI-95%) and proximal stenosis diameter of 0.55 (0.40-0.65/CI-95%) for right side remodeling. The coronary area shown a beta coefficient=0.54 (0.3- 0.68/CI-95%) for left side remodeling. Conclusions: The internal thoracic artery did not demonstrate difference in caliber about its laterality (left vs right). The proximal stenosis degree of the bypassed coronary artery demonstrated positive correlation with remodeling for the right side grafts. Bilateral grafts remodeling was only explained by positive correlation with the bypassed coronary area

Abstract Coronary artery disease is the leading cause of death in the world. The outcome of patients at a very high operative risk undergoing coronary artery bypass surgery has not been thoroughly investigated. Cohorts of patients underwent coronary surgery between January 1997 and December 2013 at the Oulu University Hospital, Finland. Data was acquired from electronic patient records. Statistical analysis was performed on the collected data to evaluate outcome and identify predictors of adverse events. Very high-risk patients who underwent isolated coronary artery bypass surgery had a high 30-day mortality (16.2%), but their 5-year survival was satisfactory (66.8%). Survivors of out-of-hospital cardiac arrest were compared to a control group. Immediate postoperative mortality was slightly higher in out-of-hospital cardiac arrest patients (6.3% vs. 0%, p = 0.24), but the overall 5-year survival rates were similar (80.7% vs. 84.5%). Patients with preoperative stage 3 chronic kidney disease have a higher mortality than patients with stage 1-2 chronic kidney disease. Kidney function decline/year was predictive of all-cause mortality, cardiovascular mortality and also tended to predict fatal and non-fatal cardiovascular events. The E-CABG postoperative complication grading system was used to stratify the severity and prognostic impact of postoperative complications and was shown to predict early and late mortality for these patients. The outcome of emergency coronary artery bypass surgery was studied in a multi-center setting. Increasing emergency classes, left ventricular ejection fraction ≤30%, on-pump surgery, and participating centers were independent predictors of in-hospital mortality. Survival rates at 1, 3 and 5 years were 86.4%, 81.6%, and 76.1%. Despite the high preoperative risk of these patients, the long-term outcome for coronary surgery is satisfactory. Patients with stage 3 chronic kidney disease may experience a significant decline in kidney function and poor outcome. Early referral to a nephrologist may be beneficial for these patients. The E-CABG complication grading system seems to be a promising tool for stratifying the severity and prognostic impact of complications occurring after coronary surgery. / Tiivistelmä Sepelvaltimotauti on johtavia kuolinsyitä Maailmassa. Ohitusleikkauksen tuloksia ei ole täysin selvitetty erittäin korkean riskin potilailla. Potilaat leikattiin vuosina 1997-2013. Potilastiedot hankittiin sairauskertomuksista ja kuolinsyytiedot kansallisista rekistereistä. Erittäin korkean riskin potilaiden välitön kuolleisuus ohitusleikkauksen jälkeen on korkea (30 päivän kuolleisuus 16,2 %). Viiden vuoden kuluttua leikkauksesta elossa oli 66,8% leikatuista. Ohitusleikkausta edeltävästi elvytettyjä potilaita verrattiin kontrolliryhmään. Välittömät leikkauksen jälkeinen kuolleisuus oli 6,3% vs. 0% (p = 0,24). Viiden vuoden kuluttua leikkauksesta elossa oli tutkimusryhmästä 80,7% ja kontrolliryhmästä 80,7%. Leikkausta edeltävästi keskivaikean munuaisten vajaatoiminnan omaavilla potilailla on korkeampi kuolleisuus verrattuna