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545Gomes WJ, et al. -The renewed concept of the Batista operation for ischemic cardiomyopathy: maximum ventricular reduction Bras Cir Cardiovasc 2011;26(4):544-51 Rev

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ObjectiveTo evaluate the sequential changes of hemodynamic and metabolic parameters in patients who underwent aorta no-touch off-pump coronary artery bypass surgery (OPCAB).MethodsProspective study involving twenty-seven consecutive patients who underwent aorta no-touch OPCAB. The FloTrac/PreSep/Vigileo™ system (Edwards Lifesciences) was used to continuously record heart rate (HR), mean arterial blood pressure (MABP), central venous pressure (CVP), continuous cardiac index (FCI), stroke volume (SV), stroke volume variation (SVV), and central venous oxygen saturation (ScvO2). The parameters were assessed 5 min before, during and 5 min after each anastomosis (left anterior descending [LAD], posterior descending [PD], obtuse marginal [OM] and diagonal [Dg]). Postoperative lactate was also evaluated.ResultsThere was no significant change in HR and MABP for all anastomoses, except for MABP during PD grafting (-10.1±2.7 mmHg, P=0.03). There was a significant decrease in ScvO2 only during PD and OM anastomoses (-9.4±0.4, P=0.03; -4.4±0.4, P=0.02; respectively). CVP drop after PD manipulation was strongly associated with a higher lactate during the first hours after surgery (r=-0.82; P=0.001). These hemodynamic changes were transient and entirely recovered after the heart was returned to its anatomical position. No significant differences were observed in FCI, SVV, or the systemic vascular resistance index (SVRI) during all anastomoses, except for a drop in SVRI during PD grafting (-8.03±2.3, P=0.007). SV tended to decrease during the procedure in all territories, but with statistically significant drop only in PD and OM grafting (-10.4±1.2, P=0.02; -13.6±5.1, P=0.007; respectively).ConclusionHeart displacement for performing aorta no-touch OPCAB is well tolerated, with transient and endurable hemodynamic variations.

RESUMO Objetivos: o objetivo deste estudo foi avaliar os resultados da cirurgia do câncer de reto, em uma unidade que adota os princípios da excisão total do mesorreto (ETM) com baixa taxa de amputação abdominoperineal (AAP). Métodos: os pacientes com câncer retal extraperitoneal foram submetidos a ETM ou ETM com amputação abdominoperianeal. Pacientes com tumores de reto médio foram submetidos a EMT e pacientes com tumores de reto inferior e sem critérios para AAP foram submetidos a EMT e ressecção interesfincteriana. Aqueles em que o espaço interesfincteriano foi invadido e naqueles com margem distal livre menor que 1cm ou margem radial livre de tumor foram inatingíveis foram submetidos a AAP ou excisão abdominoperineal extraelevadora (ELAPE). Avaliamos as taxas de recorrência local, sobrevida global e envolvimento da margem radial. Resultados: sessenta (89,6%) pacientes realizaram ETM e sete (10,4%) ETM + AAP, dos quais cinco realizaram ELAPE. A recidiva local, em pacientes submetidos a ETM com ressecção anterior baixa, foi de 3,3% e em pacientes submetidos a AAP, 14,3%. A taxa de recorrência local (p=0,286) ou a taxa de recorrência à distância (p=1,000) foi semelhante entre os grupos. Não houve envolvimento das margens radiais. A sobrevida após 120 meses foi semelhante (p=0,239). Conclusão: as neoplasias malignas retais, incluindo aquelas localizadas no reto baixo, podem ser tratadas cirurgicamente com baixo índice de AAP, sem comprometer os princípios oncológicos e com baixo índice de recorrência local.

Objectives: the purpose of this study was to evaluate the outcome of rectal cancer surgery, in a unit adopting the principles of total mesorectal excision (TME) with a high restorative procedure rate and with a low rate of abdominoperineal excision (APE). Methods: we enrolles patients with extraperitoneal rectal cancer undergoing TME or TME+APE. Patients with mid rectal tumors underwent TME, and patients with tumors of the lower rectum and no criteria for APE underwent TME and intersphincteric resection. Those in which the intersphincteric space was invaded and in those with a free distal margin less than 1cm or a tumor free radial margin were unattainable underwent APE or extralevator abdominoperineal excision (ELAPE). We assessed local recurrence rates, overall survival and involvement of the radial margin. Results: sixty (89.6%) patients underwent TME and seven (10.4%) TME + APE, of which five underwent ELAPE. The local recurrence, in pacientes undergoing TME+LAR, was 3.3% and in patients undergoing APE, 14.3%. The local recurrence rate (p=0.286) or the distant recurrence rate (p=1.000) was similar between groups. There was no involvement of radial margins. Survival after 120 months was similar (p=0.239). Conclusion: rectal malignancies, including those located in the low rectum, may be surgically treated with a low rate of APE without compromising oncological principles and with a low local recurrence rates.

