Submitted by Fabíola Silva (fabiola.silva@famerp.br) on 2017-05-25T19:30:55Z No. of bitstreams: 1 antoniocarlosbrandi_tese.pdf: 1540715 bytes, checksum: 85572fb595b07fb61d81ed453db08401 (MD5) / Made available in DSpace on 2017-05-25T19:30:55Z (GMT). No. of bitstreams: 1 antoniocarlosbrandi_tese.pdf: 1540715 bytes, checksum: 85572fb595b07fb61d81ed453db08401 (MD5) Previous issue date: 2015-05-20 / Introduction: Thoracic aortic diseases, including dissections, aneurysms, pseudoaneurysms among other, are serious conditions that bring serious risks of morbidity and mortality. Its incidence is low, but has been growing gradually due to the increase in life expectancy of the population, that in most cases, is associated with hypertension, smoking and diabetes mellitus. Advances in diagnostic techniques have also contributed to the identification of an increasing number of cases. The development of minimally invasive endovascular procedures has been used successfully in the treatment of these diseases, including patients with no indication for conventional surgical treatment. Objective: Evaluate the long-term results of endovascular treatment of patients with diseases of the thoracic aorta underwent implantation of self-expandable stent-grafts. Methods: This prospective study evaluated 112 patients who underwent percutaneous implantation of endoprosthesis of the thoracic aorta, from October 1998 to August 2013. Self-expandable endoprosthesis stent-graft Braile Biomédica ®, made of stainless steel and nitinol were employed. The occurrence of intraoperative and postoperative primary success, endoleaks, mortality, late evolution of the endoprosthesis and survival were evaluated in long term follow-up. Results: The mean time of the procedures was 72.66 ± 43.36 minutes (range 30-240 minutes). A total of 150 self-expandable stents were implanted in 112 patients, 61 (40.66%) of stainless steel and 89 (59.33%) of nitinol. The diameter and length of the stents of stainless steel and nitinol ranged from 24-45 mm (median 33) and 70-130 mm (median 90) 22-46 mm (median 35) and between 40 and 230 mm (median 110) respectively. The number of stents implanted per patient ranged from 1 to 4 (median 1). Primary success was observed in 100 (82.14%) of 112 patients treated. Immediate mortality occurred in seven (6.25%) patients, five (4.46%) from cardiovascular causes and two (1.78%) for non-cardiovascular causes. Late mortality occurred in 31 (27.68%) patients, 10 (8.93%) from cardiovascular causes, 12 (10.71%) for non-cardiovascular causes, two (1.78%) from natural causes-seven (6.25%) with no diagnosis. There hospital type I endoleaks occurred in four patients (3.57%), type II in five (4.46%) and three type IV (2.68%). Late endoleaks type I occurred in five (4.46%) patients and type IV in three (2.68%). Twenty-two patients (19.64%) had clinical complications in the immediate postoperative period, including nine (8.03%) pulmonary complications, four (3.57%) neurological abnormalities, three (2.67%) acute renal failure, two (1.78%) infections in the surgical incision, two (1.78%) with progression to post-implantation syndrome and one (0.89%) with laceration of the arterial access. Follow-up time ranged from 1 to 179 months (median 46). The acturial survival curve was 79,3% (IC95% 67,0-91,7) at 132 months free of death from cardiovascular causes. The logistic regression analysis showed that renal failure was the only risk factor that showed a statistically significant difference. Conclusions: The low levels of intra and postoperative complications demonstrate that the treatment is safe and effective. The high rate of survival after 132 months of follow-up