Purpose of Review: This article reviews the evidence on optimal medical therapy (OMT) versus coronary revascularization in patients with stable ischemic heart disease (SIHD) and advanced chronic kidney disease (CKD). Recent Findings: A post hoc analysis of the COURAGE trial in patients with SIHD and CKD showed no difference in freedom from angina, death, and nonfatal myocardial infarction (MI) between OMT and percutaneous intervention plus OMT compared with patients without CKD. The ISCHEMIA-CKD trial of 777 patients with advanced CKD revealed no difference in cumulative incidence of death or nonfatal MI at 3 years between OMT and revascularization but the composite of death or new dialysis was higher in the invasive arm. Additionally, there were no significant or sustained benefits in related to angina-related health status in invasive versus conservative strategy. Summary: An initial revascularization strategy does not reduce mortality or MI or relieve angina symptoms in patients with SIHD and advanced CKD.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24474号 / 医博第4916号 / 新制||医||1062(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 石見 拓, 教授 永井 洋士, 教授 大鶴 繁 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

No description available.

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.

Thesis (M. Tech. (Biomed. Tech.)) -- Central University of Technology, Free State, 2010 / The World Health Organization (WHO) has warned in 2005 that: “Coronary heart disease is now one of the leading causes of death worldwide. It is on the rise and has become a true pandemic that respects no borders” (WHO, 2005). The Heart and Stroke Foundation of South Africa more specifically estimates that approximately 33 (thirty‐three) people per day will die of a heart attack in South Africa. Despite the already high death toll resulting from AIDS in South Africa, death from a chronic disease, also including heart disease, will increase from 565 deaths per day in the year 2000, to 666 deaths per day by 2010 (Steyn, 2007). Acute coronary syndrome (ACS) is an ‘umbrella term’ describing a heterogeneous spectrum of clinical symptoms compatible with acute myocardial ischaemia (Monaco, Mathur, Martin, 2005; ACC/AHA, 2007) and an ongoing inflammatory process resulting from atherosclerosis. ACS can either be treated medically (pharmacological treatment), by percutaneous coronary intervention (PCI), or by performing coronary artery bypass graft (CABG) surgery either through on‐pump or offpump CABG surgery. By treating the ACS patient by means of CABG surgery, an inflammatory response is further triggered on top of the already existing inflammation resulting from atherosclerosis. This leads to a systemic inflammatory response (SIR), which may eventually lead to systemic inflammatory response syndrome (SIRS). This study focuses on the inflammatory response initiated by the CABG technique applied during the revascularisation of the ACS patient. Many past studies compared on‐pump and off‐pump CABG surgery, arguing not only the advantages and disadvantages of these surgeries, but also the outcomes regarding SIRS. Both types of surgery are associated with an inflammatory response resulting from tissue trauma and the use of the extracorporeal circulation (EC) in CABG surgery (Quaniers, Leruth, Albert, Limet, Defraigne, 2006). This non‐randomised, observational study primarily aimed to assess and compare the pre‐ and the post‐operative inflammatory markers between (n=60) patients with ACS undergoing either on‐pump CABG (n=30) or off‐pump CABG surgery (n=30). A secondary objective was to ascertain whether a correlation exists between the pre‐operative risk factors, the surgical procedure and the pre‐ and post‐operative inflammatory markers. Three inflammatory markers ‐ full blood count (FBC), procalcitonin (PCT) and C‐reactive protein (CRP) ‐ were analysed employing normal routine laboratory analysis. Interleukin‐6 (IL‐6) and tumour necrosis factor alpha (TNF‐α) were analysed using an enzyme amplified sensitivity immunoassay (EASI) method. The inflammatory markers were analysed pre‐operatively (baseline) and post‐operatively and at different time intervals (24, 48, 72, 96 and 120 hours post‐operatively). Pre‐operatively, all the leucocytes were already elevated in both CABG groups, as could be expected in patients with ACS resulting from the already existing atherosclerotic process and the consequent pre‐operative existing inflammatory response. A significant pre‐operative difference was moreover detected in respect of the lymphocytes between the two CABG groups (p=0.03024). A significant post‐operative difference was also detected between the two CABG groups. The following significantly elevated levels were detected in the on‐pump CABG surgical group: for WCC at 24 hours (p=0.00761), 48 hours (p=0.01520) and 72 hours (p=0.00004); for neutrophils at 24 hours (p=0.17422), 96 hours (p=0.18611) and 120 hours (p=0.12872); for lymphocytes at 48 hours (p=0.04829) and at 96 hours (p=0.01982); and, for PCT at 24 hours (p=0.00811), 48 hours (p=0.00966) and 72 hours (p=0.01823) . However, measurable values of IL‐6 levels were found to be higher in the off‐pump CABG surgical group, with significant differences manifesting between the two CABG groups at 96 hours (p=0.05352) and 120 hours (p=0.09729). No differences between the two groups could be demonstrated for eosinophils, basophils, monocytes, CRP and TNF‐α. In conclusion: despite the demonstrable inflammatory responses in both CABG groups, no difference in clinical outcomes was observed. The inflammatory responses evoked by on‐pump and off‐pump CABG procedures will, for some time to come, remain an area of interest for future research, but they are certainly not the only factors to have a bearing on surgical outcomes. The impact of intraoperative events needs to be elucidated further ‐ and in more detail ‐ in order to attempt to determine the relationship of these events on the extent of inflammatory responses and clinical outcomes, irrespective of whether the procedure is performed with or without cardiopulmonary bypass.

