Article

lock Open Access lock Peer-Reviewed

0

Views

LETTERS TO THE EDITOR

Letters to the Editor

DOI: 10.1590/S0102-76382009000100022

Cardiomyoplasty

Dear Mr. Editor


It is undeniable that we are living in a time of change of the heart surgery. With the maturity reached by the fiftieth anniversary of this speciality, we realize that some cycles have occurred. Despite the immeasurable progress and substantial improvement of outcomes in all types of heart surgery procedures, a clinical entity still needs our deepest attention, that is the heart failure syndrome. This is clear in the European Journal of Cardio-Thoracic Surgery of February (vol 35, No. 02, 2009), on which the first six articles deal with heart failure, starting with the editorial and culminating with an article about the management of diastolic heart failure in cardiac surgery. Mainly, it starts with cardiomyoplasty. And cardiomyoplasty is the reason I write this letter. I mean, due to the editor of our Journal. When watching the lectures of PhD Professor Domingo M. Braile about heart failure, we always have heard and still hear the message about the fact that cardiomyoplasty was neglected early and that it could be an interesting option.

We enter in a cycle of modern approach to heart failure patients, on which the treatment must be multidisciplinary and requires full cooperation between surgeons and cardiologists. A number of innovative options are being implemented, such as cell therapy and ventricular assist devices, however, there is a considerable contingent of patients who may have better quality of life and increased survival with existing procedures on which we surgeons are trained: CABG, replacement and valve repair, ventricular reconstruction, and resynchronization therapy after heart transplantation.

Another almost immeasurable amount of patients will have no option. Either by stagnancy in the number of organ donors or the high mortality on the waiting list or, finally, the limitations and contra-indications to heart transplantation. Due to the greater involvement of surgeons in heart failure programs, the greatest knowledge of imaging methods, better care of patients and major advance in terms of electrophysiology make us believe that cardiomyoplasty will return. Twenty five years after the initiation of cardiomyoplasty, we have strong reasons to invest in this technique: 1) new concepts in preservation and muscle stimulation, 2) maturity of indications and contra-indications, 3) overcome in resynchronization therapy, 4) the use of associated implantable defibrillators; 5) the urgent need for alternatives to transplantation, 6) the cost, and the insoluble problems with the anti-clotting and the ventricular assist devices infection.

Thanks to PhD Professor Braile for allowing us to view more distant horizons.


Gustavo Calado A Ribeiro, Campinas-SP






The Stretchers from Emergency Room (ER)


In July 1990, Professor Adib Jatene wrote on Folha de São Paulo: "The ER of the Clinics Hospital always has more patients on stretchers than in bed".

This fact, reported by the press, resulted in the superintendent's resignation, as written by him.

In the article from 1990, he describes the dedication of a nursing assistant - Joaninha - true symbol of the Clinics Hospital's employees.

The number of stretchers, as usual, was greater than beds. And he recalls that he imediatly felt what the ER stretchers mean.

Despite the dedication of many Joaninhas, the ER stretcher is a symbol and a libel: symbol of the unequal struggle of Health personnel to meet those suffering. Symbol of fraternity and solidarity, who does not hesitate to assist, even under unfavorable conditions, and does not surrender, stands, waits, believes and acts with the braveness of those who fulfills a mission, not a timetable. Symbol of dignity, who does not reject the charity and donates his own work, not to the Government, but to the patient, while claims to this same Government. Libel against the indifference, the inability of this Government to solve the problem and the lack of political will and humanity, because the Government does not sorely feel the social problems.

In Brazil, we are used to find the culprits, and not to offer solutions, that is what we need now.

More than one hundred years ago, Dr. João Penido, in Minas, addressed his colleagues and authorities during a cholera epidemic that threatened the city, assuming that the news was true, but he did not have resources to solve the problem. Any costs, any measures, all medicines, depended on the central government. Thus, the alternative of Municipal Councils was to request all through the Provincial Assembly but they were not met at all.

The situation is still actual. The SUS was created under municipal basis. The Constitution and health legislation are progressive, but stiffened bureaucracy obstructs the advancement of decent and quality public services. The law is not fulfilled, the plans are disrespected, the projects are stopped (see University Hospitals, in permanently unfinished works and totally damaged inside). Competent technicians are changed by patronized politicians.

Nineteen years have passed since the article by Dr. Adib was published. Has anything changed?

Yes, things have changed for worse. Why it has to be?

The establishment of SUS under public basis - was only in the speech. Nineteen years old, my dear teacher, and what do we have?

A post-mature SUS from incubator, with urgent need for oxygen, warm and much support. Joaninhas's dedication and affection to help it to survive.

The difficulties have worsened: the ER stretchers became the ER floor. The series of problems increased the viability of the sector. Low sequential investment leads directly to three consequences: damage of what already exists in the sector, real impossibility of greater control and efficiency increasingly far.

While the Federal Government constitutionally extended the number of citizens with universal right to health, resources have diminished and SUS beneficiaries have multiplied by five.

Uncrossing lines were crossed; misdirection lines led to chaos: the decreasing line of the spent resources, wrongly used or stolen from Ministry of Health ("Sanguessugas", "Mensalão", ambulances and others) with the upward line of the number of people with "right" to health resources - especially to ER.

Another key point in Health is human resources subject. When speaking about salary, there is no limit and serious distortions in the salary of the Health personnel. And salary is not the primary issue. The issue involves working conditions, technical, human and social training as well.

It is essential to establish the profissional in only one job, with appropriate salary and decent conditions, what certainly will help on improving the quality of services with lower costs.

Simple and autonomous organizations are needed, with statistical informations (costs, production and quality of services), as the main tool of social control, aiming at greater transparency in the services management. The directors should not implore for a simple change of a bored barrel.

The approach model to ensure health should undoubtedly be revised, but enough about pompous and demagogic discourse! It is not acceptable that we have to suffer with the "strokes" (human suffering linked to greater financial expenses) when resources and time to the effective control of blood pressure and its controllable causes were not spent.

It should not be discussed a medicine for poor people, but a streamline of the global focus on health.

The ER stretchers from 1990 to 2009.

My dear professor, the battle is inglorious but we have not lost the hope yet (Until when?), because there are today - 19 years later - Joaninhas who maintain lighted that flame of fraternity, equality and freedom.

The great revolution that SUS intends to do in health is a human resources management, health policy and financing.

There are enemies of this system: those who lost or lose with its true establishment and all those who profit with its inefficiency. However, the Brazilian citizens will be the most jeopardized.

We need, as noted by Professor Jatene 19 years ago, "combine more efforts attempting to solve this problem that has been lasting for decades", stop finding culprits but offer solutions. Because, until when can we rely only on Joaninhas who, with their love and dedication, thank God, save lives?


Alexandre Brick, Brasília/DF







Multidisciplinary approach

Dear Dr. Braile,


We read with great interest the review of "Renault JA et al. Respiratory physiotherapy in the pulmonary dysfunction after cardiac surgery. Rev Bras Cir Cardiovasc.2008:23 (2)". It is an admirable manuscript that aimed at physiotherapy maneuvers on patients undergone heart surgery, which further highlights the importance of multidisciplinary work.

Undoubtedly, such quality articles contribute to the growth of this important mean of intellectual activities transcription, in addition to the international reach.

We congratulate all the editorial board for the initiative and accomplishment of a journal with inter- and transdisciplinary focusing on cardiovascular surgery area.

Regards,


Vitor Engrácia Valenti, Luiz Carlos de Abreu - São Paulo/SP
CCBY All scientific articles published at bjcvs.org are licensed under a Creative Commons license

Indexes

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