for these critically ill patients show the benefits of endovascular technique to treatment of thoracic aorta diseases. / Introdução: Doenças da aorta torácica, incluindo as dissecções, aneurismas, pseudoaneurismas entre outras, são condições graves que trazem sérios riscos de morbimortalidade. Sua incidência é baixa, porém, vem crescendo gradativamente em virtude do aumento da expectativa de vida da população que, na maioria dos casos, está associada à hipertensão arterial, tabagismo e diabetes. Os avanços nas técnicas diagnósticas também têm contribuído para a identificação de um número cada vez maior de casos. O desenvolvimento de procedimentos endovasculares minimamente invasivos vem sendo utilizado com sucesso no tratamento destas doenças, inclusive em pacientes sem indicação para tratamento cirúrgico convencional. Objetivo: Avaliar os resultados em longo prazo do tratamento endovascular de pacientes portadores de doenças da aorta torácica submetidos ao implante de endopróteses autoexpansíveis stent-grafts. Casuística e Métodos: Estudo prospectivo que avaliou 112 pacientes submetidos ao implante percutâneo de endoprótese na aorta torácica, no período de outubro de 1998 a agosto de 2013. Foram empregadas endopróteses autoexpansíveis stent-grafts da Braile Biomédica®, confeccionadas em aço inox e nitinol. Foram avaliadas a ocorrência de complicações intra e pós-operatórias, sucesso primário, endoleak, mortalidade, evolução tardia da endoprótese e a sobrevivência em seguimento de longo prazo. Resultados. O tempo médio dos procedimentos foi de 72,66±43,36 minutos (variação 30-240 minutos). Foram implantadas um total de 150 endopróteses autoexpansíveis em 112 pacientes, sendo 61 (40,66%) de aço inox e 89 (59,33%) de nitinol. O diâmetro e comprimento dos stents de aço inox e de nitinol variaram de 24-45 mm (mediana 33) e 70-130 mm (mediana 90), 22-46 mm (mediana 35) e 40 a 230 mm (mediana 110), respectivamente. O número de endopróteses implantadas por paciente variou de 1 a 4 (mediana 1). Sucesso primário foi observado em 100 (82,14%) dos 112 pacientes tratados. A mortalidade hospitalar ocorreu em sete (6,25%) pacientes, cinco (4,46%) por causas cardiovasculares e dois (1,78%) por causas não cardiovasculares. A mortalidade tardia ocorreu em 31 (27,68%) pacientes, 10 (8,93%) por causas cardiovasculares, 12 (10,71%) por causas não cardiovasculares, dois (1,78%) por causas naturais e sete (6,25%) sem diagnóstico. No período hospitalar, ocorreu endoleak do tipo I em quatro pacientes (3,57%), tipo II em cinco (4,46%) e tipo IV em três (2,68%). Endoleak tardio do tipo I ocorreu em cinco (4,46%) pacientes e do tipo IV em três (2,68%). Vinte e dois pacientes (19,64%) apresentaram complicações clínicas no pós-operatório imediato, incluindo nove (8,03%) complicações pulmonares, quatro (3,57%) alterações neurológicas, três (2,67%) pacientes com insuficiência renal aguda, duas (1,78%) incisões cirúrgicas com infecção, duas (1,78%) síndromes pós-implante e uma (0,89%) laceração do acesso arterial. O tempo de seguimento variou de 1 a 179 meses (mediana 46). A curva atuarial de sobrevivência foi de 79,3% (IC95% 67,0-91,7) aos 132 meses livre de mortalidade por causas cardiovasculares. A análise de regressão logística mostrou que a insuficiência renal foi o único fator de risco para mortalidade que apresentou diferença estatisticamente significante. Conclusões. Os baixos índices de complicações intra e pós-operatórias demonstram que o tratamento é seguro e eficaz. O alto índice de sobrevivência após 132 meses de seguimento para estes pacientes graves mostram os benefícios da técnica endovascular no tratamento das doenças da aorta torácica.

