Volume 2025
ORIGINAL ARTICLE
Diaphragm Dysfunction After Cardiac Surgery
Braz J Cardiovasc Surg 2025;
e20230239
Publish in: 7/31/2025
Introduction: Diaphragm elevation is commonly seen after cardiac surgery, mostly due to
phrenic nerve injury. However, only historical data is available on the
incidence of diaphragm elevation and its consequences during recovery.
Objective: We aim to provide contemporary insights into the incidence of diaphragm dysfunction in patients undergoing cardiac surgery and its effect on postoperative outcomes.
Methods: Records of all patients undergoing cardiac surgery through sternotomy between 2015 and 2016 at the Radboud University MedicalCentre were retrospectively reviewed. Diaphragm position and elevation were evaluated on available chest radiography. Right-sided diaphragm elevation was defined as the right diaphragm being > 3.0 cm above the left diaphragm; left-sided diaphragm elevation was defined as < 0.5 cm below or above the level of the right diaphragm.
Results: A total of 1510 patients have undergone cardiac surgery through sternotomy during the study period, of which 1316 patients were included in the final analysis. Of these 1316 patients, 13% (n = 179) had pre-existing diaphragm elevation, 27% (n = 351) had a new diaphragm elevation postoperative-y, and 60% (n = 786) had no diaphragm elevation. No statistically significant differences were found between the groups in the occurrence of postoperative (pulmonary) complications or mortality. Of patients who developed new diaphragm elevation postoperatively, 65% recovered in the follow-up period.
Conclusion: New postoperative diaphragm elevation occurs in 27% of patients undergoing cardiac surgery. However, new postoperative diaphragm elevation is not associated with a higher incidence of postoperative complications and spontaneous recovery is seen in most patients.
Keywords: Cardiac surgery. Diaphragm Elevation. Phrenic Nerve Injury
Objective: We aim to provide contemporary insights into the incidence of diaphragm dysfunction in patients undergoing cardiac surgery and its effect on postoperative outcomes.
Methods: Records of all patients undergoing cardiac surgery through sternotomy between 2015 and 2016 at the Radboud University MedicalCentre were retrospectively reviewed. Diaphragm position and elevation were evaluated on available chest radiography. Right-sided diaphragm elevation was defined as the right diaphragm being > 3.0 cm above the left diaphragm; left-sided diaphragm elevation was defined as < 0.5 cm below or above the level of the right diaphragm.
Results: A total of 1510 patients have undergone cardiac surgery through sternotomy during the study period, of which 1316 patients were included in the final analysis. Of these 1316 patients, 13% (n = 179) had pre-existing diaphragm elevation, 27% (n = 351) had a new diaphragm elevation postoperative-y, and 60% (n = 786) had no diaphragm elevation. No statistically significant differences were found between the groups in the occurrence of postoperative (pulmonary) complications or mortality. Of patients who developed new diaphragm elevation postoperatively, 65% recovered in the follow-up period.
Conclusion: New postoperative diaphragm elevation occurs in 27% of patients undergoing cardiac surgery. However, new postoperative diaphragm elevation is not associated with a higher incidence of postoperative complications and spontaneous recovery is seen in most patients.
Keywords: Cardiac surgery. Diaphragm Elevation. Phrenic Nerve Injury
Prolonged Mechanical Ventilation and Extubation Failure in Children and Adolescents Undergoing Cardiac Surgery
Braz J Cardiovasc Surg 2025;
e20230281
Publish in: 7/31/2025
Introduction: Mechanical ventilation (MV) is one of the factors that may be associated with
postoperative complications of cardiac surgeries. This study aimed to verify
the clinical and biological factors related to prolonged MV and extubation
failure in children and adolescents submitted to cardiac surgeries.
Method: This retrospective cohort included all patients aged between 0 and 15 years at the Unidade de Recuperação Cardio-Torácica Pediátrica who were submitted to the first extubation after cardiac surgery. Those tracheostomized and under MV before the surgery or who suffered accidental extubation were excluded. The following data was collected — age, weight, and sex; body mass index (BMI); heart disease; surgical severity (Risk Adjustment for Congenital Heart Surgery-1); hospitalization period and length of stay at intensive care unit; MV, cardiopulmonary bypass, and anoxia duration; use of continuous sedation (midazolam and/or fentanyl); pulmonary hypertension; nitric oxide use; Down syndrome, extubation site, and failure. The outcomes were prolonged MV and extubation failure.
Results: A total of 233 patients were included — 79 (33.9%) aged below 12 months, 47 (20.2%) had Down syndrome, and 215 (92.3%) presented low BMI. Down syndrome patients and those under continuous sedation in the immediate postoperative period presented a higher risk of prolonged MV (P<0.001). Moreover, patients aged below 12 months (P=0.048) and those under prolonged MV (P=0.006) presented the highest risk of extubation failure.
