ALEXANDRE CIAPPINA HUEB
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- Comparison between off-pump and on-pump coronary artery bypass grafting in patients with severe lesions at the circumflex artery territory: 5-year follow-up of the MASS III trial(2015) MELO, Rodrigo Morel Vieira de; HUEB, Whady; REZENDE, Paulo Cury; COSTA, Leandro Menezes Alves da; OIKAWA, Fernando Teiichi Costa; LIMA, Eduardo Gomes; HUEB, Alexandre Ciappina; SCUDELER, Thiago Luis; KALIL FILHO, RobertoOBJECTIVES: The technical difficulty in the revascularization of the circumflex artery territory with off-pump surgery may compromise the outcome of this method in clinical follow-up. We aimed to evaluate cardiac events in patients with stable coronary artery disease and severe obstruction of the circumflex system, undergoing coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass. METHODS: MASS III was a single-centre study that evaluated 308 patients with multivessel coronary artery disease randomized to on-pump (153) or off-pump (155) CABG. Of this total, 260 (84.4%) patients had, on coronary angiography, at least one 70% obstruction in the circumflex territory (141 on-pump and 119 off-pump). The combined outcome was death, myocardial infarction, target vessel revascularization (angioplasty or surgery) or hospitalization for cardiac causes. Variables with possible associations (P < 0.1) were included in the multivariate analysis. RESULTS: The two groups were well matched for demographics and clinical and angiographic characteristics. After 5 years of follow-up, off-pump CABG had higher combined events than on-pump had: 25 (21%) vs 17 (12%), hazard ratio 1.88, 95% confidence interval 1.02-.48, P = 0.041. In the multivariate model with the inclusion of the following variables: age (P = 0.09) and complete revascularization (P = 0.68), off-pump surgery remained as a predictor of combined events in 5 years, P = 0.03. CONCLUSIONS: In patients with multivessel coronary artery disease and severe lesions in the circumflex territory, off-pump coronary artery bypass surgery resulted in a higher incidence of cardiac events at 5-year follow-up.
- Ten-year outcomes of patients randomized to surgery, angioplasty, or medical treatment for stable multivessel coronary disease: Effect of age in the Medicine, Angioplasty, or Surgery Study II trial(2013) REZENDE, Paulo Cury; HUEB, Whady; GARZILLO, Cibele Larrosa; LIMA, Eduardo Gomes; HUEB, Alexandre Ciappina; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoObjective: With progressive aging, coronary artery disease has been diagnosed at more advanced ages. Although patients aged 65 years or more have been referred to surgical or percutaneous coronary interventions, the best option for coronary artery disease treatment remains uncertain. The current study compared the 3 treatment options for coronary artery disease in patients aged 65 years or more and analyzed the impact of age in treatment options. Methods: Patients were separated according to age: 65 years or more (n = 200) and less than 65 years (n = 411). All patients were followed for 10 years. The rates of overall mortality, acute myocardial infarction, and new revascularizations were analyzed. Results: Of 200 patients aged 65 years or more, 68 were randomized to medical therapy, 68 were randomized to percutaneous coronary intervention, and 64 were randomized to coronary artery bypass grafting. At 10 years, overall survival was 63% (medical therapy), 69% (percutaneous coronary intervention), and 66% (coronary artery bypass grafting) (P = .93). The survival free of combined events was 43% (medical therapy), 38% (percutaneous coronary intervention), and 66% (coronary artery bypass grafting) (P = .007). The survival free of myocardial infarction was 82% (medical therapy), 77% (percutaneous coronary intervention), and 90%(coronary artery bypass grafting) (P = .17), and survival free of new revascularizations was 59% (medical therapy), 58% (percutaneous coronary intervention), and 91% (coronary artery bypass grafting) (P = .0003). When the 2 age groups were compared, survival free of myocardial infarction for patients treated by percutaneous coronary intervention was 77% (older patients) and 92% (younger patients) (P = .004). Conclusions: In this analysis, treatment options for patients aged 65 years or more who have coronary artery disease yield similar overall survival. However, coronary artery bypass grafting was associated with fewer coronary events, and percutaneous coronary intervention was associated with a higher incidence of myocardial infarction.
- Behavior of Ultrasensitive C-Reactive Protein in Myocardial Revascularization with and without Cardiopulmonary Bypass(2018) ABRANTES, Rafael Diniz; HUEB, Alexandre Ciappina; HUEB, Whady; JATENE, Fabio B.Objective: To analyze the inflammation resulting from myocardial revascularization techniques with and without cardiopulmonary bypass, based on ultrasensitive C-reactive protein (US-CRP) behavior. Methods: A prospective non-randomized clinical study with 136 patients was performed. Sixty-nine patients were enrolled for Group 1 (on-pump coronary artery bypass-ONCAB) and 67 patients were assigned to Group 2 (off-pump coronary artery bypass-OPCAB). All study participants had blood samples collected for analysis of glucose, triglycerides, creatinine, total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) and creatinephosphokinase (CPK) in the preoperative period. The samples of creatinephosphokinase MB (CKMB), troponin I (TnI) and US-CRP were collected in the preoperative period and at 6, 12, 24, 36, 48 and 72 hours after surgery. We also analyzed the preoperative biological variables of each patient (age, smoking, diabetes mellitus, left coronary trunk lesion, body mass index, previous myocardial infarction, myocardial fibrosis). All angiographically documented patients with >70% proximal multiarterial stenosis and ischemia, documented by stress test or classification of stable angina (class II or III), according to the Canadian Cardiovascular Society, were included. Reoperations, combined surgeries, recent acute myocardial infarction, recent inflammatory disease, deep venous thrombosis or recent pulmonary thromboembolism, acute kidney injury or chronic kidney injury were not included. Results: Correlation values between the US-CRP curve and the ONCAB group, the treatment effect and the analyzed biological variables did not present expressive results. Laboratory variables were evaluated and did not correlate with the applied treatment (P>0.05). Conclusion: The changes in the US-CRP at each moment evaluated from the postoperative period did not show any significance in relation to the surgical technique applied.
