Article

lock Open Access lock Peer-Reviewed

0

Views

ARTIGO ORIGINAL

Cardiomioplastia: novo gerador da Biotronic

Domingo M BraileI; Marcelo J. F SoaresI; Dorotéia R. S SouzaI; Max SchaldachII

DOI: 10.1590/S0102-76381994000100004

RESUMO

Na cardiomioplastia, a contração do músculo esquelético, submetido à estimulação elétrica sobre a parede ventricular dilatada, aumenta a função ventricular, que é dependente das condições prévias do coração e da doença de base. Um dos problemas principais que interfere no sucesso da substituição do músculo cardíaco é a estimulação sincrónica do miocárdio e o músculo esquelético. A estimulação desse músculo a longo prazo tem sido possível graças a eletrodos especiais associados à estimulação progressiva seqüencial, adaptando-o à função cardíaca, através da transformação gradual de fibras glicolíticas expostas à fadiga em oxidativas lentas altamente resistentes. O gerador de pulsos "Myos" (Biotronik) tem sido utilizado em nosso Serviço para estimulação elétrica do músculo grande dorsal em sincronização com o miocárdio. Esse tipo de cardiomioestimulador com circuito eletrônico e bateria de lítio armazena um programa de estimulação responsável por diferentes modos operacionais, adaptados por um programa de computação. Para a programação do cardiomioestimulador, o momento da sincronização do trem de pulso com a abertura da valva aórtica é de extrema importância. O modo M de alta velocidade é utilizado para avaliar este sincronismo. A avaliação clínica da cardiomioplastia tem como base os resultados obtidos de 32 pacientes, com idade de 22 a 72 anos (média = 46,2 anos). A maioria (72%) dos pacientes apresentou miocardiopatia dilatada por causa indeterminada, 24% de origem chagásica, 3% virótica e 3% por periparto. Os índices de mortalidade hospitalar e tardia foram ambos de 12,5% e de 3,1%, respectivamente, excluindo-se os chagásicos. A sobrevida atuarial foi de 81,3+-0,22% após 6 anos e de 94.4+-0,1 % após 5 anos, retirando-se os chagásicos. Os índices médios de diâmetros sistólico (55,1 mm), diastólico (70,7 mm), encurtamento segmentar (22,8%) e fração de ejeção (51,0%), referentes a seguimento médio de 14,2 meses, refletem que a cardiomioplastia pode ser efetiva na assistência do ventrículo esquerdo. A escolha do paciente parece ser a chave para o bom resultado operatório a curto e longo prazos.

ABSTRACT

In the cardiomyoplasty, the contraction of the skeleton muscle, undergone electric stimulation on the dilated ventricle wall, increases the ventricle function, which is dependent of the heart and the base disease previous conditions. One of the main problems which interferes with the sucess of the cardiac muscle replacement is the myocardial synchronic stimulation and the skeleton muscle. The stimulation of this muscle in long-term has been possible because of the special electrodes associated with the sequential progressive stimulation, adjusting it to the cardiac function, through the gradual transformation of glicolitic fibers exposed to fatigue in highly resistant slow oxidizers. The pulse generator Myos (Biotronik) has been used in our center for electrical stimulation of the latissimus dorsalis in synchronization with the myocardium. This electronic circuit and lithium battery type of cardiomyostimulator stores a stimulation program responsible for different operational modes, adapted by acomputer program. In order to program the cardiomyostimulator, the moment of the pulse synchronization with the aortic valve opening is extremely important. The high velocity M mode is utilized to evaluate the synchronism. The cardiomyoplasty clinical evaluation is based on the results obtained from 32 patients at 22 ti 72 years old (average=46.2 years) most of patients (72%) presented dilated myocardiopathy due to undetermined cause, 24% of chagasic origin, 3% virus and 3% due to peripartum. Hospital and late mortality rate were both 12.5% and 3.1% and 3.7% respectively, excluding the chagasic patients. The actuarial survival was 81.3 + - 0.22% after 6 years and 94.4 + - 0.1 % after 5 years, withdrawing the chagasic patients. The average indexes of systolic diameters (55,1 mm), diastolic (70,7 mm), segmental shortening (22.8%) and ejection fraction (51.0%), related to an average follow-up of 14.2 months, reflect that the cardiomyoplasty can be effective to assist the left ventricle. Choosing the right patient seems to be key to the goog operative result in short and long terms.
Texto completo disponível apenas em PDF.