Conclusion: Patients with continuous sedation or Down syndrome required longer MV. In addition, children younger than 12 months or under prolonged MV presented a high extubation failure rate.
Keywords: Mechanical Ventilation; Pediatric Cardiac Surgery; Extubation; Children
Method: This retrospective cohort included all patients aged between 0 and 15 years at the Unidade de Recuperação Cardio-Torácica Pediátrica who were submitted to the first extubation after cardiac surgery. Those tracheostomized and under MV before the surgery or who suffered accidental extubation were excluded. The following data was collected — age, weight, and sex; body mass index (BMI); heart disease; surgical severity (Risk Adjustment for Congenital Heart Surgery-1); hospitalization period and length of stay at intensive care unit; MV, cardiopulmonary bypass, and anoxia duration; use of continuous sedation (midazolam and/or fentanyl); pulmonary hypertension; nitric oxide use; Down syndrome, extubation site, and failure. The outcomes were prolonged MV and extubation failure.
Results: A total of 233 patients were included — 79 (33.9%) aged below 12 months, 47 (20.2%) had Down syndrome, and 215 (92.3%) presented low BMI. Down syndrome patients and those under continuous sedation in the immediate postoperative period presented a higher risk of prolonged MV (P<0.001). Moreover, patients aged below 12 months (P=0.048) and those under prolonged MV (P=0.006) presented the highest risk of extubation failure.
Conclusion: Patients with continuous sedation or Down syndrome required longer MV. In addition, children younger than 12 months or under prolonged MV presented a high extubation failure rate.
Keywords: Mechanical Ventilation; Pediatric Cardiac Surgery; Extubation; Children
One-stage Surgery for Intracardiac Leiomyomatosis
Braz J Cardiovasc Surg 2025;
e20230291
Publish in: 7/31/2025
Introduction: Intracardiac leiomyomatosis is a rare, histologically benign, but biologically aggressive tumor developed from uterus. This study aimed to summarize our experience with one-stage surgery for intracardiac leiomyomatosis.
Methods: We retrospectively reviewed seven patients who underwent surgical treatment for intracardiac leiomyomatosis between May 2016 and November 2021.
Results: All seven patients were female, aged 35 to 57 years. All lesions in the veins and cardiac chambers were removed entirely. Four of the seven patients received tumor thrombectomy through an abdominal approach. The other three patients received median sternotomy and cardiopulmonary bypass. No perioperative deaths or serious complications occurred during the observation period. The mean operation time in the abdominal approach group was shorter than that in the cardiopulmonary bypass group (308.9 ± 93.2 minutes vs. 486.3 ± 108.6 minutes; P=0.031). Blood loss during surgery in the abdominal approach group was less than that in the cardiopulmonary bypass group (1625 ± 216 mL vs. 2500 ± 1080 mL; P=0.148). All seven patients were free from tumor recurrence or death during the follow-up.
Conclusion: For patients with intracardiac intravenous leiomyomatosis single-stage operation through an abdominal approach under the surveillance of intraoperative transesophageal echocardiography without the need for cardiopulmonary bypass for specified patients is feasible. Patients in the abdominal approach group can benefit from a shorter operation time and less blood loss. In our small series of varied presentations and tumor extent, we have been able to avoid two-stage surgery, because even short-term interval between the two operations may result in recurrence.
Keywords: Cardiopulmonary bypass; Chambers; Transesophageal Echocardiography; Leiomyomatosis; Sternotomy; Surveillance in Disasters; Thrombectomy;
Methods: We retrospectively reviewed seven patients who underwent surgical treatment for intracardiac leiomyomatosis between May 2016 and November 2021.
Results: All seven patients were female, aged 35 to 57 years. All lesions in the veins and cardiac chambers were removed entirely. Four of the seven patients received tumor thrombectomy through an abdominal approach. The other three patients received median sternotomy and cardiopulmonary bypass. No perioperative deaths or serious complications occurred during the observation period. The mean operation time in the abdominal approach group was shorter than that in the cardiopulmonary bypass group (308.9 ± 93.2 minutes vs. 486.3 ± 108.6 minutes; P=0.031). Blood loss during surgery in the abdominal approach group was less than that in the cardiopulmonary bypass group (1625 ± 216 mL vs. 2500 ± 1080 mL; P=0.148). All seven patients were free from tumor recurrence or death during the follow-up.