Thesis (M. Tech. (Clinical technology)) - Central University of technology, Free State, 2012 / The objective of this study was to investigate whether intra-operative regional cerebral tissue oxygen saturation (NIRS) and hemodynamic monitoring in patients with Acute Coronary syndrome (ACS) during coronary bypass graft surgery (CABG on-pump vs. off-pump) can predict clinical outcomes and complications. Data from 60 CABG patients (30 on-pump and 30 off-pump) were analyzed. The regional cerebral tissue oxygen saturation was monitored by using near-infrared spectroscopy (NIRS). The sensors were positioned in the middle of the patient's forehead and the cables were connected to the sensors and to the INVOS 5100C® Oximeter. According to NIRS values obtained, patients were subdivided into two groups. Patients in Group 1 had absolute NIRS values more than 50 or less than a 20% drop from the baseline value. Patients in Group 2 had absolute NIRS values of less than 50 or a drop of more than 20% from the baseline value. The lowest value recorded during the procedure was recorded for this purpose, irrespective of the time this value was obtained. Intra-operative hemodynamic monitoring was captured by a computer software program (Supplier Datex Ohmeda, South Africa). In order to describe surgical outcomes several parameters were analysed and compared. This included a Pre- and Post-operative Mini-Mental state examination that was performed to identify neurological outcomes or impairment. The NIRS values and trends in relation to renal function (U&E and creatinine, urine output, and urine electrolytes), as well as clinical outcomes were analyzed post-operatively for the different groups. Clinical outcomes were described using the Society of Thoracic Surgeons Database (STS database) data fields, and specifically the recording of complications. The overall clinical outcomes were analysed between the on-pump and off-pump groups as well as the NIRS results between the two groups. In order to elucidate the predictive role of NIRS the patients were divided into groups with either impaired /reduced NIRS values or acceptable NIRS values according to published results where a reduction of more than 20% from baseline or absolute values of less than 50 were associated with inferior outcomes. Finally, the predictive value of NIRS was evaluated within the on- and then the off-pump groups. In this analysis the outcomes of patients with reduced NIRS values was compared to those of patients with acceptable NIRS values. The study demonstrated that by far the majority of patients with reduced cerebral flow/oxygen delivery as reflected in cerebral NIRS, had on-pump CABG procedures (84% fell in risk group 2). It also showed that a NIRS reduction of more than 20 % from baseline and values of less than 50, has an impact on post–operative renal function. Monitoring of cerebral oximetry intra-operatively by using near-infrared spectroscopy during cardiac surgery (especially in on-pump cardiac surgery patients) allows the perfusionist and anaesthesiologist to detect cerebral desaturation and to intervene as necessary. This study also showed a tendency towards less renal function impairment in patients with absolute NIRS values > 50 or where there was < 20% drop from baseline. It is probably important to consider studying the time spend below 50 or a drop of more than 20% from baseline NIRS values, or the “area under the curve” as a specific factor contributing to the increased risk for post-operative complications applied on an increased study population. The study supports the routine use of NIRS as a non-invasive trend monitor of cerebral saturation and certainly initiated interventions by both anaesthetic and perfusion staff which contributed to excellent clinical outcomes in this research study.