Submitted by Fabíola Silva (fabiola.silva@famerp.br) on 2017-08-09T13:04:41Z No. of bitstreams: 1 alexandrevbrick_tese.pdf: 2077531 bytes, checksum: 63dcd34fc3468a693198938254751cdd (MD5) / Made available in DSpace on 2017-08-09T13:04:41Z (GMT). No. of bitstreams: 1 alexandrevbrick_tese.pdf: 2077531 bytes, checksum: 63dcd34fc3468a693198938254751cdd (MD5) Previous issue date: 2016-05-06 / Introduction: Atrial fibrillation (AF) is the most common arrhythmia with high morbidity and mortality rates. The use of catheter ablation for treatment of AF has stimulated the use of energy sources such as ultrasound (US) in surgery to cause injuries in endocardial way, epicardial way or both, replacing the section and suture of the atrial wall. The presence of previous heart disease, most often injury of the mitral valve in patients with chronic atrial fibrillation (CAF) justifies the surgical treatment of this arrhythmia concomitant to the valve surgery. Objective: To evaluate surgical treatment of CAF with US in patients with mitral valve disease, considering: 1- Preoperative clinical characteristics of patients undergoing surgical treatment of CAF and 2- Follow up of patients in the immediate postoperative period, in hospital and later high up to 60 months. Patients and Method: We retrospectively and consecutively studied 100 patients with CAF and mitral valve disease who underwent surgical treatment using US ablation, aged between 18 and 70 years (43.56 ± 4,94 anos), 63 (63%) were female and 37 (37%) were male. Patient data were reviewed prospectively by consulting the control reports, including demographic variables (gender and age) and heart [signs and symptoms, underlying disease, functional class, hospital stay, surgical procedure time, ablation time, intraoperative and postoperative (immediately discharged and later up to 60 months)]. It was used the actuarial curve (Kaplan-Meier) for the study of permanence without recurrence after 12, 24, 36, 48 and 60 months in patients with CAF. Results: From the patients studied, 86% had rheumatic mitral valve disease, 14% degeneration of the mitral valve, 40% were patients with mitral regurgitation, 19% of mitral lesion, 36% of mitral stenosis and 5% of mitral restenosis. The main symptoms included palpitations related to tachycardia by CAF (70%), congestive heart failure (70%), previous episodes of acute pulmonary edema (27%), stroke by thromboembolism accident (13%) and peripheral embolism (7%). The functional class of patients was III/IV. The early results showed that 94% of patients undergoing ablation US reversed the rate of CAF, being 86% in sinus rhythm and 8% in atrioventricular block, which was transient. At hospital discharge was observed maintenance of sinus rhythm in 86% of patients and recurrence of CAF in 8%. At follow-up after 60 months 83.8% of patients maintained the sinus rhythm. Conclusions: Patients with rheumatic mitral valve disease often have failure and mitral stenosis, palpitations related to tachycardia by CAF and congestive heart failure. Surgical treatment of CAF with US concomitant to the mitral valve surgery is feasible and satisfactory, with maintenance of sinus rhythm in most patients (83.8%) after 60 months of follow-up. / Introdução: A fibrilação atrial (FA) é a mais frequente arritmia com taxa elevada de morbimortalidade. A utilização de ablação por cateter para tratamento de FA estimulou o uso de fontes de energia como ultrassom (US) em procedimento cirúrgico para provocar lesões por vias endocárdica, epicárdica ou ambas, em substituição à secção e sutura da parede atrial. A presença de cardiopatia prévia, na maioria das vezes, lesão da valva mitral, em pacientes com fibrilação atrial crônica (FAC), justifica o tratamento cirúrgico dessa arritmia concomitante à cirurgia valvar. Objetivo: Avaliar tratamento cirúrgico da FAC com US em pacientes com lesão valvar mitral, considerandose: 1- caracterização clínica pré-operatória de pacientes submetidos a tratamento cirúrgico da fibrilação atrial crônica e, 2- acompanhamento de pacientes no pós-operatório imediato, na alta hospitalar e tardio até 60 meses. Casuística e Método: Foram estudados retrospectivamente e de forma consecutiva 100 pacientes portadores de FAC e lesão valvar mitral submetidos a tratamento cirúrgico por meio de ablação com US, com idade entre 18 e 70 anos (43,56 ± 4,94 anos), sendo 63 (63%) do sexo feminino e 37 (37%) do masculino. Dados dos pacientes foram revisados prospectivamente por meio de consulta a fichas de controle, incluindo variáveis demográficas (sexo e idade) e cardíacas [sinais e sintomas, doença de base, classe funcional, tempo de permanência hospitalar, tempo de procedimento cirúrgico, tempo de ablação, complicações intra e pós-operatórias (imediato, alta hospitalar e tardio até 60 meses)]. Foi utilizada a curva atuarial (Kaplan-Meier) para estudo da permanência sem recidiva após 12, 24, 36, 48 e até 60 meses em pacientes com FAC. Resultados: Dos pacientes estudados, 86% tinham doença mitral reumática, 14% degeneração da valva mitral, 40% eram portadores de insuficiência mitral, 19% de dupla lesão mitral, 36% de estenose mitral e 5% de reestenose mitral. Os principais sintomas incluíram palpitações relacionadas à taquicardia pela FAC (70%), insuficiência cardíaca congestiva (70%), episódio prévio de edema agudo de pulmão (27%), acidente vascular encefálico por tromboembolismo (13%) e embolia periférica (7%). A classe funcional dos pacientes foi III/IV. Os resultados imediatos mostraram que 94% dos pacientes submetidos à ablação com US reverteram o ritmo de FAC, sendo 86% em ritmo sinusal e 8% em bloqueio atrioventricular, que foi transitório. Na alta hospitalar observou-se manutenção do ritmo sinusal em 86 pacientes e recidiva da FAC em 8. No acompanhamento, após 60 meses, 83,8% dos pacientes mantinham o ritmo sinusal. Conclusões: Pacientes com doença mitral reumática apresentam frequentemente insuficiência e estenose mitral, palpitações relacionadas à taquicardia pela fibrilação atrial crônica e insuficiência cardíaca congestiva. O tratamento cirúrgico da FAC com US concomitante a cirurgia valvar mitral é factível e satisfatório, com manutenção do ritmo sinusal na maioria dos pacientes (83,8%), após 60 meses de seguimento.