Conclusion: For patients with intracardiac intravenous leiomyomatosis single-stage operation through an abdominal approach under the surveillance of intraoperative transesophageal echocardiography without the need for cardiopulmonary bypass for specified patients is feasible. Patients in the abdominal approach group can benefit from a shorter operation time and less blood loss. In our small series of varied presentations and tumor extent, we have been able to avoid two-stage surgery, because even short-term interval between the two operations may result in recurrence.
Keywords: Cardiopulmonary bypass; Chambers; Transesophageal Echocardiography; Leiomyomatosis; Sternotomy; Surveillance in Disasters; Thrombectomy;
Evaluation of Transcutaneous Non-Invasive Blood Gas Analysis for Monitoring Gas Exchange in Pediatric Cardiac Surgical Patients Post Extubation
Braz J Cardiovasc Surg 2025;
e20240010
Publish in: 7/31/2025
Introduction: Pediatric cardiac surgery patients need close post-extubation monitoring for
ventilation. Non-invasive transcutaneous partial pressure of oxygen
(TcPO2) and transcutaneous partial pressure of carbon dioxide
(TcPCO2) offer continuous insights and in improving care.
Objective: To investigate the correlation of transcutaneous blood gases (TcPO2, TcPCO2) with arterial blood gases i.e. arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2).
Methods: We conducted a study on 30 pediatric post-cardiac surgery patients (four months to three years old) who were extubated and exhibited stable hemodynamics (inotropic score ≤ 5), normal sinus rhythm, and no respiratory or heart failure signs. Continuous transcutaneous and intermittent arterial blood gas monitoring started one hour after extubation, with recordings every 30 minutes for four hours. A single observer conducted probe calibration and data recording to minimize variability, while analysis of 240 paired samples included correlation coefficient, linear regression, Bland-Altman analysis, and Mountain plot.
Results: The r-value between PaCO2 and TcPCO2 was 0.95, r2-value of 0.9060 (P<0.001). Bland-Altman showed a bias of 2.579, and 95% limits of agreement were -6.4 to 1.3. The r-value between PaO2 and TcPO2 was 0.8942, r2-value of 0.7996 (P<0.001); bias of 20.171 and 95% limit of agreement of -0.5 to 40.9. The Mountain plot revealed a median of 2.57 for PaCO2vs. TcPCO2 and 20.17 for PaO2vs. TcPO2.
Conclusion: Transcutaneous carbon dioxide values are interchangeable with arterial PaCO2 in our population study, acting as a surrogate in postoperative pediatric cardiac surgery. Confirmation with arterial blood gases is needed if discrepancies occur.
Keywords: Child, Transcutaneous Blood Gas Monitoring; Carbon dioxide; Oxygen; Calibration; Heart failure; Cardiac surgical procedures; Hemodynamics
Objective: To investigate the correlation of transcutaneous blood gases (TcPO2, TcPCO2) with arterial blood gases i.e. arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2).
Methods: We conducted a study on 30 pediatric post-cardiac surgery patients (four months to three years old) who were extubated and exhibited stable hemodynamics (inotropic score ≤ 5), normal sinus rhythm, and no respiratory or heart failure signs. Continuous transcutaneous and intermittent arterial blood gas monitoring started one hour after extubation, with recordings every 30 minutes for four hours. A single observer conducted probe calibration and data recording to minimize variability, while analysis of 240 paired samples included correlation coefficient, linear regression, Bland-Altman analysis, and Mountain plot.
Results: The r-value between PaCO2 and TcPCO2 was 0.95, r2-value of 0.9060 (P<0.001). Bland-Altman showed a bias of 2.579, and 95% limits of agreement were -6.4 to 1.3. The r-value between PaO2 and TcPO2 was 0.8942, r2-value of 0.7996 (P<0.001); bias of 20.171 and 95% limit of agreement of -0.5 to 40.9. The Mountain plot revealed a median of 2.57 for PaCO2vs. TcPCO2 and 20.17 for PaO2vs. TcPO2.
Conclusion: Transcutaneous carbon dioxide values are interchangeable with arterial PaCO2 in our population study, acting as a surrogate in postoperative pediatric cardiac surgery. Confirmation with arterial blood gases is needed if discrepancies occur.
Keywords: Child, Transcutaneous Blood Gas Monitoring; Carbon dioxide; Oxygen; Calibration; Heart failure; Cardiac surgical procedures; Hemodynamics
Comparison of the Effects of Blood Cardioplegia and Del Nido Cardioplegia on Postoperative Intensive Care Needs, Drainage, and Renal Functions in Patients Undergoing Isolated Coronary Artery Bypass
Braz J Cardiovasc Surg 2025;
e20240237
Publish in: 7/31/2025
Objective: A variety of cardioplegia techniques with different components are
implemented to ensure myocardial protection, in addition to keeping the
operationa field immobile and free of blood during cardiac surgery. The
implemented cardioplegia has unwanted negative effects on other end organs.