potilaisiin, joiden munuaistoiminta on normaalia tai lievästi heikentynyt. Munuaisten vajaatoiminnan eteneminen ennusti kokonaiskuolleisuutta, sydän- ja verisuonikuolleisuutta ja enteili sydän- ja verisuonitapahtumia. E-CABG leikkauksen jälkeisten komplikaatioiden luokittelujärjestelmällä luokiteltiin leikkauksen jälkeisten komplikaatioiden vaikeusastetta ja ennusteellista vaikutusta. E-CABG luokat ja pisteytys ennustivat 1kk, 3kk kuolleisuutta ja kuolleisuutta pidemmällä aikavälillä. Päivystysohitusleikkauksen tuloksia tutkittiin monikeskusasetelmassa. Sairaalakuolleisuutta ennustivat päivystysleikkausluokitteluluokan vakavuus, vasemman kammion ejektiofraktio ≤30%, perfuusiossa tehty leikkaus ja leikkaava keskus. Potilaiden elossaololuvut olivat 1, 3 ja 5 vuoden kohdalla 86,4%, 81,6%, and 76,1%. Leikkaustulokset erittäin korkean riskin potilailla ohitusleikkauksesta ovat kohtuullisia leikkausta edeltävään riskiarvioon suhteutettuna. Näin ollen tämän potilasryhmän sepelvaltimotaudin hoito leikkaamalla on perusteltua. Keskivaikean munuaisten vajaatoiminnan omaavien potilaiden munuaissairauden etenemiseen seuranta-aikana liittyy kuolleisuutta ja sydän- ja verisuonitapahtumia. Aikaisessa vaiheessa tehty nefrolgin konsultaatio voi parantaa näiden potilaiden munuaisfunktiota. E-CABG komplikaatioiden luokittelujärjestelmä vaikuttaa lupaavalta työkalulta ohitusleikkauksen jälkeisten komplikaatioiden luokitteluun ja ennustevaikutuksien arviointiin.

Objetivos: O objetivo deste estudo é analisar a perviedade da artéria torácica interna direita (ATID) pediculada, anteroaórtica em anastomose para a região anterior do coração na cirurgia de revascularização do miocárdio (RM), em relação à artéria torácica interna esquerda (ATIE). Métodos: No período de dezembro de 2008 a dezembro de 2011, 100 pacientes foram selecionados para serem submetidos a cirurgia de RM sem circulação extracorpórea (CEC), de forma prospectiva. Eles foram agrupados em Grupo 1 (G-1) e Grupo 2 (G-2), cada um com 50 pacientes, com randomização por computador e conhecimento da técnica no início da cirurgia. No G-1, os pacientes receberam ATIE para a região anterior do coração e complementação da RM com a ATID livre para ramos da circunflexa (CX) e outros enxertos arteriais ou venosos para a coronária direita (CD) e/ou ramos. Os pacientes do G-2 receberam ATID pediculada para a região anterior do coração e complementação da RM com ATIE, pediculada, para ramos da CX e outros enxertos arteriais ou venosos para a CD e/ou ramos. A perviedade das artérias torácicas internas direita e esquerda foi avaliada através de angiotomografia coronária multislice, 64 canais, no 6º mês de pós-operatório. Resultados: Os dois grupos eram semelhantes quanto aos dados clínicos de pré-operatório, como exemplo: diabetes mellitus, hipertensão arterial sistêmica, obesidade. Os dois grupos apresentaram predominância do sexo masculino com 75,6% e 88% nos grupos 1 e 2, respectivamente. Cinco pacientes migraram do G-1 para o G-2 em virtude de doença ateromatosa na aorta ascendente e um deles foi excluído por ter que utilizar enxerto composto. A média de anastomoses distais no G-1 foi de 3,48 (DP=0,72), e no G-2 foi de 3,20 (DP=0,76). Não ocorreu mediastinite em nenhum paciente. Uma paciente do G-1 apresentou osteomielite, e necessitou de intervenção cirúrgica. Dois pacientes do G-1 foram submetidos a reoperação por sangramento. Os resultados das angiotomografias coronarianas com 96 pacientes re-estudados mostram que todas as ATIs, fosse a direita ou a esquerda, utilizadas pediculadas para a região anterior do coração encontravam-se sem oclusões ou estenoses, configurando 