O presente trabalho teve por finalidade estudar as alterações do sistema circulatório provocadas pela cirurgia cardíaca sob circulação extracorpórea, 12 pacientes adultos, anestesiados e curarizados, selecionados aleatoriamente, sendo 6 deles valvopatas e 6 coronariopatas. As alterações respiratórias foram verificadas por medidas da mecânica respiratória e da ventilação-oxigenação pulmonar. Do ponto de vista mecânico, o sistema respiratório foi analisado como um todo e individualizando os seus componentes - pulmões e parede torácica, tanto do ponto de vista elástico como também fluxo-resistivo. A análise das propriedades resistivas do sistema respiratório foi feita através de um método que se utiliza da insuflação pulmonar com fluxo constante, seguida de uma oclusão súbita das vias aéreas. Esta análise permite que tanto para o sistema respiratório como também para os pulmões e parede torácica, obtenha-se o valor resistivo máximo (Rmax) bem como o valor mínimo da resistência (Rmin) ao lado das resistências geradas pelas desigualdades do sistema (Ru). Este estudo foi feito graças a estimativa das diferentes respostas de frequência de cada um destes componentes. As medidas de ventilação-oxigenação foram aferidas pelo cálculo do \"shunt\" pulmonar (Qs/Q) e gradiente alvéolo-arterial de oxigenio P(A-a)O2. Tanto as medidas mecânicas como as de ventilação-oxigenação foram feitas na vigência de uma fração inspirada de O2 de 100% e realizadas de 15 a 30 minutos após a entubação traqueal, sendo repetidas logo após o fechamento do tórax. [...] / The aim of this work was to study the respiratory alterations caused by cardiac surgery under cardiopulmonary bypass in 12 randomly selected anesthetized paralyzed adult patients; 6 with acquired valvar disease and 6 with ischmic cardiopathy. Respiratory alterations were assessed by respiratory mechanics and lung ventilation-oxygenation measurements. Respiratory mechanics analyzed the respiratory system as a whole and partitioned into its components: lung and chest wall, measuring both the elastic and resistive properties were measured using a constant inflation flow followed bu a sudden occlusion. This analysis provides the maximum resistance value (Rmax), the minimum resistance value (Rmin), and the resistance caused by the uneven distribution of mechanical properties within the system (Ru), for respiratory system, lung and chest wall. This analysis is based on the frequency dependence differences of each component of respiratory system. The ventilation-oxygenation evaluation was done by the calculation of pulmonary shunt and the alveolar arterial oxygen gradient (P (A-a)O2). Both mechanical and ventilation-oxygenation measurement were done with a oxygen inspired fraction of 1 and performed 15 to 30 minutes after tracheal intubation and repeated just after thorax closure. [...]