In this study, our aim was to compare the effects of Del Nido cardioplegia
and blood cardioplegia solutions on postoperative intensive care duration,
drainage, and renal functions for patients undergoing cardiopulmonary bypass
and bypass graft operations.
Methods: Selections were made from patients undergoing elective bypass graft operations in our clinic from January 1, 2022 to December 31, 2023. Patients were randomly selected, retrospectively assessed, and divided into two groups — De Nido group (Group 1) and blood cardioplegia group (Group 2). Comparisons were made between these groups in terms of intensive care duration, drainage, and renal functions.
Results: The study included 120 patients. The Del Nido cardioplegia group included 60 patients, with 60 patients in the blood cardioplegia group. Comparisons between the groups found that the aortic cross-clamping duration was significantly high in Group 1 (P = 0.014). The noradrenaline dose given to Group 1 was high (P = 0.004). In terms of renal injury, significant degree of elevation was present in Group 1 (P = 0.027). The longer aortic cross-clamping duration in Group 1 may be assessed as a determinant factor for noradrenaline dose and acute kidney injury.
Conclusion: This study concluded that it willbe appropriate to choose the cardioplegia method by performing broader meta-analysis studies and minimizing limiting factors.
Keywords: Surgery. Cardiopulmonary bypass. Acute kidney injury. Induced Heart Arrest. Constriction. Drainage
Methods: Selections were made from patients undergoing elective bypass graft operations in our clinic from January 1, 2022 to December 31, 2023. Patients were randomly selected, retrospectively assessed, and divided into two groups — De Nido group (Group 1) and blood cardioplegia group (Group 2). Comparisons were made between these groups in terms of intensive care duration, drainage, and renal functions.
Results: The study included 120 patients. The Del Nido cardioplegia group included 60 patients, with 60 patients in the blood cardioplegia group. Comparisons between the groups found that the aortic cross-clamping duration was significantly high in Group 1 (P = 0.014). The noradrenaline dose given to Group 1 was high (P = 0.004). In terms of renal injury, significant degree of elevation was present in Group 1 (P = 0.027). The longer aortic cross-clamping duration in Group 1 may be assessed as a determinant factor for noradrenaline dose and acute kidney injury.
Conclusion: This study concluded that it willbe appropriate to choose the cardioplegia method by performing broader meta-analysis studies and minimizing limiting factors.
Keywords: Surgery. Cardiopulmonary bypass. Acute kidney injury. Induced Heart Arrest. Constriction. Drainage
Study Design Update of the Off-pump versus On-pump Coronary Artery Bypass Grafting in Frail Patients: FRAGILE Trial
Braz J Cardiovasc Surg 2025;
e20250199
Publish in: 7/31/2025
The Off-pump versus On-pump Coronary Artery Bypass Grafting in Frail Patients (FRAGILE Trial) is a multicenter, randomized controlled trial comparing off-pump and on-pump coronary artery bypass grafting in frail or pre-frail patients undergoing coronary artery bypass grafting. This manuscript presents an update to the FRAGILE Trial study design, detailing protocol modifications made in response to the time gap between the study’s conception and its actual implementation. These changes were implemented early in the trial and were formally approved by the Ethics Committee, ensuring the scientific and ethical integrity of the study and reinforcing its relevance to address a gap in a vulnerable patient population.
Keywords: Coronary Artery Bypass Grafts; CABG; Frailty Syndrome; Outcomes; Coronary Artery DiseaseBiopsychosocial Prognosis Scale for Coronary Artery Bypass Grafting – Brazilian Version: Adaptation and Content Validity
Braz J Cardiovasc Surg 2025;
e20230371
Publish in: 7/31/2025
Introduction: The Biopsychosocial Prognosis Scale for Coronary Artery Bypass Grafting (BIPROSCAB) assesses biophysical symptoms and psychosocial experiences following coronary artery bypass grafting (CABG), thereby enabling the targeting of interventions to improve post-procedure biopsychosocial prognosis. The aim of this study was to adapt the BIPROSCAB for use in Brazil and assess the content validity of the adapted version.
Methods: For the cross-cultural adaptation, English-Portuguese translations, synthesis of translations, back-translations, assessment of back-translations for conceptual consistency by the authors of the original instrument, and evaluation of semantic, idiomatic, cultural, and conceptual equivalences by 11 expert judges were performed. Modifications were made based on suggestions until consensus > 80% was achieved. For the content validity assessment, experts assessed the clarity, theoretical relevance, and practical pertinence of the items, which were considered adequate when the content validity ratio (CVR) > 0.635. Post-CABG patients completed the questionnaire and evaluated understandability of the items.