- Accuracy of Myocardial Biomarkers in the Diagnosis of Myocardial Infarction After Revascularization as Assessed by Cardiac Resonance: The Medicine, Angioplasty, Surgery Study V (MASS-V) Trial(2016) HUEB, Whady; GERSH, Bernard J.; COSTA, Leandro Menezes Alves da; OIKAWA, Fernando Teiichi Costa; MELO, Rodrigo Morel Vieira de; REZENDE, Paulo Cury; GARZILLO, Cibele Larrosa; LIMA, Eduardo Gomes; NOMURA, Cesar Higa; VILLA, Alexandre Volney; HUEB, Alexandre Ciappina; STRUNZ, Celia Maria Cassaro; FAVARATO, Desiderio; TAKIUTI, Myrthes Emy; ALBUQUERQUE, Cicero Piva de; SILVA, Expedito Eustaquio Ribeiro da; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoBackground. The lack of a correlation between myocardial necrosis biomarkers and electrocardiographic abnormalities after revascularization procedures has resulted in a change in the myocardial infarction (MI) definition. Methods. Patients with stable multivessel disease who underwent percutaneous or surgical revascularization were included. Electrocardiograms and concentrations of high-sensitive cardiac troponin I (cTnI) and creatine kinase (CK)-MB were assessed before and after procedures. Cardiac magnetic resonance and late gadolinium enhancement were performed before and after procedures. MI was defined as more than five times the 99th percentile upper reference limit for cTnI and 10 times for CK-MB in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), respectively, and new late gadolinium enhancement for cardiac magnetic resonance. Results. Of the 202 patients studied, 69 (34.1%) underwent on-pump CABG, 67 (33.2%) off-pump CABG, and 66 (32.7%) PCI. The receiver operating characteristic curve showed the accuracy of cTnI for on-pump CABG, off-pump CABG, and PCI patients was 21.7%, 28.3%, and 52.4% and for CK-MB was 72.5%, 81.2%, and 90.5%, respectively. The specificity of cTnI was 3.6%, 9.4%, and 42.1% and of CK-MB was 73.2%, 86.8%, and 96.4%, respectively. Sensitivity of cTnI was 100%, 100%, and 100% and of CK-MB was 69.2%, 64.3%, and 44.4%, respectively. The best cutoff of cTnI for on-pump CABG, off-pump CABG, and PCI was 6.5 ng/mL, 4.5 ng/mL, and 4.5 ng/mL (162.5, 112.5, and 112.5 times the 99th percentile upper reference limit) and of CK-MB was 37.5 ng/mL, 22.5 ng/mL, and 11.5 ng/mL (8.5, 5.1, and 2.6 times the 99th percentile upper reference limit), respectively. Conclusions. Compared with cardiac magnetic resonance, CK-MB was more accurate than cTnI for diagnosing MI. These data suggest a higher troponin cutoff for the diagnosis of procedure-related MI. (C) 2016 by The Society of Thoracic Surgeons
- Impact of Chronic Kidney Disease on Long-Term Outcomes in Type 2 Diabetic Patients With Coronary Artery Disease on Surgical, Angioplasty, or Medical Treatment(2016) LIMA, Eduardo Gomes; HUEB, Whady; GERSH, Bernard J.; REZENDE, Paulo Cury; GARZILLO, Cibele Larrosa; FAVARATO, Desiderio; HUEB, Alexandre Ciappina; GARCIA, Rosa Maria Rahmi; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoBackground. Coronary artery disease (CAD) among patients with diabetes and chronic kidney disease (CKD) is not well studied, and the best treatment for this condition is not established. Our aim was to compare three therapeutic strategies for CAD in diabetic patients stratified by renal function. Methods. Patients with multivessel CAD that underwent coronary artery bypass graft (CABG), angioplasty (percutaneous coronary intervention [PCI]), or medical therapy alone (MT) were included. Data were analyzed according to glomerular filtration rate in three strata: normal (>90 mL/min), mild CKD (60 to 89 mL/min), and moderate CKD (30 to 59 mL/min). End points comprised overall rate of mortality, acute myocardial infarction, and need for additional revascularization. Results. Among patients with normal renal function (n = 270), 122 underwent CABG, 72 PCI, and 76 MT; among patients with mild CKD (n = 367), 167 underwent CABG, 92 PCI, and 108 MT; and among patients with moderate CKD (n = 126), 46 underwent CABG, 40 PCI, and 40 MT. Event-free survival was 80.4%, 75.7%, 67.5% for strata 1, 2, and 3, respectively (p = 0.037). Survival rates among patients with no, mild, and moderate CKD are 91.1%, 89.6%, and 76.2%, respectively (p = 0.001) (hazard ratio 