Made available in DSpace on 2016-08-19T18:16:06Z (GMT). No. of bitstreams: 1 dissertacao Lea.pdf: 69266 bytes, checksum: f60351433176b7ed5ac2e326bfa1bf71 (MD5) Previous issue date: 2012-04-20 / Objective: To compare the mortality of men and women undergoing coronary artery bypass surgery (CABG) alone and identifying factors related differences occasionally found. Methods: Retrospective cohort study conducted with 215 patients who underwent coronary bypass surgery consecutively from January 2007 to December 2008. Results: Women had a higher average age. Low body surface and dyslipidemia was more prevalent in women (1.65 vs. 1.85, p <0.001: 53% vs 30%, p = 0.001), whereas smoking history and previous myocardial infarction were more prevalent among men (35 % vs 14.7% p = 0.001, 20% vs 2.7%, p = 0.007). Regarding the complications in the postoperative period, there was a higher rate of transfusions in women. The overall mortality rate was 5.6%, however there was no statistically significant difference in mortality between men and women. It was observed that among patients who died the mean body surface was lower than that of patients who progressed without this complication. Conclusion: There was no difference in mortality between the sexes after CABG in our department. / Objetivo: Comparar a morbimortalidade de homens e mulheres submetidos à cirurgia de revascularização isolada e identificando fatores relacionados as diferenças eventualmente encontradas. Métodos: Estudo de Coorte retrospectivo realizado com 215 pacientes, submetidos a cirurgia de revascularização miocárdica isolada, consecutivamente, de janeiro de 2007 a dezembro de 2008. Resultados: As mulheres apresentaram idade media mais elevada. Baixa superfície corpórea e dislipidemia foram mais prevalentes nas mulheres (1,65 vs 1,85, p<0,001: 53% vs 30%, p=0,001), enquanto história de tabagismo e infarto do miocárdio prévio foram mais prevalentes nos homens (35% vs 14,7%p=0,001; 20% vs 2,7%, p=0,007). Em relação às complicações no pós-operatório, houve maior taxa de transfusão de hemoderivados nas mulheres. A taxa de mortalidade geral foi de 5,6%, no entanto não houve diferença estatisticamente significante na mortalidade entre homens e mulheres. Foi observado que entre os pacientes que evoluíram para óbito a media da superfície corpórea era menor que a dos pacientes que evoluíram sem essa complicação. Conclusão: Não houve diferença de mortalidade entre os sexos após revascularização miocárdica neste serviço.

O presente trabalho teve por finalidade estudar as alterações do sistema circulatório provocadas pela cirurgia cardíaca sob circulação extracorpórea, 12 pacientes adultos, anestesiados e curarizados, selecionados aleatoriamente, sendo 6 deles valvopatas e 6 coronariopatas. As alterações respiratórias foram verificadas por medidas da mecânica respiratória e da ventilação-oxigenação pulmonar. Do ponto de vista mecânico, o sistema respiratório foi analisado como um todo e individualizando os seus componentes - pulmões e parede torácica, tanto do ponto de vista elástico como também fluxo-resistivo. A análise das propriedades resistivas do sistema respiratório foi feita através de um método que se utiliza da insuflação pulmonar com fluxo constante, seguida de uma oclusão súbita das vias aéreas. Esta análise permite que tanto para o sistema respiratório como também para os pulmões e parede torácica, obtenha-se o valor resistivo máximo (Rmax) bem como o valor mínimo da resistência (Rmin) ao lado das resistências geradas pelas desigualdades do sistema (Ru). Este estudo foi feito graças a estimativa das diferentes respostas de frequência de cada um destes componentes. As medidas de ventilação-oxigenação foram aferidas pelo cálculo do \"shunt\" pulmonar (Qs/Q) e gradiente alvéolo-arterial de oxigenio P(A-a)O2. Tanto as medidas mecânicas como as de ventilação-oxigenação foram feitas na vigência de uma fração inspirada de O2 de 100% e realizadas de 15 a 30 minutos após a entubação traqueal, sendo repetidas logo após o fechamento do tórax. [...] / The aim of this work was to study the respiratory alterations caused by cardiac surgery under cardiopulmonary bypass in 12 randomly selected anesthetized paralyzed adult patients; 6 with acquired valvar disease and 6 with ischmic cardiopathy. Respiratory alterations were assessed by respiratory mechanics and lung ventilation-oxygenation measurements. Respiratory mechanics analyzed the respiratory system as a whole and partitioned into its components: lung and chest wall, measuring both the elastic and resistive properties were measured using a constant inflation flow followed bu a sudden occlusion. This analysis provides the maximum resistance value (Rmax), the minimum resistance value (Rmin), and the resistance caused by the uneven distribution of mechanical properties within the system (Ru), for respiratory system, lung and chest wall. This analysis is based on the frequency dependence differences of each component of respiratory system. The ventilation-oxygenation evaluation was done by the calculation of pulmonary shunt and the alveolar arterial oxygen gradient (P (A-a)O2). Both mechanical and ventilation-oxygenation measurement were done with a oxygen inspired fraction of 1 and performed 15 to 30 minutes after tracheal intubation and repeated just after thorax closure. [...]