100% de perviedade. No G-1, um enxerto livre da ATID para ramos da CX apresentava oclusão total, em dois pacientes havia estenose leve, em um deles havia estenose moderada na anastomose proximal na aorta ascendente e outro apresentava diminuição de calibre na sua porção distal. Em três pacientes o enxerto de segmento de veia safena para ramos da CD se encontravam ocluídos. No G-2, dois pacientes apresentavam oclusão total na ATIE pediculada para ramos da CX, e outro apresentava estenose moderada na porção distal da ATIE utilizada sequencial para dois ramos marginais. Em dois pacientes o enxerto de segmento de veia safena para ramos da CD se encontravam ocluídos. Não houve óbitos em nenhum dos grupos. Conclusão: A cirurgia de RM com utilização da ATID pediculada, anterógrada para o RIA, apresenta resultado semelhante ao da ATIE utilizada para essa mesma coronária. / Objective: To analyze the patency of the pedicled, anteroaortic, right internal mammary artery (RIMA) anastomosed to the left anterior descending (LAD) and branches in coronary artery bypass graft surgery (CABG), in comparison with the left internal mammary artery (LIMA). Methods: From December 2008 to December 2011, 100 patients were selected to undergo a prospective off-pump coronary artery bypass graft surgery and were randomly divided by computer into Group 1 (G-1) and Group 2 (G-2), so that the technique was known at the beginning of the surgery. In each group, with 50 patients, the patency of both right and left internal mammary arteries, which were used pedicled to the LAD, was comparatively studied through coronary computed tomography angiography. G-1 had 50 patients who received the LIMA to the LAD or LAD/diagonal (sequential) and had the CABG complemented with the free RIMA to circumflex branches and other arterial or venous grafts to the right coronary artery (RCA) and/or branches. G-2 had 50 patients who received the pedicled RIMA to the LAD or LAD/diagonal (sequential) and had the CABG complemented with the pedicled LIMA to circumflex branches and other arterial or venous grafts to the RCA and/or branches. Results: Both groups were similar in pre-operative clinical data, such as: diabetes mellitus, systemic arterial hypertension, obesity. Also, there was predominance of males in both groups, with 75,6% and 88% in Groups 1 and 2 respectively. Five patients were switched from G-1 to G-2 owing to atheromatous disease in the ascending aorta, and one of them was dropped for having to use composite graft. The average of distal anastomosis in G-1 was 3,48 (standard deviation (SD=0,72) and in G-2 was 3,20 (SD=0,76). Mediastinitis didn\'t occur in any patient. A patient from G-1 had osteomyelitis that required surgical intervention. Two patients from G-1 underwent reoperation because of bleeding. The 64-slice coronary computed tomography angiography was performed in the 6th postoperative month; 96 patients have been re-studied so far and all pedicled IMAs to the LAD were patent. In G-1 a free RIMA graft to the circumflex branches presented total occlusion, another two had a discreet stenosis and in one moderate at the proximal anastomosis and one more had a string signal at the distal portion. In G-2 two patients had total occlusion of the pedicled LIMA to circumflex artery branches, and another one presented moderate stenosis at its distal portion. In two patients the saphenous vein graft to the RCA branches were occluded. There were no deaths in any of the groups. Conclusion: The CABG surgery using the pedicled, anteroaortic RIMA to the LAD has a similar outcome to that of the LIMA used for this same coronary.

