Avaliação da densidade microvascular sistêmica no pós-operatório imediato de cirurgia cardíaca valvar: um estudo observacional
Avaliação da densidade microvascular sistêmica no pós-operatório imediato de cirurgia cardíaca valvar: um estudo observacional
Data
2025
Autores
Fernandes, Marcos Vinicius
Journal Title
Journal ISSN
Volume Title
Publisher
Instituto Nacional de Cardiologia
Resumo
Introdução: As cirurgias cardíacas, principalmente as valvares, mantêm sua importância no manejo das cardiopatias, a despeito do surgimento de novos tratamentos percutâneos menos invasivos. Extensa literatura demonstra que a cirurgia cardíaca impõe estresse fisiológico significativo ao organismo do paciente por diversos motivos, incluindo o uso da circulação extracorpórea (CEC), essencial para a maioria dos procedimentos. O manejo pós-operatório destes pacientes, particularmente na Unidade de Terapia Intensiva (UTI), ainda é desafiador, particularmente considerando a avaliação da perfusão tecidual. Objetivo: Analisar a microcirculação sistêmica de pacientes submetidos a cirurgia cardíaca valvar, correlacionando esses dados com seus desfechos clínicos e laboratoriais no período pós-operatório. Método: Estudo observacional, transversal, unicêntrico que incluiu pacientes internados no Instituto Nacional de Cardiologia para realização de cirurgia cardíaca valvar eletiva com uso de CEC. Realizada avaliação da microcirculação sistêmica por meio do posicionamento na região sublingual de um microscópio portátil (Cytocam, Braedius medical, Huizen, Holanda) utilizando tecnologia de iluminação incidente em campo escuro (IDF). Cada paciente foi avaliado em duas etapas: 1) durante a internação, no pré-operatório de cirurgia cardíaca valvar a ser realizada nas 48 horas seguintes; 2) no pós-operatório imediato de cirurgia cardíaca, nas primeiras quatro horas da chegada do paciente à UTI. Além da avaliação da microcirculação, dados demográficos, clínicos e laboratoriais foram obtidos em cada uma das etapas supracitadas. Realizada posteriormente análise offline dos dados de microcirculação obtidos por meio do software Cytocam tools 3.1.4 e correlacionados os resultados com os dados clínicos de cada paciente. Resultados: Foram incluídos 23 pacientes com idade entre 49 ± 13 anos. O número total (TNCV, p=0,0006), comprimento total (TLCV, p=0,0005) e densidade (CVD, p=0,0005) dos vasos capilares foram maiores após a cirurgia. Por outro lado, o número total (TNNCV, p = 0,05), comprimento total (TLNCV, p = 0,07) e densidade (NCVD, p = 0,07) de vasos não capilares após a cirurgia não diferiram em comparação aos valores correspondentes antes da cirurgia. A TNCV foi maior após a cirurgia do que antes da cirurgia em pacientes que receberam infusão de milrinona (P=0,002), mas não em pacientes que não receberam milrinona (P=0,05). O mesmo padrão de resposta foi observado em relação ao TLCV (P=0,0006 e P=0,06, respectivamente). Além disso, no grupo de pacientes que receberam infusão de
milrinona após a cirurgia, o número de microvasos capilares e não capilares foi positivamente correlacionado com o uso de milrinona. Conclusões: O presente estudo revelou uma melhora significativa no número total, comprimento e densidade dos vasos capilares em pacientes no pós-operatório de cirurgia cardíaca valvar, especialmente naqueles tratados com milrinona, sem observar, contudo, alterações nos vasos não capilares. Esses achados destacam a potencial eficácia dos vasodilatadores e inotrópicos no aprimoramento da microcirculação sistêmica durante o período pós-operatório, sugerindo a necessidade de investigações adicionais nesta área. Além disso, contribuiu para a compreensão do comportamento da microcirculação sistêmica após cirurgia cardíaca, ressaltando-se a importância de sua monitorização na UTI visto que distúrbios microcirculatórios podem persistir mesmo quando os parâmetros de macrocirculação (por exemplo pressão arterial e frequência cardíaca) encontram-se adequados.
Palavras-chave: Microcirculação; Período pós-operatório; Procedimentos cirúrgicos cardíacos; Implante de prótese de valva cardíaca.