Justificativa e objetivos: Estudo longitudinal, prospectivo, randomizado para avaliar a influência do uso de um ou dois drenos pleuromediastinais na dor pós-operatória, na função pulmonar e na liberação de interleucinas pró-inflamatórias dos pacientes submetidos à revascularização do miocárdio. Casuística e método: 33 pacientes escalados para cirurgia eletiva de revascularização do miocárdio, com uso de CEC, foram alocados por sorteio em dois grupos: grupo GDU (dreno único) e grupo GDD (dreno duplo). No período pósoperatório foram avaliadas a intensidade da dor, a performance ventilatória por meio das medidas da CVF e da VEF1 e foram quantificadas as concentrações de interleucinas nos três primeiros dias do período pós-operatório. Resultados: 33 pacientes analisados, 16 no grupo GDU e 17 no grupo GDD. O grupo GDU apresentou valores espirométricos maiores que o grupo GDD (p<0,001) no pós-operatório, denotando menor interferência do dreno na respiração. A PaO2 arterial, no primeiro e segundo PO, aumentou significantemente no grupo GDU quando comparada com o grupo GDD (p<0,001). A intensidade da dor no grupo GDU, antes e após a espirometria, foi menor que no grupo GDD (p<0,001). Houve aumento significativo dos valores espirométricos em ambos os grupos, após a retirada do dreno pleural. As variações das concentrações de interleucina não foram significativas quando se compararam valores intra e intergrupos, embora tenha havido uma tendência a aumento da IL- 6, no primeiro dia de pós-operatório no grupo GDD. Conclusão: O uso de apenas um dreno torácico altera menos a função pulmonar, possibilita uma melhor recuperação dos parâmetros respiratórios, além de mostrar eficácia semelhante a dois drenos na drenagem torácica. / BACKGROUND AND OBJECTIVES: A prospective, randomized, longitudinal study to evaluate the influence of one or two pleuromediastinal drains on postoperative pain, pulmonary function, and the release of proinflammatory interleukins from patients undergoing myocardial revascularization. Patients and methods: 33 patients who underwent elective coronary artery bypass grafting (CABG) were randomized into two groups: GDU group (single drain) and GDD group (double drain). In the postoperative period, pain intensity, ventilatory performance were measured through FVC and FEV1 measurements, and interleukin concentrations were quantified in the first three days of the postoperative period. Results: 33 patients were analyzed, 16 in the GDU group and 17 in the GDD group. The GDU group presented higher spirometric values than the GDD group (p <0.001) in the postoperative period, indicating less interference of the drain in the breath. The arterial PaO2, in the first and second PO, increased significantly in the GDU group when compared to the GDD group (p <0.001). The pain intensity in the GDU group, before and after spirometry, was lower than in the GDD group (p <0.001). There was a significant increase in spirometric values in both groups, after the pleural drainage was removed. Variations in interleukin concentrations were not significant when comparing intra and intergroup values, although there was a tendency for IL-6 to increase on the first postoperative day in the GDD group. Conclusion: The use of only one thoracic drainage modifies pulmonary function less, allows better recovery of respiratory parameters, and shows similar efficacy to two drains in the thoracic drainage.

