BackgroundThe choice of prosthesis for mitral valve replacement still remains controversial. This study assessed mortality, bleeding events and reoperation in patients who underwent mitral valve replacement surgery with biological or mechanical substitutes.MethodsA total of 352 patients who underwent mitral valve replacement surgery between 1990 and 2008 with 5 to 23 years of follow-up were retrospectively evaluated in a cohort study.ResultsThe 5, 10, 15 and 20 year survival rates after surgery using a mechanical substitute were 87.7%, 74.2%, 69.3% and 69.3%, respectively, while after surgery with a biological substitute, they were 87.6%, 71.0%, 64.2% and 56.6%, respectively. There was no significant difference between the two groups (p = 0.38). In the multivariate analysis, the factors associated with death were age, bleeding events and renal failure. The probabilities of remaining free of reoperation at 5, 10, 15 and 20 years after surgery using a mechanical substitute were 94.4%, 92.7%, 92.7% and 92.7%; after surgery with a bioprosthesis, they were 95.9%, 86.4%, 81.2% and 76.5%, respectively (p = 0.073). There was a significantly higher incidence of reoperation for the bioprosthetic valve replacement group (p = 0.008). The probabilities of remaining free of bleeding events at 5, 10, 15 and 20 years after surgery using a mechanical substitute were 95.0%, 91.0%, 89.6% and 89.6%, respectively, while after surgery with a bioprosthesis, they were 96.9%, 94.0%, 94.0% and 94.0%, (p = 0.267).ConclusionsThe authors concluded that: 1) mortality during follow-up was statistically similar for both groups; 2) there was a greater tendency to reoperation in the bioprosthesis group; 3) the probability of remaining free from reoperation remained unchanged after 10 years’ follow-up for patients with mechanical substitute valves; 4) the probability of remaining fee from bleeding events remained unchanged after 10 years’ follow-up for patients given bioprostheses; 5) the baseline characteristics of patients were the greatest determinants of later mortality after surgery; 6) the type of prosthesis was not an independent predictive factor of any of the outcomes tested in the multivariate analysis.

Purpose: To ascertain the most appropriate treatment for chronic, stable, coronary artery disease (CAD) in patients submitted to elective coronary angiography. Patients and Methods: A total of 814 patients included in the prospective cohort study were referred for elective coronary angiography and were followed up on average for 6±1.9 years. Main outcomes were all-cause death, cardiovascular death, non-fatal myocardial infarction (MI) and stroke and late revascularization and their combinations as major adverse cardiac and cerebral events (MACCE): MACCE-1 included cardiovascular death, nonfatal MI, and stroke; MACCE-2 was MACCE-1 plus late revascularization. Survival curves and adjusted Cox proportional hazard models were used to explore the association between the type of treatment and outcomes. Results: All-cause death was lower in participants submitted to percutaneous coronary intervention (PCI) (0.41, 0.16-1.03, P=0.057) compared to medical treatment (MT). Coronary-artery bypass grafting (CABG) had an overall trend for poorer outcomes: cardiovascular death 2.53 (0.42-15.10), combined cardiovascular death, nonfatal MI, and stroke 2.15 (0.73-6.31) and these events plus late revascularization (2.17, 0.86-5.49). The corresponding numbers for PCI were 0.27 (0.05-1.43) for cardiovascular death, 0.77 (0.32-1.84) for combined cardiovascular death, nonfatal MI, and stroke and 2.35 (1.16-4.77) with the addition of late revascularization. These trends were not influenced by baseline blood pressure, left ventricular ejection fraction and previous MI. Patients with diabetes mellitus had a significantly higher risk of recurrent revascularization when submitted to PCI than CABG. Conclusion: Patients with confirmed CAD in elective coronary angiography do not have a better prognosis when submitted to CABG comparatively to medical treatment. Patients treated with PCI had a trend for the lower incidence of combined cardiovascular events, at the expense of additional revascularization procedures. Patients without significant CAD had a similar prognosis than CAD patients treated with medical therapy.