<p>Deep breathing exercises are widely used in the postoperative care to prevent or reduce pulmonary complications, but no scientific evidence for the efficacy has been found after coronary artery bypass grafting (CABG) surgery. </p><p>The aim of the thesis was to describe postoperative pulmonary function and to evaluate the efficacy of deep breathing exercises performed with or without a blow bottle device for positive expiratory pressure (PEP) 10 cmH₂O or an inspiratory resistance-positive expiratory pressure (IR-PEP) mask with an inspiratory pressure of -5 cmH₂O and an expiratory pressure of +10 to +15 cmH₂O. </p><p>Patients undergoing CABG were instructed to perform 30 slow deep breaths hourly during daytime for the first four postoperative days. Patient management was similar in the groups, except for the different breathing techniques. </p><p>Measurements were performed preoperatively, on the fourth postoperative day and four months after surgery. The immediate effect of the deep breathing exercises was examined on the second postoperative day. Pulmonary function was assessed by spirometry, diffusion capacity for carbon monoxide and arterial blood gases. Atelectasis was determined by chest roentgenograms or spiral computed tomography (CT). </p><p>Lung volumes were markedly reduced on the fourth postoperative day. Four months after surgery the pulmonary function was still significantly reduced. On the second and fourth postoperative day all patients had atelectasis visible on CT. A single session of deep breathing exercises performed with or without a mechanical device caused a significant reduction in atelectasis and an improvement in oxygenation. No major differences between deep breathing performed with or without a blow bottle or IR-PEP-device were found, except for a lesser decrease in total lung capacity in the blow bottle group on the fourth postoperative day. Patients who performed deep breathing exercises after CABG had significantly smaller atelectasis and better pulmonary function on the fourth postoperative day compared to a control group who performed no exercises.</p>

Deep breathing exercises are widely used in the postoperative care to prevent or reduce pulmonary complications, but no scientific evidence for the efficacy has been found after coronary artery bypass grafting (CABG) surgery. The aim of the thesis was to describe postoperative pulmonary function and to evaluate the efficacy of deep breathing exercises performed with or without a blow bottle device for positive expiratory pressure (PEP) 10 cmH2O or an inspiratory resistance-positive expiratory pressure (IR-PEP) mask with an inspiratory pressure of -5 cmH2O and an expiratory pressure of +10 to +15 cmH2O. Patients undergoing CABG were instructed to perform 30 slow deep breaths hourly during daytime for the first four postoperative days. Patient management was similar in the groups, except for the different breathing techniques. Measurements were performed preoperatively, on the fourth postoperative day and four months after surgery. The immediate effect of the deep breathing exercises was examined on the second postoperative day. Pulmonary function was assessed by spirometry, diffusion capacity for carbon monoxide and arterial blood gases. Atelectasis was determined by chest roentgenograms or spiral computed tomography (CT). Lung volumes were markedly reduced on the fourth postoperative day. Four months after surgery the pulmonary function was still significantly reduced. On the second and fourth postoperative day all patients had atelectasis visible on CT. A single session of deep breathing exercises performed with or without a mechanical device caused a significant reduction in atelectasis and an improvement in oxygenation. No major differences between deep breathing performed with or without a blow bottle or IR-PEP-device were found, except for a lesser decrease in total lung capacity in the blow bottle group on the fourth postoperative day. Patients who performed deep breathing exercises after CABG had significantly smaller atelectasis and better pulmonary function on the fourth postoperative day compared to a control group who performed no exercises.