INTRODUÇÃO E OBJETIVOS: A Circulação extracorpórea (CEC) é associada a ativação leucocitária, resposta inflamatória e disfunção pulmonar. Objetivou-se avaliar os efeitos da filtragem leucocitária sobre a resposta inflamatória e a função pulmonar em indivíduos submetidos à revascularização do miocárdio (RM) com CEC. MÉTODO: Após aprovação pelo Comitê de Ética Institucional e obtenção do consentimento informado dos indivíduos, foi realizado estudo prospectivo randomizado, para comparar indivíduos adultos submetidos à RM com CEC, utilizando-se filtragem leucocitária (n=09) ou filtro standard (n=11) durante a CEC. Tomografia computadorizada (CT) de tórax, espirometria, análise da oxigenação e hemograma foram realizados antes da cirurgia. A anestesia foi induzida por via venosa com etomidato (0,3 mg.kg-1), sufentanil (0,3 ug.kg-1), pancurônio (0,08 mg.kg-1) e mantida com isoflurano (0,5 - 1,0 CAM) e sufentanil (0,5 ug.kg-1.h-1). A ventilação mecânica utilizou volume corrente de 8 mL.kg-1, com FiO2 de 0,6 e PEEP de 5 cm H2O, exceto durante a CEC. No grupo Filtragem, durante a CEC, foi inserido um filtro de leucócitos na linha arterial do circuito (LG-6, Pall Biomedical Products) e, no grupo Controle, foi utilizado o filtro Standard. Contagem leucocitária foi realizada após a indução, aos 5, 25 e 50 min de CEC, ao final da cirurgia, com 12 e 24 h PO. Dados hemodinâmicos, PaO2/FiO2, fração de Shunt, interleucinas, elastase e mieloperoxidase foram colhidos antes e após a CEC, no final da cirurgia, com 6,12 e 24 h PO. Trinta minutos depois da indução, e trinta após a CEC, três amostras sequenciais de ar exalado foram colhidas para análise de óxido nítrico (NO), por quimiluminescência. Espirometria e CT de tórax foram realizadas no primeiro dia pós-operatório. Os dados foram analisados por meio de ANOVA de duplo fator para medidas repetidas. RESULTADOS: O tempo de CEC foi similar entre os grupos controle e filtragem (86,78 ± 19,58 versus 104,64 ± 27,76 min, p=0,161). O grupo Filtragem mostrou menor contagem leucocitária que o grupo Controle até 50 min de CEC (3384 ± 2025 versus 6478 ± 3582 U.mm-3 U.mm-3, p=0,036), menor fração de shunt até 6 h PO (10 ± 2% versus 16 ± 5%, p=0,040) e menores níveis de IL-10 até o final da cirurgia (1571 ± 1137 pg.mL-1 versus 3108 ± 1694 pg.mL-1, p=0,031). Não houve diferença estatisticamente significativa entre os grupos em relação ao restante dos parâmetros avaliados (p > 0,05). CONCLUSÕES: A filtragem leucocitária durante a CEC, quando comparada à utilização de filtro convencional, promove diminuição da contagem de neutrófilos até 50 minutos de CEC, menor liberação de IL-10 até o final da cirurgia e menor alteração da fração de shunt intrapulmonar até 6 h PO, protegendo os pulmões apenas temporariamente contra a injúria aguda relacionada / BACKGROUND AND OBJECTIVE: The Cardiopulmonary bypass (CPB) is related to leukocyte activation, inflammatory response and lung dysfunction. The aim of this study was to evaluate the effects of CPB-leukocyte filtration on the inflammatory response and lung function after coronary artery bypass grafting (CABG). METHODS: After approval by the institutional ethics committee and informed consent, a prospective randomized study was performed to compare CABG-patients undergoing CPB-leukocyte filtration (n=9) or standard CPB (n=11). Espirometry, chest computed tomography (CT), oxygenation analysis and leukocyte count were performed before surgery. Anesthesia induction was performed intravenously with etomidate (0,3 mg.kg-1), sufentanil (0,3 ug.kg-1), pancuronium bromide (0,08 mg.kg-1) e sustained with isoflurano (0,5 - 1,0 CAM) and sufentanil (0,5 ug.kg-1.h-1). The tidal volume used during mechanical ventilation was 8 mL.kg-1, the FiO2 0.6 and PEEP 5 cm H2O, except during CPB. In Filtered group, during CPB, was inserted a leukocyte filter in the arterial line of CPB circuit (LG-6, Pall Biomedical Products) and, in Control group, the Standard arterial line filter was utilized. Hemodynamic data, PaO2/FiO2, shunt fraction, interleukins, elastase and myeloperoxidase were evaluated before and after CPB, at the end of surgery, and 6, 12 and 24 h PO. Thirty minutes after induction, and Thirty after CPB, three sequential exhaled air samples were collected to perform analysis of nitric oxide (NO), by chemiluminescence technique. Espirometry and chest CT were performed on first PO. Data were analyzed using two-factor ANOVA for repeated measurements. RESULTS: Length of CPB was similar in the filtered and control groups (86.78 ± 19.58 versus 104.64 ± 27.76 min, p = 0.161). The filtered group showed lower neutrophil counts than the control group up to 50 minutes of CPB (3384 ± 2025 versus 6478 ± 3582 U/mm-3, p = 0.036), lower shunt fraction up to 6 hours after surgery (10 ± 2% versus 16 ± 5%, p = 0.040), and lower levels of IL-10 at the end of surgery (1571 ± 1137 pg.ml-1 versus 3108 ± 1694 pg.ml-1, p = 0.031). There were no significant differences between the groups with respect to rest of the parameters evaluated (p >u0,05). CONCLUSIONS: The leukocyte filtration during CPB, when compared to the use of conventional filter, promotes lower neutrophil counts up to 50 minutes of CPB, lower levels of IL-10 at the end of surgery and lower shunt fraction up to 6 hours after surgery, protecting the lungs only temporarily against the acute injury related Trial registration: Clinicaltrials.gov identifier: NCT01469676

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.