Resultados de pacientes submetidos à cirurgia de substituição valvar aórtica usando próteses mecânicas ou biológicasOutcomes of patients subjected to aortic valve replacement surgery using mechanical or biological prosthesesThis study was carried out at Clinics Hospital of Porto Alegre, Porto Alegre, RS, Brazil. AbstractObjective: This paper evaluates outcomes in patients subjected to surgery for replacement of the aortic valve using biological or mechanical substitutes, where selection of the type of prosthesis is relevant.Methods: Three hundred and one patients, randomly selected, who had been subjected to aortic valve replacement surgery between 1990 and 2005, with a maximum follow-up period of 20 years.Results: Survival at 5, 10 and 15 years after surgery using mechanical substitute was 83.9%, 75.4% and 60.2% and, for biological substitute, was 89.3%, 70.4% and 58.4%, respectively (P=0.939). Factors associated with death were: age, obesity, pulmonary disease, arrhythmia, bleeding and aortic valve failure. Probability free of reoperation for these patients at 5, 10 and 15 years after surgery using mechanical substitute was 97.9%, 95.8% and 95.8% and, for those using bioprostheses, was 94.6%, 91.0% and 83.3%, respectively (P=0.057). Factors associated with reoperation were: renal failure, prosthesis endocarditis and age. Probability free of bleeding events at 5, 10 and 15 years after surgery using mechanical substitute was 94.5%, 91.7% and 91.7% and, for bioprostheses, was 98.6%, 97.8% and 97.8%, respectively (P=0.047). Factors associated with bleeding events were: renal failure and mechanical prostheses.Conclusions: The authors have concluded that: 1) mortality was statistically similar in the groups; 2) patient characteristics at baseline were a major determinant of late mortality after surgery; 3) there was a tendency toward reoperation in the bioprostheses group; 4) patients using mechanical prosthesis had more bleeding events as time passed; 5) data presented in this paper is in accordance with current literature. Descriptors 327Almeida AS, et al. -Outcomes of patients subjected to aortic valve replacement surgery using mechanical or biological prostheses Bras Cir Cardiovasc 2011;26(3):326-37 Rev

INTRODUCTION Coronary artery bypass graft (CABG) surgery is associated with higher survival rates and better quality of life among patients with coronary artery disease. 1,2 Use of left internal thoracic artery (LITA) grafts has been correlated with long-term benefits, 3 but this often requires pleurotomy and insertion of tubes to drain the cavity. 4,5 Pleural drains can be inserted into the subxiphoid region or the intercostal space with the main objective of maintaining or restoring the negative pressure of the pleural space. 6 However, they may impair the integrity of the ventilatory system, thereby compromising the respiratory mechanics and gas exchange after surgery. 7-9 Respiratory muscle strength may be evaluated through maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), which indicate the strength of the inspiratory and expiratory muscle groups respectively. 10 Predictions for MIP and MEP according to age and sex should preferably be considered within their clinical setting, because they may lead to a prognosis of postoperative pulmonary complications like respiratory muscle fatigue or failure. 11-13 MIP and MEP can be measured with the aid of a manometer or manovacuometer. In addition to being practical and non-invasive, this equipment has low cost, is easy to apply at the bedside and only requires simple inspiration and expiration movements from the patient. Studies on individuals undergoing CABG surgery have shown that insertion of the pleural drain in the subxiphoid position can minimize the chance of trauma to the thoracic wall, may preserve respiratory function in the immediate postoperative period and may lead to lower levels of subjective pain, compared with lateral intercostal insertion. 14-20 However, most of these studies

ResumoObjetivo: Os autores têm como objetivo relatar um caso de hipomelanose de Ito (HI), uma síndrome neurocutânea rara, com alterações neurológicas e cromossômicas associadas ao comprometimento cutâneo e pneumonias de repetição.Relato do caso: Este relato é referente a um paciente masculino, 1 ano e 11 meses, internado no Hospital Universitário São Vicente de Paulo por broncopneumonia bilateral. Ao exame foram observadas máculas hipocrômicas na pele compatíveis com HI, além de atraso do desenvolvimento neuropsicomotor. O paciente foi submetido à bióp-sia incisional de pele das lesões do abdômen, eletroencefalograma, ressonância magnética e estudo citogenético.Resultados: Os exames histológico e imunoistoquímico evidenciaram ausência de melanina e diminuição de melanócitos em áreas focais da epiderme, respectivamente. O eletroencefalograma apresentou disfunção córtico-subcortical difusa. A ressonância magnética do encéfalo foi compatível com cisto aracnoídeo em região temporal. O cariótipo evidenciou mosaicismo cromossômico com uma linhagem normal (46,XY) e uma linhagem celular que apresentava deleção intersticial nas bandas 22.2 -24.2 do braço longo do cromossomo 10 (25%).Conclusões: Os autores, com o presente estudo, destacam a importância das lesões de pele na definição etiológica das desordens neuropediátricas.J Pediatr (Rio J) 2001; 77(1): 59-62: hipomelanose de Ito, síndromes neurocutâneas, incontinência pigmentar acromiante. AbstractObjectives: The authors report a case of hypomelanosis of Ito (HI), a rare neurocutaneous syndrome, with neurological and chromosomal alterations associated to the cutaneous involvement and recurrent pneumonia.Case report: This is the case of a male patient, 1 year and 11 months old, hospitalized with bilateral bronchopneumonia at the São Vicente de Paulo Hospital. Examining the patient, hypochromic maculas in the skin, compatible with HI, and a delay in the neuropsychomotor development were observed. The patient was submitted to incisive biopsy of the skin lesions of the abdomen, electroencephalogram, magnetic resonance and cytogenetic evaluation.Results: The histologic and immunohistochemistry exams evinced melanin absence and melanocyte reduction in focal areas of the epidermis, respectively. The electroencephalogram revealed diffuse cortico-subcortical disfunction. The encephalon magnetic resonance imaging was compatible with arachnoid cyst in the temporal region. The cariotipo evinced chromosome mosaic with a normal lineage (46,XY) and a cellular lineage revealing interstitial deletion in the 22.2 -24.2 bands of the arm of chromosome 10 (25%).Conclusions: With the present study, the authors emphasize the importance of skin lesions in the etiologic definition of neuropediatric disorders.