Results: Three rounds were required to achieve the desired agreement in the cross-cultural adaptation process. In the content evaluation by experts, only one round was needed, with CVR > 0.635. Following content evaluation by patients, it was decided to reverse the order of the response scale to an ascending order.
Conclusion: The Brazilian version, BIPROSCAB-Br, is equivalent to the original instrument and has satisfactory evidence of content validity. Additional psychometric assessments are needed for use in Brazil.
Keywords: Cross-Cultural Comparasion; Prognosis; Psychometry; Coronary artery bypass; Consensus
Methods: For the cross-cultural adaptation, English-Portuguese translations, synthesis of translations, back-translations, assessment of back-translations for conceptual consistency by the authors of the original instrument, and evaluation of semantic, idiomatic, cultural, and conceptual equivalences by 11 expert judges were performed. Modifications were made based on suggestions until consensus > 80% was achieved. For the content validity assessment, experts assessed the clarity, theoretical relevance, and practical pertinence of the items, which were considered adequate when the content validity ratio (CVR) > 0.635. Post-CABG patients completed the questionnaire and evaluated understandability of the items.
Results: Three rounds were required to achieve the desired agreement in the cross-cultural adaptation process. In the content evaluation by experts, only one round was needed, with CVR > 0.635. Following content evaluation by patients, it was decided to reverse the order of the response scale to an ascending order.
Conclusion: The Brazilian version, BIPROSCAB-Br, is equivalent to the original instrument and has satisfactory evidence of content validity. Additional psychometric assessments are needed for use in Brazil.
Keywords: Cross-Cultural Comparasion; Prognosis; Psychometry; Coronary artery bypass; Consensus
Ex vivo Coronary Angiography: Safety of Iopromide in Cold Preservation of Pig Hearts
Braz J Cardiovasc Surg 2025;
e20240080
Publish in: 7/31/2025
Objective: To evaluate the effects of intracoronary iopromide (Ultravist®, Germany) administration on the recovery of cardiac pump function and cardiomyocytes metabolism during ex vivo cold preservation of pig hearts in the early posttransplant period.
Methods: Three-month-old mini pigs weighing 73 ± 2.8 kg were used as experimental models (n=12). Physiological parameters were obtained with the IntelliVue MP70 system (Philips, Netherlands). Blood samples were taken from the coronary sinus to evaluate myocardial ischemia markers - troponin I, creatine phosphokinase-MB, lactate dehydrogenase, and lactate - and apex biopsy was performed before and after the ischemia period according to the protocol. Myocardial samples were taken from the left ventricle and prepared according to the protocol either.
Results: Twelve orthotopic heart transplantations were performed during the study. Sample size was divided into two groups with six each. Cardiac output was 5.11 (4.99; 5.41) l/min and 5.77 (4.97; 6.62) l/min (P-0.0009) after 120 minutes of cardiac activity in both groups. Change of lactate dehydrogenase, creatine phosphokinase-MB, and troponin I levels in the coronary sinus blood were significantly higher in the early reperfusion period. However, there were no statistically significant differences between the groups (P>0.05). Myocardial oxygen consumption was considerably reduced during reperfusion but returned to baseline by 60 minutes of postischemia without significant differences between groups (P>0.05).
Conclusion: We observed that intracoronary iopromide administration was safe during the ex vivo stage cold preservation phase of the study. Intracoronary iopromide administration did not affect cardiac pump function and cardiomyocytes metabolism in the early posttransplant period.
Keywords: Cardiac output; Cold Temperature; Coronary sinus; Creatine Kinase; Myocardial ischemia; Myocytes; Cardiac; Ischemia; L-Lactate Dehydrogenase; Lactic acid; Swine; Troponin I;
Methods: Three-month-old mini pigs weighing 73 ± 2.8 kg were used as experimental models (n=12). Physiological parameters were obtained with the IntelliVue MP70 system (Philips, Netherlands). Blood samples were taken from the coronary sinus to evaluate myocardial ischemia markers - troponin I, creatine phosphokinase-MB, lactate dehydrogenase, and lactate - and apex biopsy was performed before and after the ischemia period according to the protocol. Myocardial samples were taken from the left ventricle and prepared according to the protocol either.
Results: Twelve orthotopic heart transplantations were performed during the study. Sample size was divided into two groups with six each. Cardiac output was 5.11 (4.99; 5.41) l/min and 5.77 (4.97; 6.62) l/min (P-0.0009) after 120 minutes of cardiac activity in both groups. Change of lactate dehydrogenase, creatine phosphokinase-MB, and troponin I levels in the coronary sinus blood were significantly higher in the early reperfusion period. However, there were no statistically significant differences between the groups (P>0.05). Myocardial oxygen consumption was considerably reduced during reperfusion but returned to baseline by 60 minutes of postischemia without significant differences between groups (P>0.05).