REFERÊNCIAS

1. ACKER, M. A.; ANDERSON, W. A.; HAMMOND, R. L. - One to eleven weeks experience. J Thorac. Cardiovasc. Surg., 94: 613-674, 1987.

2. AL-AMOLEND, W.; BULLER, A.; POPE, R. - Long term stimulation of cat fast-twitch skeletal muscle. Nature, 244: 227, 1973. [MedLine]

3. ARMENTI, F.; BITTO, T.; MACOVIAL, J. - Transformation of canine diaphragm to fatigue resultant muscle by phrenic nerve stimulation. Surg. Forum, 35: 258, 1984.

4. BRAILE, D. M.; SOARES, M. J. F.; RODRIGUES, M. C. Z.; RAMIN, S. L.; THEVENARD, R. S.; ZAIANT-CHICK, M.; SOUZA, D. R. S. - Cardiomioplastia: estudo clínico de 26 pacientes em 6 anos. Rev. Bras. Marcapasso Arritmia, 6: 71-83, 1993.

5. BULLER, A.; ECCLES, J.; ECCLES, R. - Differentiation of fast and slow muscles in the cat hind limb. J. Physiol, 150: 399, 1960. [MedLine]

6. BULLER, A.; ECCLES, J.; ECCLES, R. - Interaction between motor nervous and muscles in respect of the characteristic speeds of their responses. J. Physiol, 150: 417, 1960. [MedLine]

7. CARPENTIER, A. & CHACHQUES, J. C. - Latissimus dorsi cardiomyoplasty to increase cardiac output. In: RABAGO, G. & COOLEY, D. A. (eds). Heart valve replacement: current status and future trends. New York, Futura Publishing, 1987. p. 473-486.

8. CARPENTIER, A. & CHACHQUES, J. C. - Myocardial substitution with a stimulated skeletal muscle: first successful clinical case (letter). Lancet, 1:1267, 1985. [MedLine]

9. CARPENTIER, A. C. & CHACHQUES, J. C. - Successful cardiomyoplasty with an electrostimulated latissimus dorsi muscle flap. In: Proc, 14th Meeting of the Neurolletric Society. Greece, Neurolletric Society, 1987, p.27.

10. CARPENTIER, A.; CHACHQUES, J. C.; ACAR, C. - Dynamic cardiomyoplasty at seven years. J. Thorac. Cardiovasc. Surg., 106: 42-54, 1993.

11. CHACHQUES, J. C. - Effect of latissimus dorsi dynamic cardiomyoplasty on ventricular function. Circulation, 78: 203-216, 1988.

12. CHACHQUES, J. C. & CARPENTIER, A. - Postoperative management. In: CARPENTIER, A., CHACHQUES J-C & GRANDJEA P. (eds.) Cardiomyoplasty. New York, Futura Publishing, 1991, p. 131-146.

13. CHACHQUES J. C.; GRANDJEAN, P. A.; CARPENTIER, A. P. - Patient managment and clinical follow-up after cardiomyoplasty. J. Cardiac. Surg., 6: 89-99, 1991.

14. CHACHQUES, J.; GRANDJEAN, P.; VASSEUR, B. - Electrophysiological conditioning of latissimus dorsi muscle flap for myocardial assistance. Artif Organs, 9: 27, 1985. [MedLine]

15. CHEKANOV, V. & KRAKOVSKY, A - Possibilities of transformation of skeletal muscle. In: CHEKANOV V; KRAKOVSKY A. (eds). Cardiomyoplasty. Moscou, 1989. p. 22-38.