One-lung ventilation (OLV) as an established procedure during thoracic surgery may be injurious in terms of increased mechanical stress characterised by alveolar cell stretch and overdistension, increased cyclic tidal recruitment of alveolar units, compression of alveolar vessels and increased pulmonary vascular resistance. This may result in ventilation-induced lung injury with pro-inflammatory cytokine production, leukocyte recruitment and neutrophil-dependent tissue destruction. Despite the consequences of delivering the whole tidal volume (VT) to only a single lung, relatively high VT are used during OLV to maintain arterial oxygenation and carbon dioxide elimination. However, this may increase mechanical stress in the dependent lung and may aggravate alveolar injury. There is a lack of data on the alveolar immune consequences of OLV. Therefore, the present studies investigate the epithelial damage and pro-inflammatory response induced by mechanical ventilation and OLV. OLV induced pulmonary injury, but alveolar damage in the ventilated lung decreased by reduction of the tidal volume in patients scheduled for thoracic surgery (study I). The use of the volatile anaesthetic desflurane in OLV patients attenuated the OLV-induced alveolar immune response (study II). Furthermore, an experimental model of thoracic surgery was established to investigate the systemic and pulmonary consequences of OLV and thoracic surgery in comparison with the effects of conventional two-lung ventilation and spontaneous breathing. The experimental data indicate that beside the pulmonary immune response volatile anaesthetics have also modulated the plasma concentrations of cytokines during and after OLV (study III). In contrast, OLV and thoracic surgery increased the expression of pro-inflammatory mRNA in BAL cells and lung tissue samples. General anaesthesia did not affect this response (study 4). The results of the present studies indicate that OLV and thoracic surgery may be injurious to the lung tissue to a similar degree. The recruitment and activation of alveolar granulocytes characterise the alveolar damage. The administration of different anaesthetics modulates the activation of alveolar cells, specified by decreased inflammatory mediator release in subjects that receive desflurane anaesthesia, which does not affect the expression of cytokine mRNA in alveolar cells and lung tissue samples.

1. INTRODUCTION Spontaneous pneumothorax is one of the most common types of aeropathic syndrome, caused by chronic obstructive pulmonary diseases, tuberculosis and complicated lung cancer. Nearly two hundred years have passed since the first description of the first cases of pneumothorax. Although during this period the scientist´s view of the etiology, pathogenesis, diagnostics and treatment methods has changed, a number of issues related to the diagnostics and treatment of this complication of pulmonary diseases remain unsolved. The aim of the treatment of spontaneous pneumothorax is to remove the cause of this condition, to perform the decompression of the pleural cavity, to induce the obliteration of the pleural cavity and to prevent the recurrence of the disease. Pleural puncture and drainage of the pleural cavity are not sufficiently effective – the incidence of incomplete lung expansion and rapid recurrence of the disease (relapse) reaches 25% [Mova VA, 1999]. Urgent thoracotomy is performed in cases when the drainage of the pleural cavity fails to reduce the symptoms of the aeropathic syndrome and breathing and blood circulation insufficiency caused by the spontaneous pneumothorax. Frequently thoracotomy is performed after pleural drainage in cases of exudative pleuritis or starting pleural empyema. The postoperative period is marked by a large number of complications and prolongation of hospital stay, and post-operative mortality in the group of geriatric... [to full text]

La ventilation unipulmonaire (SLV; Single Lung Ventilation) pendant les chirurgies thoraciques entraîne des altérations cardio-pulmonaires et hémodynamiques importantes. L’objectif de ce projet de recherche consiste à étudier l’impact de la SLV sur l’oxymétrie cérébrale et sa relation avec les complications post opératoires. La première étude inclut vingt patients ayant subi une chirurgie thoracique nécessitant une SLV. L’oxymétrie a été mesurée à l’aide de l’oxymètre cérébral absolu FORESIGHTTM (CASMED, USA) afin d’étudier les changements de la saturation cérébrale absolue (SctO2) tout le long de la chirurgie. La SctO2 ainsi que les paramètres de monitorage standard (BIS, SpO2, pression sanguine, fréquence cardiaque) ont été notés à toutes les cinq minutes à partir de l’induction jusqu’au réveil. Une analyse sanguine (paO2, paCO2, Hb) a été effectuée à toutes les quinze minutes. La deuxième étude effectuée consistait d’étudier la relation entre la désaturation cérébrale en oxygène et les complications post opératoires. Pour