Objetivos: O objetivo deste estudo é analisar a perviedade da artéria torácica interna direita (ATID) pediculada, anteroaórtica em anastomose para a região anterior do coração na cirurgia de revascularização do miocárdio (RM), em relação à artéria torácica interna esquerda (ATIE). Métodos: No período de dezembro de 2008 a dezembro de 2011, 100 pacientes foram selecionados para serem submetidos a cirurgia de RM sem circulação extracorpórea (CEC), de forma prospectiva. Eles foram agrupados em Grupo 1 (G-1) e Grupo 2 (G-2), cada um com 50 pacientes, com randomização por computador e conhecimento da técnica no início da cirurgia. No G-1, os pacientes receberam ATIE para a região anterior do coração e complementação da RM com a ATID livre para ramos da circunflexa (CX) e outros enxertos arteriais ou venosos para a coronária direita (CD) e/ou ramos. Os pacientes do G-2 receberam ATID pediculada para a região anterior do coração e complementação da RM com ATIE, pediculada, para ramos da CX e outros enxertos arteriais ou venosos para a CD e/ou ramos. A perviedade das artérias torácicas internas direita e esquerda foi avaliada através de angiotomografia coronária multislice, 64 canais, no 6º mês de pós-operatório. Resultados: Os dois grupos eram semelhantes quanto aos dados clínicos de pré-operatório, como exemplo: diabetes mellitus, hipertensão arterial sistêmica, obesidade. Os dois grupos apresentaram predominância do sexo masculino com 75,6% e 88% nos grupos 1 e 2, respectivamente. Cinco pacientes migraram do G-1 para o G-2 em virtude de doença ateromatosa na aorta ascendente e um deles foi excluído por ter que utilizar enxerto composto. A média de anastomoses distais no G-1 foi de 3,48 (DP=0,72), e no G-2 foi de 3,20 (DP=0,76). Não ocorreu mediastinite em nenhum paciente. Uma paciente do G-1 apresentou osteomielite, e necessitou de intervenção cirúrgica. Dois pacientes do G-1 foram submetidos a reoperação por sangramento. Os resultados das angiotomografias coronarianas com 96 pacientes re-estudados mostram que todas as ATIs, fosse a direita ou a esquerda, utilizadas pediculadas para a região anterior do coração encontravam-se sem oclusões ou estenoses, configurando 100% de perviedade. No G-1, um enxerto livre da ATID para ramos da CX apresentava oclusão total, em dois pacientes havia estenose leve, em um deles havia estenose moderada na anastomose proximal na aorta ascendente e outro apresentava diminuição de calibre na sua porção distal. Em três pacientes o enxerto de segmento de veia safena para ramos da CD se encontravam ocluídos. No G-2, dois pacientes apresentavam oclusão total na ATIE pediculada para ramos da CX, e outro apresentava estenose moderada na porção distal da ATIE utilizada sequencial para dois ramos marginais. Em dois pacientes o enxerto de segmento de veia safena para ramos da CD se encontravam ocluídos. Não houve óbitos em nenhum dos grupos. Conclusão: A cirurgia de RM com utilização da ATID pediculada, anterógrada para o RIA, apresenta resultado semelhante ao da ATIE utilizada para essa mesma coronária. / Objective: To analyze the patency of the pedicled, anteroaortic, right internal mammary artery (RIMA) anastomosed to the left anterior descending (LAD) and branches in coronary artery bypass graft surgery (CABG), in comparison with the left internal mammary artery (LIMA). Methods: From December 2008 to December 2011, 100 patients were selected to undergo a prospective off-pump coronary artery bypass graft surgery and were randomly divided by computer into Group 1 (G-1) and Group 2 (G-2), so that the technique was known at the beginning of the surgery. In each group, with 50 patients, the patency of both right and left internal mammary arteries, which were used pedicled to the LAD, was comparatively studied through coronary computed tomography angiography. G-1 had 50 patients who received the LIMA to the LAD or LAD/diagonal (sequential) and had the CABG complemented with the free RIMA to circumflex branches and other arterial