16. DEWAR, M. L. & CHIU, R. C. - Cardiomyoplasty and the pulse-train stimulator. In: CHIU, R. C. - Biomechanical cardiac assist cardiomyoplasty and muscle-powered devices. New York, Futura Publishing, 1986. p. 43-57.

17. DEWAR, M. L.; DRINKWATER, D. C.; CHIU, R. C. - Synchronously stimulated skeletal muscle graft for myocardial repair. J. Thorac. Cardiovasc. Surg., 87: 325, 1984. [MedLine]

18. DIAZ, J. H. - Miocardioplastia: experiencia cubana. 1990. Tese Doutorado. Havana, Instituto de Cardiologia.

19. DRINKWATER, O.; CHIU, R. C.; MODY, D. - Cardiac assist and myocardial repair with synchronously stimulated skeletal muscle. Surg. Forum., 31: 271, 1980.

20. DUMCIUS, A.; SALCIUS, K.; GIEDRAITIS, S.; SIRVINSKAS, E.; KIBISA, R.; SKUCAS, J. - Myoventriculoplasty with the use of programmed physiologically controlled electroneuro-stimulation (letter). J. Thorac. Cardiovasc. Surg., 97: 636-637, 1989. [MedLine]

21. GAINES, W. E.; GOLDBERG, N. H.; MERGNER, W. J. - Reconstruction of the right ventricular outflow tract with a revascularized free flap of striated muscle. Surg. Forum, 36: 250-253, 1985.

22. GRANDJEAN, P. A. - Electrical stimulation of skeletal muscles. In: CARPENTIER, A.; CHACHQUES, J-C.; GRANDJEAN, P. (eds.) Cardiomyoplasty. New York, Futura Publishing, 1991. p. 39-62.

23. HUME, W. I. - Construction of a functioning accessory miocardium. Trans. South. Surg. Assoc., 79: 200-202, 1968.

24. JATENE, A. D.; MOREIRA, L. F. P.; STOLF, N. A. G. - Left ventricular function changes after cardiomyoplasty in patients with dilated cardiomiopathy. J. Thorac. Cardiovasc. Surg., 102: 132-139, 1991.

25. KANTROWITZ, A. & McKINNON, W. - The experimental use of the diaphragm as an auxiliary myocardium. Surg. Forum, 9: 266-268, 1959.

26. KUSABA, E.; SCHRAUT, W.; SAWATONS, S. - A diaphragmatic graft for augmenting LV function: a flexibility study. Trans. Am. Soc. Artif. Inter. Organs, 19: 251, 1973.

27. LEINER, A. A.; MOREIRA, F. P.; CHAGAS, A. C. P. - Biomechanical circulatory assistance: importance of aerobic capacity of normal and conditioned skeletal muscles. Trans. Am. Soc. Artif. Intern. Organs, 34: 716-720, 1988.

28. MACOVIAK, J.; STEPHENSON, L. W.; ALAVI, A. A. - Effect of electrical stimulation on diaphragmatic muscle used to enlarge right ventricle. Surg., 90: 271, 1981

29. MACOVIAK, J.; STEPHENSON, L. W.; SPIELMAN, S. - Electrophysiological and mechanical characteristics of diaphragmatic autograft used to enlarge right ventricle. Surg. Forum, 31: 270, 1980.

30. MANION, J. F.; ACKER, M. A.; MAMMOND, R. L.; FALKMEYER, W.; DUCKET, S.; STEPHENSON, N. - Power output of skeletal muscle ventricles in circulation: short-term studies. Circulation, 76: 155-162, 1987. [MedLine]

31. MANNION, J. F. & STEPHENSON, L. - Potencial uses of skeletal muscle for myocardial assistance. Surg. Clin. N. Am., 65: 679-687, 1985.