Conclusion: We observed that intracoronary iopromide administration was safe during the ex vivo stage cold preservation phase of the study. Intracoronary iopromide administration did not affect cardiac pump function and cardiomyocytes metabolism in the early posttransplant period.
Keywords: Cardiac output; Cold Temperature; Coronary sinus; Creatine Kinase; Myocardial ischemia; Myocytes; Cardiac; Ischemia; L-Lactate Dehydrogenase; Lactic acid; Swine; Troponin I;
The Impact of International Missions in Provision of Cardiac Services and Skill Transfer in Respect to Coronary Artery Bypass Grafting at Jakaya Kikwete Cardiac Institute - Tanzania
Braz J Cardiovasc Surg 2025;
e20240075
Publish in: 7/31/2025
Objective: To assess how efficient the local team attained skills are after several
visits made by international missions in respect to number of coronary
artery bypass grafting surgery performed and the overall patient
outcome.
Methods: This was a retrospective study that included all patients who were operated on at the center after being diagnosed with chronic coronary artery disease from May 2016 to December 2023. Patients’ demographic data were retrieved from patients’ files coupled with theatre record file, entered into a structured questionnaire, and then, in a statistical program.
Results: A total of 290 patients underwent coronary artery bypass grafting at the center. The international missions performed a total of 159 (54.8%) operations, while the local team operated a total of 131 (45.2%) patients. The study showed significant statistical difference in terms of total operation time (95% confidence interval [CI] = 5.67, 6.01 vs. 95% CI = 6.32, 6.66), aortic cross-clamping time (95% CI = 75.92, 90.00 vs. 95% CI = 111.19, 126.65), and total cardiopulmonary bypass time (95% CI = 115.9, 134.75 vs. 95% CI = 174.52, 201.27) between the international missions and local surgical team, respectively. The mortality rate was higher in patients operated on by the local team (13.7%) than by international missions (8.8%), however there was no statistical difference.
Conclusion: This study has shown the beneficial advantage of international surgical missions to newly established open-heart centers with advanced facilities and skill-deprived team. International surgical missions have greatly contributed to the progression of the center as they oversee and support the programs.
Keywords: Coronary Artery Disease; Cardiopulmonary bypass; Constriction; Medical Missions; Demography
Methods: This was a retrospective study that included all patients who were operated on at the center after being diagnosed with chronic coronary artery disease from May 2016 to December 2023. Patients’ demographic data were retrieved from patients’ files coupled with theatre record file, entered into a structured questionnaire, and then, in a statistical program.
Results: A total of 290 patients underwent coronary artery bypass grafting at the center. The international missions performed a total of 159 (54.8%) operations, while the local team operated a total of 131 (45.2%) patients. The study showed significant statistical difference in terms of total operation time (95% confidence interval [CI] = 5.67, 6.01 vs. 95% CI = 6.32, 6.66), aortic cross-clamping time (95% CI = 75.92, 90.00 vs. 95% CI = 111.19, 126.65), and total cardiopulmonary bypass time (95% CI = 115.9, 134.75 vs. 95% CI = 174.52, 201.27) between the international missions and local surgical team, respectively. The mortality rate was higher in patients operated on by the local team (13.7%) than by international missions (8.8%), however there was no statistical difference.
Conclusion: This study has shown the beneficial advantage of international surgical missions to newly established open-heart centers with advanced facilities and skill-deprived team. International surgical missions have greatly contributed to the progression of the center as they oversee and support the programs.
Keywords: Coronary Artery Disease; Cardiopulmonary bypass; Constriction; Medical Missions; Demography
Effect of Systemic Immune-Inflammation Index on Prognosis in Non-Functional Mitral Regurgitation Patients Undergoing Isolated Mitral Valve Replacement
Braz J Cardiovasc Surg 2025;
e20230362
Publish in: 7/31/2025
Objective: To investigate the effect of preoperative and postoperative systemic
immune-inflammation index (SII) values on early prognosis in patients with
nonfunctional mitral regurgitation etiology undergoing isolated mitral valve
replacement (MVR).
Methods: A total of 176 patients with isolated MVR performed from 2015 to 2021 were retrospectively investigated. The platelet, lymphocyte, and neutrophil counts were measured, and SII, neutrophil/lymphocyte ratio (NLR), and platelet/lymphocyte ratio (PLR) values were calculated preoperatively and on the first and fourth days postoperatively. The correlations with postoperative 30-day early-term prognosis and mortality were investigated.