ResumoObjetivo: Os autores têm como objetivo relatar um caso de hipomelanose de Ito (HI), uma síndrome neurocutânea rara, com alterações neurológicas e cromossômicas associadas ao comprometimento cutâneo e pneumonias de repetição.Relato do caso: Este relato é referente a um paciente masculino, 1 ano e 11 meses, internado no Hospital Universitário São Vicente de Paulo por broncopneumonia bilateral. Ao exame foram observadas máculas hipocrômicas na pele compatíveis com HI, além de atraso do desenvolvimento neuropsicomotor. O paciente foi submetido à bióp-sia incisional de pele das lesões do abdômen, eletroencefalograma, ressonância magnética e estudo citogenético.Resultados: Os exames histológico e imunoistoquímico evidenciaram ausência de melanina e diminuição de melanócitos em áreas focais da epiderme, respectivamente. O eletroencefalograma apresentou disfunção córtico-subcortical difusa. A ressonância magnética do encéfalo foi compatível com cisto aracnoídeo em região temporal. O cariótipo evidenciou mosaicismo cromossômico com uma linhagem normal (46,XY) e uma linhagem celular que apresentava deleção intersticial nas bandas 22.2 -24.2 do braço longo do cromossomo 10 (25%).Conclusões: Os autores, com o presente estudo, destacam a importância das lesões de pele na definição etiológica das desordens neuropediátricas.J Pediatr (Rio J) 2001; 77(1): 59-62: hipomelanose de Ito, síndromes neurocutâneas, incontinência pigmentar acromiante. AbstractObjectives: The authors report a case of hypomelanosis of Ito (HI), a rare neurocutaneous syndrome, with neurological and chromosomal alterations associated to the cutaneous involvement and recurrent pneumonia.Case report: This is the case of a male patient, 1 year and 11 months old, hospitalized with bilateral bronchopneumonia at the São Vicente de Paulo Hospital. Examining the patient, hypochromic maculas in the skin, compatible with HI, and a delay in the neuropsychomotor development were observed. The patient was submitted to incisive biopsy of the skin lesions of the abdomen, electroencephalogram, magnetic resonance and cytogenetic evaluation.Results: The histologic and immunohistochemistry exams evinced melanin absence and melanocyte reduction in focal areas of the epidermis, respectively. The electroencephalogram revealed diffuse cortico-subcortical disfunction. The encephalon magnetic resonance imaging was compatible with arachnoid cyst in the temporal region. The cariotipo evinced chromosome mosaic with a normal lineage (46,XY) and a cellular lineage revealing interstitial deletion in the 22.2 -24.2 bands of the arm of chromosome 10 (25%).Conclusions: With the present study, the authors emphasize the importance of skin lesions in the etiologic definition of neuropediatric disorders.

Considering that the world's population average age is increasing and the proportions of those over the age of 80, the fastest growing population worldwide, new approaches to health care and treatment will be necessary. Due to the development of new drugs and by means of transluminal coronary angioplasty or coronary artery bypass graft, many elderly patients had their lives prolonged and their quality of life improved. We carried out a bibliography review to search for evidence to support the best treatment choice according to the clinical manifestation of the patient.

IntroductionMyocardial protection is essential for successful cardiac surgery, and the search for an ideal cardioplegic solution has continued since its beginning. In this context, Custodiol, del Nido and modified del Nido are single-dose cardioplegic solutions with good safety profiles and great relevance in modern surgical practice. While these solutions have all been evaluated for their impact on patient outcomes independently, limited research exists comparing them directly. Thus, the present study aims to examine the effects of these cardioplegic solutions on myocardial protection and clinical outcomes in adult patients undergoing elective cardiac surgery. The assessment of the increase in myocardial injury biomarkers in patients submitted to all treatment methods may be considered a major strength of our study.Methods and analysisThis is a clinical trial study protocol that will compare myocardial protection and clinical outcomes among three patient groups based on which cardioplegic solution was used. Patients will be randomised to receive del Nido (n=30), modified del Nido (n=30) or Custodiol (n=30). Myocardial injury biomarkers will be measured at the baseline and 2 hours, 12 hours and 24 hours after the cardiopulmonary bypass. Clinical outcomes will be assessed during the trans operative period and the intensive care unit stay, in addition to other haematological parameters.Ethics and disseminationThis protocol and its related documents were approved by the Research Ethics Committee of the Hospital Nossa Senhora da Conceição, Brazil, registered under no. 4.029.545. The findings of this study will be published in a peer-reviewed journal in the related field.Trial registration numberRBR-7g5s66.