0.69; 95% confidence interval 0.51 to 0.95; p = 0.024 for stratum 1 versus 3). We found no differences for overall number of deaths or acute myocardial infarctions irrespective of strata. The need of new revascularization was different in all strata, favoring CABG (p < 0.001, p < 0.001, and p = 0.029 for no, mild, and moderate CKD, respectively). Conclusions. Mortality rates were higher in patients with mild and moderate CKD. Higher event-free survival was observed in the CABG group among patients with no and mild CKD. Besides, CABG was associated with less need for new revascularization compared with PCI and MT in all renal function strata. This trial was registered at http://www.controlled-trials.com as ISRCTN66068876. (C) 2016 by The Society of Thoracic Surgeons
- Off-pump versus On-pump Coronary Artery Bypass Grafting in Frail Patients: Study Protocol for the FRAGILE Multicenter Randomized Controlled Trial(2017) MEJIA, Omar Asdrubal Vilca; SA, Michel Pompeu Barros Oliveira; DEININGER, Maurilio Onofre; DALLAN, Luis Roberto Palma; SEGALOTE, Rodrigo Coelho; OLIVEIRA, Marco Antonio Praca de; ATIK, Fernando Antibas; SANTOS, Magaly Arrais dos; SILVA, Pedro Gabriel Melo de Barros e; MILANI, Rodrigo Mussi; HUEB, Alexandre Ciappina; MONTEIRO, Rosangela; LIMA, Ricardo Carvalho; LISBOA, Luiz Augusto Ferreira; DALLAN, Luis Alberto Oliveira; PUSKAS, John; JATENE, Fabio BiscegliIntroduction:Advances in modern medicine have led to people living longer and healthier lives. Frailty is an emerging concept in medicine yet to be explored as a risk factor in cardiac surgery. When it comes to CABG surgery, randomized controlled clinical trials have primarily focused on low-risk (ROOBY, CORONARY), elevated-risk (GOPCABE) or high-risk patients (BBS), but not on frail patients. Therefore, we believe that off-pump CABG could be an important technique in patients with limited functional capacity to respond to surgical stress. In this study, the authors introduce the new national, multicenter, randomized, controlled trial ""FRAGILE"", to be developed in the main cardiac surgery centers of Brazil, to clarify the potential benefit of off-pump CABG in frail patients. Methods:FRAGILE is a two-arm, parallel-group, multicentre, individually randomized (1:1) controlled trial which will enroll 630 patients with blinded outcome assessment (at 30 days, 6 months, 1 year, 2 years and 3 years), which aims to compare adverse cardiac and cerebrovascular events after off-pump versus on-pump CABG in prefrail and frail patients. Primary outcomes will be all-cause mortality, acute myocardial infarction, cardiac arrest with successful resuscitation, low cardiac output syndrome/cardiogenic shock, stroke, and coronary reintervention. Secondary outcomes will be major adverse cardiac and cerebrovascular events, operative time, mechanical ventilation time, hyperdynamic shock, new onset of atrial fibrillation, renal replacement therapy, reoperation for bleeding, pneumonia, length of stay in intensive care unit, length of stay in hospital, number of units of blood transfused, graft patency, rate of complete revascularization, neurobehavioral outcomes after cardiac surgery, quality of life after cardiac surgery and costs. Discussion:FRAGILE trial will determine whether off-pump CABG is superior to conventional on-pump CABG in the surgical treatment of pre-frail and frail patients.
conferenceObject Usefullness of Early Release Peak of Cardiac Biomarkers for Detection of Myocardial Infarction Related to Coronary Revascularization Procedures. A Cardiac Magnetic Resonance Study(2014) MELO, Rodrigo M. Vieira de; OIKAWA, Fernando T.; COSTA, Leandro M.; REZENDE, Paulo C.; SCUDELER, Thiago L.; NOMURA, Cesar H.; VILLA, Alexandre V.; HUEB, Alexandre C.; HUEB, Whady; KALIL FILHO, RobertoconferenceObject Measurement of Myocardial Necrosis Biomarkers After Surgical or Percutaneous Intervention Assessed by Cardiac Magnetic Resonance for Diagnosis of Procedure-Related Myocardial Infarction. The MASS-5 Trial(2014) HUEB, Whady; REZENDE, Paulo C.; COSTA, Leandro M.; MELO, Rodrigo M. Vieira de; OIKAWA, Fernando T.; NOMURA, Cesar H.; VILLA, Alexandre V.; STRUNZ, Celia M.; HUEB, Alexandre C.; SILVA, Expedito E.; RAMIRES, Jose A.; KALIL FILHO, Roberto