or venous grafts to the right coronary artery (RCA) and/or branches. G-2 had 50 patients who received the pedicled RIMA to the LAD or LAD/diagonal (sequential) and had the CABG complemented with the pedicled LIMA to circumflex branches and other arterial or venous grafts to the RCA and/or branches. Results: Both groups were similar in pre-operative clinical data, such as: diabetes mellitus, systemic arterial hypertension, obesity. Also, there was predominance of males in both groups, with 75,6% and 88% in Groups 1 and 2 respectively. Five patients were switched from G-1 to G-2 owing to atheromatous disease in the ascending aorta, and one of them was dropped for having to use composite graft. The average of distal anastomosis in G-1 was 3,48 (standard deviation (SD=0,72) and in G-2 was 3,20 (SD=0,76). Mediastinitis didn\'t occur in any patient. A patient from G-1 had osteomyelitis that required surgical intervention. Two patients from G-1 underwent reoperation because of bleeding. The 64-slice coronary computed tomography angiography was performed in the 6th postoperative month; 96 patients have been re-studied so far and all pedicled IMAs to the LAD were patent. In G-1 a free RIMA graft to the circumflex branches presented total occlusion, another two had a discreet stenosis and in one moderate at the proximal anastomosis and one more had a string signal at the distal portion. In G-2 two patients had total occlusion of the pedicled LIMA to circumflex artery branches, and another one presented moderate stenosis at its distal portion. In two patients the saphenous vein graft to the RCA branches were occluded. There were no deaths in any of the groups. Conclusion: The CABG surgery using the pedicled, anteroaortic RIMA to the LAD has a similar outcome to that of the LIMA used for this same coronary.

Introdução: A falta de sistemas estruturados de custeio nas organizações hospitalares, principalmente filantrópicas, tem dificultado a análise da cobertura dos custos pelo repasse do Sistema Único de Saúde (SUS) aos procedimentos realizados. Objetivo: Identificar a percentagem de cobertura do repasse de verba do SUS para a cirurgia de revascularização miocárdica (CRM), em um hospital filantrópico do município de São Paulo, que possui um sistema de custeio consolidado. Método: Estudo de abordagem quantitativa, transversal e descritiva. Utilizou-se um banco de dados com registro de CRM denominado REVASC, criado pela instituição em 2009 e de inclusão contínua. As informações para a pesquisa foram coletadas de 13 de março a 30 de setembro de 2012. A escolha do período foi devido ao início da inclusão de informações sobre custo e repasse do SUS. A população alvo foi de 1913 pacientes e amostra de 1362 (71,2%). Resultados: O custo total médio da internação por paciente foi de R$16.196,91. A média de repasse pelo SUS foi de R$6.992,91(48,66%), observando-se um déficit de 9.204,00 (51,34%). A média de idade foi de 61,4 anos e 69,9% eram do sexo masculino. A média do tempo de permanência hospitalar (TPH) foi de 11,23 dias, sendo 2,42 dias na terapia intensiva e 8,49 dias no pós-operatório. A maioria dos pacientes (69,5%) apresentou um TPH maior que sete dias, considerada prolongada pela instituição. Ao comparar o Grupo 1 (TPH7dias) e Grupo 2 (TPH>7dias), este apresentou custo, receita, diferença entre custo-receita e diferença percentual significativamente maiores que os pacientes do Grupo1. Ao associar o TPH com fatores de risco houve diferença apenas no Grupo 2 que apresentou maior idade, maior número de diabetes e de insuficiência renal crônica. Em relação às complicações pós-operatórias houve diferença em relação a transfusão sanguínea, fibrilação atrial, sangramento importante, pneumonia, insuficiência renal aguda, infarto agudo do miocárdio perioperatório, hemodiálise, acidente vascular encefálico, ventilação mecânica prolongada e reoperação por sangramento / mediastinite, também com incidência maior no Grupo2. Conclusão: O repasse do SUS cobriu menos