Introduction: Cardiac surgeries, especially valve surgeries, maintain their importance in the management of heart diseases, despite the emergence of new, less invasive percutaneous treatments. Extensive literature demonstrates that cardiac surgery imposes significant physiological stress on patients for several reasons, including the use of cardiopulmonary bypass (CPB), essential for most procedures. The post-operative management of these patients, particularly in the Intensive Care Unit (ICU), remains challenging, particularly considering the assessment of tissue perfusion. Objective: To analyze the systemic microcirculation of patients undergoing heart valve surgery, correlating these data with their clinical and laboratory outcomes in the postoperative period. Method: This was an observational, cross-sectional, single-center study that included patients admitted to the National Institute of Cardiology for elective heart valve surgery using CPB. Systemic microcirculation was assessed by positioning a portable microscope (Cytocam, Braedius medical, Huizen, Netherlands) in the sublingual region using incident dark field imaging (IDF) technology. Each patient was evaluated at two stages: 1) during hospitalization, in the preoperative period of heart valve surgery scheduled within the next 48 hours; 2) in the immediate postoperative period of cardiac surgery, within the first 4 hours of the patient's arrival at the ICU. In addition to microcirculation assessment, demographic, clinical and laboratory data were obtained at each aforementioned stages. Offline analysis of microcirculation data was performed using Cytocam tools 3.1.4 software, and the results were correlated with each patient's clinical data. Results: 23 patients aged between 49 ± 13 years were included. The total number (TNCV, p=0.0006), total length (TLCV, p=0.0005) and density (CVD, p=0.0005) of capillary vessels were higher after surgery. On the other hand, the total number (TNNCV, p = 0.05), total length (TLNCV, p = 0.07) and density (NCVD, p = 0.07) of non-capillary vessels after surgery did not differ compared to the corresponding values before surgery. TNCV was higher after surgery than before surgery in patients who received Milrinone infusion (p=0.002), but not in patients who did not receive Milrinone (p=0.05). The same response pattern was presented in relation to TLCV (p=0.0006 and p=0.06, respectively). Furthermore, in the group of patients who received Milrinone infusion postoperatively, the number of capillary and non-capillary microvessels positively correlated with Milrinone use. Conclusions: The present study demonstrated a significant improvement in the total number, length and density of capillary vessels in patients in the postoperative period of heart valve surgery, especially in those treated with Milrinone, without, however, observing changes in non-capillary vessels. These findings highlight the potential effectiveness of vasodilators and inotropes in improving systemic microcirculation during the postoperative period, indicating the need for additional investigations in this area. Furthermore, it contributed to the understanding of the behavior of systemic microcirculation after cardiac surgery, highlighting the importance of monitoring it in the ICU since microcirculatory disorders can persist even when macrocirculation parameters (e.g. blood pressure and heart rate) are adequate. Keywords: Microcirculation; Postoperative period; Cardiac surgical procedures; Heart valve prosthesis implantation
Introduction: Cardiac surgeries, especially valve surgeries, maintain their importance in the management of heart diseases, despite the emergence of new, less invasive percutaneous treatments. Extensive literature demonstrates that cardiac surgery imposes significant physiological stress on patients for several reasons, including the use of cardiopulmonary bypass (CPB), essential for most procedures. The post-operative management of these patients, particularly in the Intensive Care Unit (ICU), remains challenging, particularly considering the assessment of tissue perfusion. Objective: To analyze the systemic microcirculation of patients undergoing heart valve surgery, correlating these data with their clinical and laboratory outcomes in the postoperative period. Method: This was an observational, cross-sectional, single-center study that included patients admitted to the National Institute of Cardiology for elective heart valve surgery using CPB. Systemic microcirculation was assessed by positioning a portable microscope (Cytocam, Braedius medical, Huizen, Netherlands) in the sublingual region using incident dark field imaging (IDF) technology. Each patient was evaluated at two stages: 1) during hospitalization, in the preoperative period of heart valve surgery scheduled within the next 48 hours; 2) in the immediate postoperative period of cardiac surgery, within the first 4 hours of the patient's arrival at the ICU. In addition to microcirculation assessment, demographic, clinical and laboratory data were obtained at each aforementioned stages. Offline analysis of microcirculation data was performed using Cytocam tools 3.1.4 software, and the results were correlated with each patient's clinical data. Results: 23 patients aged between 49 ± 13 years were included. The total number (TNCV, p=0.0006), total length (TLCV, p=0.0005) and density (CVD, p=0.0005) of capillary vessels were higher after surgery. On the other hand, the total number (TNNCV, p = 0.05), total length (TLNCV, p = 0.07) and density (NCVD, p = 0.07) of non-capillary vessels after surgery did not differ compared to the corresponding values before surgery. TNCV was higher after surgery than before surgery in patients who received Milrinone infusion (p=0.002), but not in patients who did not receive Milrinone (p=0.05). The same response pattern was presented in relation to TLCV (p=0.0006 and p=0.06, respectively). Furthermore, in the group of patients who received Milrinone infusion postoperatively, the number of capillary and non-capillary microvessels positively correlated with Milrinone use. Conclusions: The present study demonstrated a significant improvement in the total number, length and density of capillary vessels in patients in the postoperative period of heart valve surgery, especially in those treated with Milrinone, without, however, observing changes in non-capillary vessels. These findings highlight the potential effectiveness of vasodilators and inotropes in improving systemic microcirculation during the postoperative period, indicating the need for additional investigations in this area. Furthermore, it contributed to the understanding of the behavior of systemic microcirculation after cardiac surgery, highlighting the importance of monitoring it in the ICU since microcirculatory disorders can persist even when macrocirculation parameters (e.g. blood pressure and heart rate) are adequate. Keywords: Microcirculation; Postoperative period; Cardiac surgical procedures; Heart valve prosthesis implantation
Description
Palavras-chave
Microcirculação, Período pós-operatório, Procedimentos cirúrgicos cardíacos, Implante de prótese de valva cardíaca, Microcirculation, Postoperative period, Cardiac surgical procedures, Heart valve prosthesis implantation
Citação
Fernandes MV. Avaliação da densidade microvascular sistêmica no pós-operatório imediato de cirurgia cardíaca valvar: um estudo observacional. Rio de Janeiro. dissertação [Mestrado Profissional em Ciências Cardiovasculares] Instituto Nacional de Cardiologia - INC; 2025.