Results: Mean age of the patients was 55.4 years, 69.9% were female, and 30.1% were male. At 30-day follow-up, 9% (n = 16) of patients died. There were significant positive correlations observed between age (P < 0.001), preoperative NLR (P = 0.003), preoperative SII (P = 0.02), and postoperative fourth day NLR (P < 0.001) values with 30-day mortality. Receiver operating characteristic analysis identified that age + preoperative SII (P < 0.001), age + preoperative NLR (P < 0.001), and age + postoperative fourth day NLR (P = 0.001) combinations were significant predictive factors for 30-day mortality. There was a significant positive correlation between postoperative fourth day SII value with intensive care unit (ICU) admission duration (P < 0.001, Ρ = 0.308).
Conclusion: For non-functional, isolated MVR patients, preoperative and postoperative fourth day SII and NLR values were found to provide an idea about 30-day prognosis. Additionally, patients with high postoperative fourth day SII values were observed to have longer ICU stays.
Keywords: Lymphocytes. Blood platelets. Neutrophils. Mitral valve insufficiency. Mortality. Prognosis.
Methods: A total of 176 patients with isolated MVR performed from 2015 to 2021 were retrospectively investigated. The platelet, lymphocyte, and neutrophil counts were measured, and SII, neutrophil/lymphocyte ratio (NLR), and platelet/lymphocyte ratio (PLR) values were calculated preoperatively and on the first and fourth days postoperatively. The correlations with postoperative 30-day early-term prognosis and mortality were investigated.
Results: Mean age of the patients was 55.4 years, 69.9% were female, and 30.1% were male. At 30-day follow-up, 9% (n = 16) of patients died. There were significant positive correlations observed between age (P < 0.001), preoperative NLR (P = 0.003), preoperative SII (P = 0.02), and postoperative fourth day NLR (P < 0.001) values with 30-day mortality. Receiver operating characteristic analysis identified that age + preoperative SII (P < 0.001), age + preoperative NLR (P < 0.001), and age + postoperative fourth day NLR (P = 0.001) combinations were significant predictive factors for 30-day mortality. There was a significant positive correlation between postoperative fourth day SII value with intensive care unit (ICU) admission duration (P < 0.001, Ρ = 0.308).
Conclusion: For non-functional, isolated MVR patients, preoperative and postoperative fourth day SII and NLR values were found to provide an idea about 30-day prognosis. Additionally, patients with high postoperative fourth day SII values were observed to have longer ICU stays.
Keywords: Lymphocytes. Blood platelets. Neutrophils. Mitral valve insufficiency. Mortality. Prognosis.
Papillary Fibroelastomas: 16-Year Single-Center Experience
Braz J Cardiovasc Surg 2025;
e20230431
Publish in: 7/31/2025
Introduction: Papillary fibroelastoma is a rare primary benign cardiac tumor. The majority
of patients are asymptomatic. Complications may result in embolic events,
syncope, ventricular arrhythmias, and sudden death. In this study, we report
on a series of papillary fibroelastomas documented in our institution.
Methods: Medical history records from period between 2007 and 2022 were reviewed for all the patients diagnosed with cardiac papillary fibroelastomas treated surgically and confirmed histologically. Clinical, tumor, and demographic characteristics, echocardiography findings, and treatment modalities were analyzed.
Results: In a sixteen-year period, 12 cases of papillary fibroelastomas were documented. The percentage of female patients was 83.3%. The average age was 59.0 ± 11.2 years. Average diameter of tumor was 1.2 cm. The aortic valve was the most common origin site, with six cases (50%). In two cases (17%), the mitral valve was involved. There were single cases of tumor (8% each) found on the tricuspid valve, in the left atrium, in the left ventricle, and in the right ventricle. All patients were treated successfully by complete resection.
Conclusion: PFEs are generally small and single tumors. Complete surgical resection of the tumor has a good prognosis and is a safe, efficient, and definitive treatment.
Keywords: Heart Ventricules; Cardiac Papillary Fibroelastoma; Aortic valve; Tricuspid Valve; Mitral Valve; Sudden Death; Echocardiography
Methods: Medical history records from period between 2007 and 2022 were reviewed for all the patients diagnosed with cardiac papillary fibroelastomas treated surgically and confirmed histologically. Clinical, tumor, and demographic characteristics, echocardiography findings, and treatment modalities were analyzed.
Results: In a sixteen-year period, 12 cases of papillary fibroelastomas were documented. The percentage of female patients was 83.3%. The average age was 59.0 ± 11.2 years. Average diameter of tumor was 1.2 cm. The aortic valve was the most common origin site, with six cases (50%). In two cases (17%), the mitral valve was involved. There were single cases of tumor (8% each) found on the tricuspid valve, in the left atrium, in the left ventricle, and in the right ventricle. All patients were treated successfully by complete resection.