da metade do custo total médio da internação em CRM (48,66%). Embora o valor do repasse do SUS tenha aumentado conforme a elevação do custo, esse ressarcimento foi desproporcional ao custo total, resultando numa diferença percentual de receita cada vez mais negativa a cada aumento do custo e da permanência hospitalar. / Introduction: The lack of structured expense systems in hospital organizations, especially when philanthropic, has hindered the analysis of the coverage of costs by transfer of funds from the Unified Healthcare System (SUS) for the procedures performed. Objective: To identify the percentage of coverage of the transfer of funds from SUS for coronary artery bypass surgery (CABG) in a philanthropic hospital that has a consolidated expense system in the municipality of São Paulo. Method: A quantitative, cross-sectional, and descriptive study. A databank containing data with CABG records called REVASC was used, created by the institution in 2009 with ongoing data inclusion. Information for the research was collected from March 13 to September 30, 2012. The choice of that period was due to the start of inclusion of information on costs and the transfer of funds from SUS. The target population was made up of 1913 patients and a sample of 1362 (71.2%). Results: The total mean cost of hospitalization per patient was R$16,196.91. The mean transfer of funds by SUS was R$6,992.91 (48.66%), with a deficit of 9,204.00 (51.34%). The mean age of the subjects was 61.4 years, and 69.9% of them were men. The mean hospital stay (HS) was 11.23 days, in which 2.42 days were in intensive therapy, and 8.49 days in the postoperative unit. Most of the patients (69.5%) had a HS longer than seven days, considered prolonged by the institution. When comparing Group 1 (HS 7 days) and Group 2 (HS >7 days), the latter group showed costs, revenue, difference between cost and revenue, and percentage difference significantly greater than did the patients from Group 1. In associating the HS with risk factors, there was a greater difference only in Group 2, which showed a higher age, and greater number individuals with diabetes and chronic renal failure. As to postoperative complications, there was a difference as to blood transfusion, atrial fibrillation, significant bleeding, pneumonia, acute renal failure, perioperative acute myocardial infarct, hemodialysis, cerebrovascular accident, prolonged mechanical ventilation, and reoperation due to bleeding/mediastinitis, also with an incidence greater than in Group 2. Conclusion: The financial provision from SUS covered less than half the total mean cost of hospitalization for CABG (48.66%). Although the value transferred from SUS increased according to cost elevation, this reimbursement was disproportional to the total cost, resulting in an increasingly negative percentage difference of revenue for each increase in cost and in hospital stay.

Introdução: A falta de sistemas estruturados de custeio nas organizações hospitalares, principalmente filantrópicas, tem dificultado a análise da cobertura dos custos pelo repasse do Sistema Único de Saúde (SUS) aos procedimentos realizados. Objetivo: Identificar a percentagem de cobertura do repasse de verba do SUS para a cirurgia de revascularização miocárdica (CRM), em um hospital filantrópico do município de São Paulo, que possui um sistema de custeio consolidado. Método: Estudo de abordagem quantitativa, transversal e descritiva. Utilizou-se um banco de dados com registro de CRM denominado REVASC, criado pela instituição em 2009 e de inclusão contínua. As informações para a pesquisa foram coletadas de 13 de março a 30 de setembro de 2012. A escolha do período foi devido ao início da inclusão de informações sobre custo e repasse do SUS. A população alvo foi de 1913 pacientes e amostra de 1362 (71,2%). Resultados: O custo total médio da internação por paciente foi de R$16.196,91. A média de repasse pelo SUS foi de R$6.992,91(48,66%), observando-se um déficit de 9.204,00 (51,34%). A média de idade foi de 61,4 anos e 69,9% eram do sexo masculino. A média do tempo de permanência hospitalar (TPH) foi de 11,23 dias, sendo 2,42 dias na terapia intensiva e 8,49 dias no pós-operatório. A maioria dos pacientes (69,5%) apresentou um TPH maior que sete dias, considerada prolongada pela instituição. Ao comparar o Grupo 1 (TPH7dias) e Grupo 2 (TPH>7dias), este apresentou custo, receita, diferença entre custo-receita e diferença percentual significativamente maiores que os pacientes do Grupo1. Ao associar o TPH com fatores de risco houve diferença apenas no Grupo 2 que apresentou maior idade, maior número de diabetes e de insuficiência renal crônica. Em relação às complicações pós-operatórias houve diferença em relação a transfusão sanguínea, fibrilação atrial, sangramento importante, pneumonia, insuficiência renal aguda, infarto agudo do miocárdio perioperatório, hemodiálise, acidente vascular encefálico, ventilação mecânica prolongada e reoperação por sangramento / mediastinite, também com incidência maior no Grupo2. Conclusão: O repasse do SUS cobriu menos da metade do custo total médio da internação em CRM (48,66%). Embora o valor do repasse do SUS tenha aumentado conforme a elevação do custo, esse ressarcimento foi desproporcional ao custo total, resultando numa diferença percentual de receita cada vez mais negativa a cada aumento do custo e da permanência hospitalar. / Introduction: The lack of structured expense systems in hospital organizations, especially when philanthropic, has hindered the analysis of the coverage of costs by transfer of funds from the Unified Healthcare System (SUS) for the procedures performed. Objective: To identify the percentage of coverage of the transfer of funds from SUS for coronary artery bypass surgery (CABG) in a philanthropic hospital that has a consolidated expense system in the municipality of São Paulo. Method: A quantitative, cross-sectional, and descriptive study. A databank containing data with CABG records called REVASC was used, created by the institution in 2009 with ongoing data inclusion. Information for the research was collected from March 13 to September 30, 2012. The choice of that period was due to the start of inclusion of information on costs and the transfer of funds from SUS. The target population was made up of 1913 patients and a sample of 1362 (71.2%). Results: The total mean cost of hospitalization per patient was R$16,196.91. The mean transfer of funds by SUS was R$6,992.91 (48.66%), with a deficit of 9,204.00 (51.34%). The mean age of the subjects was 61.4 years, and 69.9% of them were men. The mean hospital stay (HS) was 11.23 days, in which 2.42 days were in intensive therapy, and 8.49 days in the postoperative unit. Most of the patients (69.5%) had a HS longer than seven days, considered prolonged by the institution. When comparing Group 1 (HS 7 days) and Group 2 (HS >7 days), the latter group showed costs, revenue, difference between cost and revenue, and percentage difference significantly greater than did the patients from Group 1. In associating the HS with risk factors, there was a greater difference only in Group 2, which showed a higher age, and greater number individuals with diabetes and chronic renal failure. As to postoperative complications, there was a difference as to blood transfusion, atrial fibrillation, significant bleeding, pneumonia, acute renal failure, perioperative acute myocardial infarct, hemodialysis, cerebrovascular accident, prolonged mechanical ventilation, and reoperation due to bleeding/mediastinitis, also with an incidence greater than in Group 2. Conclusion: The financial provision from SUS covered less than half the total mean cost of hospitalization for CABG (48.66%). Although the value transferred from SUS increased according to cost elevation, this reimbursement was disproportional to the total cost, resulting in an increasingly negative percentage difference of revenue for each increase in cost and in hospital stay.