cette fin, les scores Clavien et SOFA mesurant l’amplitude des complications, ont été établis pour chaque patient. Les données sont présentées sous forme de moyenne et de la médiane [1er quartile, 3ème quartile; min – max]. Les vingt patients de la première étude ont montré une valeur moyenne absolue de saturation cérébrale absolue (SctO2) de 80% avant l’induction. Durant la SLV, cette valeur a chuté jusqu’à 63% et est remontée à 71% directement après extubation. Tous ces patients ont subi une désaturation durant SLV de plus que 15% comparativement à la valeur de base et 70% ont eu une désaturation de plus de 20%. La désaturation n’a pas été corrélée avec aucun des paramètres de monitorage clinique standard comme la pression artérielle, les analyses des gaz artériels, la saturation périphérique ou la PaO2. La deuxième étude incluant trente autres patients aux vingt premiers, est venue confirmer les résultats de la première étude. De plus, une analyse de corrélation entre les valeurs minimales de SctO2 obtenues durant SLV et les complications post opératoires a été effectuée. Les patients avaient une SctO2 de base de 80%, qui a chuté jusqu’à 64% pendant la SLV pour récupérer à 71% avant la fin de la chirurgie. 82% des patients ont subi des désaturations de plus de 15% des valeurs initiales et 10% ont atteint des valeurs de SctO2 entre 45 et 55%. Les valeurs minimales de SctO2 observées durant la SLV corrélaient avec le score SOFA non respiratoire (R2=0,090, p=0,0287) ainsi qu’avec le score Clavien (R2=0,098, p=0,0201), mais ne corrélait avec aucun des paramètres cliniques standards (ex : SpO¬2, PaO2, PaCO2, Hb). En définissant une valeur seuil de SctO2=65%, le «Odds ratio» d’avoir une défaillance d’organe non respiratoire est de 2.37 (IC 95%=1,18 – 4,39, p=0,043) et d’avoir une complication classifiée supérieure à un score Clavien de 0 est de 3,19 (IC 95%=1,6 – 6,34, p=0,0272). Les chirurgies thoraciques avec une SLV sont associées à des chutes significatives de SctO2, et les valeurs minimales de SctO2 semblent avoir une corrélation positive avec les complications post opératoires. / Single lung ventilation (SLV) during thoracic surgery causes important cardiopulmonary disturbances and numerous hemodynamic changes. The objective of this research project was to study the impact of the SLV on the cerebral oximetry values SctO2 and its relationship with postoperative complications. Twenty patients were included in the first study undergoing thoracic surgeries with SLV. SctO2 was measured using the FORE-SIGHT™ (CASMED, USA) oximeter in order to study SctO2 changes along the surgery. SctO2 values as well as the standard monitoring parameters (BIS, SpO2, BP, HR) were recorded every 5 min starting from the induction until the awake of the patient. A blood gas analysis (paO2, paCO2, Hb) was performed every 15 min during the SLV. The second study consisted of studying the relationship between minimal SctO2 values reached during SLV and the post-operative complications. For this, SOFA and Clavien scores were established for each patient, measuring the severity of early postoperative complications. Data are presented as mean and median [1st quartile, 3rd quartile; min – max]. Twenty patients from the first study showed a mean SctO2 baseline value of 80% before induction. During SLV, this value dropped to 63% and recovered to 71% directly after extubation. All the patients showed cerebral oxygen desaturations of more than 15% from baseline value and 70% of patients had SctO2 desaturations of more than 20%. Those désaturations did not correlate with any of the standard clinical monitoring parameters such as blood pressure, blood gas analysis, peripheral saturation or PaO2. The second study, including thirty additional patients added to the previous twenty, came to confirm the results previously obtained. Furthermore, a correlation analysis was performed between minimal absolute SctO2 values obtained during SLV and postoperative complications. The fifty patients had a mean SctO2 baseline value of 80%, dropped to 64% during SLV and recovered to 71% before the end of the surgery. 82% of the patients had a decrease of SctO2 of more than 15% from baseline values and 10% of patients reached minimal saturation values between 45 and 55%. Minimal absolute values during SLV correlated with non-respiratory SOFA (R2=0.090, p=0.0287) as well as the Clavien score (R2=0.098, p=0.0201), but did not correlate with any of the standard clinical monitoring parameters (SpO2, PaO2, PaCO2, Hb). By defining a threshold value of SctO2=65%, the Odds ratio of having a non-respiratory organ failure is 2.37 (95% CI=1.18 – 4.39, p=0.043) and a complication classified as a Clavien score higher that 0 is 3.19 (95% CI=1.60 – 6.34, p=0.0272). Thoracic surgery necessitating a SLV is associated with a significant decrease of SctO2 and minimal SctO2 values seem to positively correlate with postoperative complications.