32. MOLTENI, L.; ALMADA, H.; FERREIRA, R. - Synchronously stimulated skeletal muscle graft for left ventricular assistance. J. Thorac. Cardiovasc. Surg., 97: 439-446, 1989. [MedLine]

33. MOREIRA, L. F. P.; STOLF, N. A. G.; BOCCHI, E. A. - Resultados da cardiomioplastia no tratamento da cardiomioplastia dilatada. Rev. Bras. Cir. Cardiovasc, 8: 85-95, 1991.

34. MOREIRA, L. F. P.; BOCCHI, E. A.; SEFERIAN, P. J. - Influência da cardiomioplastia na sobrevida de pacientes portadores de cardiomiopatia dilatada. Arq. Bras. Cardiol., 57: 147-150, 1991.

35. MOREIRA, L. F.; SEFERIAN Jr. P.; BOCCHI, E. A. - Survival improvement with dynamic cardiomyoplasty in patients with dilated cardiomyopathy. Circulation, 84 (Supl. 3): III-296-III302, 1991.

36. MOREIRA, L. F. P.; STOLF, N. A. G.; JATENE, A. D. - Benefits of cardiomyoplasty for dilated cardiomyopathy. J. Thorac. Cardiovasc. Surg., 3: 140-144, 1991.

37. PAPP, M. D. - Experimental use of intercostal muscle flaps for repair of induced cardiac defects. J. Thorac. Cardiovasc. Surg., 90: 261-264, 1985. [MedLine]

38. PETTE, O. & HEILMAN, C. - Transformation of morphological, functional and metabolic properties of fast-twitch muscle as induced by long-term electrical stimulation. Basic Res. Cardiol., 72: 247-252, 1977.

39. RILEY, D. & ALLIN, E. - The effects of inactivity programmed stimulation and denervation on the histochemistry of skeletal muscle fiber types. Exp. Neurol., 40: 391, 1973. [MedLine]

40. ROSSI, M. A.; BRAILE, D. M.; SOUZA, D. R. S. - Dynamic cardiomyoplasty in chronic Chagas heart disease: clinicopathological data. Ann. Thorac. Surg., 51: 649-651, 1991. [MedLine]

41. RUGGIERO, R.; POCHETTINO, A.; HAMMOND, R. L. - Autologous skeletal muscle, an alternative for cardiac assistance. Pace, 14: 480-491, 1991.

42. SALMONS, S. - An implantable muscle stimulator. J. Physiol., 188: 13, 1967. [MedLine]

43. SALMONS. S. - The response of skeletal muscle to different patterns of use. In: PETTE, D. (ed.) Plasticity of Muscle. New York, Walter de Gruyter, 1980. p. 387.

44. SALMONS, S. & HENRIKSSON, J. - The adaptative response of skeletal muscle to increased use. Muscle Nerve, 4: 94, 1981. [MedLine]

45. SALMONS, S. & VRBOVA, G. - The influence of activity on some contractile characteristics of mammalian fast and slow muscles. J. Physiol., 201: 535, 1969. [MedLine]

46. SCHALDACH, M. G. & BRAILE, D. M. - The ANS signal utilized to optimize surgical treatment of cardiomyopathies (no preto).

47. SRETER, F.; GERGELY, J.; SALMONS, S.; ROMANUL, F. C. A. - Synthesis by fast muscle of myosin characteristic of slow muscle in response to longterm stimulation. Nature, 241: 17, 1973. [MedLine]

48. STRETER, F.; PINTER, K.; JOLEZ, F. - Fast to slow transformation of fast muscles in response to long-term phasic stimulation. Exp. Neurol., 75: 95, 1982. [MedLine]

49. VON RECUM, A.; STEELE, J.; HAMADA, D.; KANTROWITZ, A. - Long-term stimulation of a diaphragm muscle pouch. J. Surg. Res., 23: 422, 1977. [MedLine]

CCBY All scientific articles published at rbccv.org.br are licensed under a Creative Commons license

Indexes

All rights reserved 2017 / © 2024 Brazilian Society of Cardiovascular Surgery DEVELOPMENT BY