Abstract Coronary artery bypass grafting (CABG) is the treatment of choice for patients with three-vessel disease or left main stenosis. However, it is associated with considerable risk of perioperative complications such as myocardial infarction, stroke, infections, and mortality to which excessive bleeding is a contributing factor. This thesis aims to determine the factors involved in and clinical implications of bleeding after CABG. The 1st study evaluated the effects of preoperative ASA discontinuation on the patient’s outcome after CABG. The results showed that late or no discontinuation of low-dose ASA before CABG may decrease the risk of postoperative stroke without increasing the risk of postoperative bleeding. In the 2nd study the use of warfarin was found to be a safe during CABG with no excess bleeding nor other major complications. The 3rd study estimated the impact of surgeons´ performances on blood loss and need for re-exploration after CABG. With 2001 study patients, this study clearly demonstrated that an individual surgeon is a powerful determinant of postoperative bleeding and need for re-exploration after CABG. Using systematic review and meta-analysis, we estimated the risk of complications related to re-exploration for bleeding after CABG. In literature search in 2011, 8 articles with 557 923 patients fulfilled the inclusion criteria. Re-exploration for bleeding after cardiac surgery carries a significantly increased risk of postoperative mortality and morbidity, and thus has a major impact on the patient’s immediate postoperative outcome. We also studied the impact of blood transfusion on the development of post-operative stroke after CABG. Of the study population of 2 226 CABG patients, stroke occurred postoperatively in 53 patients (2.4%). The statistical analysis showed that transfusion of blood products after CABG has a strong, dose-dependent association with the risk of stroke. The use of Octaplas® and platelet transfusions seem to have an even larger impact on the development of stroke than red blood cell transfusions. The 6th study investigated the impact of transfusion of blood products on intermediate outcome after CABG in 2001 patients. The findings indicated that transfusion of any blood product is associated with a significant risk of all-cause and cardiac mortality after CABG. / Tiivistelmä Sepelvaltimotauti on yleisin kuolinsyy ja sepelvaltimoiden ohitusleikkaus hyvine pitkäaikaistuloksineen on todettu parhaaksi hoidoksi potilailla, joilla on monen suonen tai vasemman päärungon tauti. Ohitusleikkaukseen liittyy kuitenkin verenvuodon sekä näihin kytkeytyvien komplikaatioiden riski. Tämän väitöskirjan tavoitteena oli määrittää verenvuodon riskitekijöitä sekä verituotteiden siirtojen vaikutusta ohitusleikkauspotilaiden ennusteeseen. Verenhyytymistä estävien lääkkeiden tiedetään lisäävän verenvuotoja. Ensimmäinen tutkimus osoitti, että ASA:n jatkaminen keskeytyksettä ohitusleikkauksissa vähentää aivoinfarktien riskiä lisäämättä silti verenvuodon riskiä. Toisessa tutkimuksessa pitkäaikainen warfariinihoito osoittautui turvalliseksi ohitusleikkauksen aikana eikä sen käyttö lisännyt verenvuotoja eikä muita komplikaatioita. Kolmas tutkimus osoitti kirurgin taidon merkityksen verenvuotojen ja uusintaleikkausten määrään 2001 potilaalla. Verenvuotojen vuoksi tehtävien uusintaleikkausten negatiivinen vaikutus postoperatiiviseen mortaliteettiin sekä morbiditeettiin on todettu yksiselitteisesti useissa tutkimuksissa. Vuonna 2011 tehdyllä systemaattisella kirjallisuuskatsauksella ja meta-analyysillä selvitimme yhteensä 557 923 ohitusleikkauspotilaan aineistosta, että verenvuodon jälkeisiin uusintaleikkauksiin liittyy huomattava kuoleman ja komplikaatioiden riski. Verenvuotoja hoidetaan yleisesti verensiirroilla, vaikkakin useat tutkimukset ovat osoittaneet verituotteiden annon lisäävän mortaliteettia sekä komplikaatioriskiä. Viides tutkimus selvitteli sepelvaltimoleikkauksissa potilaalle annettujen verituotteiden ja leikkauksen yhteydessä sairastettujen aivoinfarktien välistä yhteyttä. Osoittautui, että verituotteiden käyttöön liittyy annosriippuvaisesti lisääntynyt riski saada aivoinfarkti leikkauksen yhteydessä. Varsinkin verihiutale- ja jääplasmasiirtoihin on todettu liittyvän vielä suurempi aivoinfarktin riski kuin punasolusiirtoihin. Kuudes tutkimus selvitteli sepelvaltimoleikkauksien yhteydessä annettujen verituotteiden vaikutusta 2001 potilaan keskipitkään ennusteeseen. Tutkimus osoitti, että minkä tahansa verituotteen antoon sepelvaltimoleikkauksissa liittyy lisääntynyt kuoleman ja sydänkuoleman riski.