Background: Composite grafting techniques for coronary artery bypass grafts (CABG) have been widely used. However, it remains unclear whether this technique provides similar blood flow to the left coronary artery when compared to the conventional alternative. We sought to compare the total blood flow to the left coronary branches that are revascularized with left internal thoracic (LITA) and radial artery (RA) grafts using composite and non-composite techniques.Method: A total of 42 patients were randomly assigned to three groups according to the CABG technique to be used: Group A or composite LITA-RA in a Y format (n=14); Group B or modified composite LITA-RA intercoronary graft with RA and LITA to RA at the left anterior descending artery (LADn=14)]; and Group C or pedicled LITA to the LAD and aortocoronary RA (n=14). The patients were submitted to postoperative blood flow velocity analysis using a 0.014 inch 12 MHz Doppler flowire. Coronary flow reserve (CFR) was calculated by determining the average hyperemic peak velocity (APV) after an injection of adenosine.Results: Proximal LITA baseline APV was 28.4 ± 4.8 cm/s in group A, 34.4 ± 7.9 cm/s in group B (p=0.0384 x C) and 25.8 ± 8.6 cm/s in group C. The CFR was 2.1 ± 0.4, 2.0 ± 0.3 and 2.0 ± 0.4 in groups A, B and C respectively (p=0.7208 A, B x C). The total Q to LCA branches was 110 ± 30 in group A, 145 ± 59 in B and 133 ± 58 mL/min in C (p=0.3232 A, B x C).Conclusions: The LITA-RA composite graft maintains an adequate CFR and conveys similar blood flow to the left coronary artery branches when compared with conventional CABG technique. The utilization of two internal thoracic arteries has given benefits [2], but this can be associated with a greater morbidity in obese and diabetic patients [3].The radial artery (RA), in spite of its easy dissection and handling, initially demonstrated unfavorable results as evidenced by cineangiography. However, with modifications in the surgical dissection technique, in the preparation and handling of the graft, the RA was safely reintroduced for the treatment of coronary artery disease [4]. This graft now gives good results over the long term [5][6][7].With experience, it seemed evident that the different sizes between the wall of the RA and the wall of the ascending aorta could compromise the proximal anastomosis of the graft.Based on works of anastomosis of the right internal thoracic artery (RITA) in the LITA [8][9][10], some surgeons started to anastomose the RA proximally to the left internal thoracic artery, to revascularize the branches of the left coronary artery (LC) [11] giving the same results in the postoperative period when compared to the RITA under the same conditions [12,13] or the RA anastomosed proximally to the aorta [7].In composite arterial grafts, all the blood flow (Q) distributed to the revascularized arteries is from the LITA. This can lead to the question about if the blood flow available from the LITA is enough to irrigate the myocardium or, if in the composite arterial grafting techni...

Background: Composite grafting techniques for coronary artery bypass grafts (CABG) have been widely used. However, it remains unclear whether this technique provides similar blood flow to the left coronary artery when compared to the conventional alternative. We sought to compare the total blood flow to the left coronary branches that are revascularized with left internal thoracic (LITA) and radial artery (RA) grafts using composite and non-composite techniques.Method: A total of 42 patients were randomly assigned to three groups according to the CABG technique to be used: Group A or composite LITA-RA in a Y format (n=14); Group B or modified composite LITA-RA intercoronary graft with RA and LITA to RA at the left anterior descending artery (LADn=14)]; and Group C or pedicled LITA to the LAD and aortocoronary RA (n=14). The patients were submitted to postoperative blood flow velocity analysis using a 0.014 inch 12 MHz Doppler flowire. Coronary flow reserve (CFR) was calculated by determining the average hyperemic peak velocity (APV) after an injection of adenosine.Results: Proximal LITA baseline APV was 28.4 ± 4.8 cm/s in group A, 34.4 ± 7.9 cm/s in group B (p=0.0384 x C) and 25.8 ± 8.6 cm/s in group C. The CFR was 2.1 ± 0.4, 2.0 ± 0.3 and 2.0 ± 0.4 in groups A, B and C respectively (p=0.7208 A, B x C). The total Q to LCA branches was 110 ± 30 in group A, 145 ± 59 in B and 133 ± 58 mL/min in C (p=0.3232 A, B x C).Conclusions: The LITA-RA composite graft maintains an adequate CFR and conveys similar blood flow to the left coronary artery branches when compared with conventional CABG technique. The utilization of two internal thoracic arteries has given benefits [2], but this can be associated with a greater morbidity in obese and diabetic patients [3].The radial artery (RA), in spite of its easy dissection and handling, initially demonstrated unfavorable results as evidenced by cineangiography. However, with modifications in the surgical dissection technique, in the preparation and handling of the graft, the RA was safely reintroduced for the treatment of coronary artery disease [4]. This graft now gives good results over the long term [5][6][7].With experience, it seemed evident that the different sizes between the wall of the RA and the wall of the ascending aorta could compromise the proximal anastomosis of the graft.Based on works of anastomosis of the right internal thoracic artery (RITA) in the LITA [8][9][10], some surgeons started to anastomose the RA proximally to the left internal thoracic artery, to revascularize the branches of the left coronary artery (LC) [11] giving the same results in the postoperative period when compared to the RITA under the same conditions [12,13] or the RA anastomosed proximally to the aorta [7].In composite arterial grafts, all the blood flow (Q) distributed to the revascularized arteries is from the LITA. This can lead to the question about if the blood flow available from the LITA is enough to irrigate the myocardium or, if in the composite arterial grafting techni...