Conclusion: PFEs are generally small and single tumors. Complete surgical resection of the tumor has a good prognosis and is a safe, efficient, and definitive treatment.
Keywords: Heart Ventricules; Cardiac Papillary Fibroelastoma; Aortic valve; Tricuspid Valve; Mitral Valve; Sudden Death; Echocardiography
Frailty Assessment to Improve Risk Stratification in Elderly Patients Undergoing Elective Cardiac Surgery
Braz J Cardiovasc Surg 2025;
e20230182
Publish in: 7/31/2025
Introduction: Frailty is a biological syndrome of the elderly characterized by decreased
physiological reserve and weakened response to stressors. Most cardiac
surgical risk models incorporate chronologic age as a risk parameter, but
not frailty. We aimed to identify the frailty assessment tool with the
highest prognostic value to predict postoperative adverse outcomes in
elderly patients undergoing cardiac surgery and to investigate whether
addition of a frailty parameter to cardiac surgical risk models would
increase predictive power.
Methods: This is a single-center, prospective, observational study. Consecutive adults, undergoing elective cardiac surgery between January and May 2020, were included. The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) and Society of Thoracic Surgeons risk scores were calculated. Fried Scale, Short Physical Performance Battery, Clinical Frailty Scale, and serum albumin were used for frailty assessment. Patients were followed-up for 30 days postoperatively or until discharge. Primary endpoint was a composite of mortality and major morbidity.
Results: One hundred sixty-four patients were included (34.76% women, median age 70 years [interquartile range, 67-74]. EuroSCORE II and albumin were the only tools significantly associated with the primary endpoint (P=0.045 and P=0.031, respectively). Model created by combination of EuroSCORE II and albumin was not associated with the primary outcome (P=0.571), however EuroSCORE II’s R-squared value increased from 0.07 to 0.144 after addition of albumin.
Conclusion: Addition of albumin measurement as a frailty marker to EuroSCORE II has the potential to improve EuroSCORE II’s ability to predict early postoperative mortality/morbidity in elderly patients undergoing cardiac surgery.
Keywords: Aged; Prognosis; Frailty; Serum Albumin; Patient Discharge, Cardiac Surgical Procedures; Risk Factors; Morbidity
Methods: This is a single-center, prospective, observational study. Consecutive adults, undergoing elective cardiac surgery between January and May 2020, were included. The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) and Society of Thoracic Surgeons risk scores were calculated. Fried Scale, Short Physical Performance Battery, Clinical Frailty Scale, and serum albumin were used for frailty assessment. Patients were followed-up for 30 days postoperatively or until discharge. Primary endpoint was a composite of mortality and major morbidity.
Results: One hundred sixty-four patients were included (34.76% women, median age 70 years [interquartile range, 67-74]. EuroSCORE II and albumin were the only tools significantly associated with the primary endpoint (P=0.045 and P=0.031, respectively). Model created by combination of EuroSCORE II and albumin was not associated with the primary outcome (P=0.571), however EuroSCORE II’s R-squared value increased from 0.07 to 0.144 after addition of albumin.
Conclusion: Addition of albumin measurement as a frailty marker to EuroSCORE II has the potential to improve EuroSCORE II’s ability to predict early postoperative mortality/morbidity in elderly patients undergoing cardiac surgery.
Keywords: Aged; Prognosis; Frailty; Serum Albumin; Patient Discharge, Cardiac Surgical Procedures; Risk Factors; Morbidity
Fate of Residual Aorta After Surgery for Type A Aortic Dissection
Braz J Cardiovasc Surg 2025;
e20240243
Publish in: 7/31/2025
Introduction: Surgical treatment of type A aortic dissection is essentially palliative.
Many patients who undergo the procedure still have a dissection flap in the
residual aorta, with a persistent patent or partially thrombosed false lumen
leaving them susceptible to the dilatation of distal aorta and aneurysm
formation.
Methods: Patients who had undergone surgery for type A aortic dissection from January 2015 till December 2022 were recruited into the study. Two follow-up computed tomography scans were performed at least six months apart, the first one at least one month after the surgery.
Results: A persistent dissection flap was found in 34 (68%) patients. All segments of residual distal aorta showed dilatation with time. Growth rate was maximum for abdominal aorta - 3.1 (1.6 - 5.4) mm/year. Patency of false lumen was the only significant factor associated with growth of lower descending thoracic aorta and abdominal aorta (P<0.05). Maximum growth was seen in the patients with partial thrombosis of the false lumen, followed by those with patent false lumen. Two patients with partially thrombosed false lumens required reintervention in the form of endovascular stenting.
Conclusion: Patients after surgery for type A aortic dissection with partially thrombosed false lumens are more prone to aortic dilatation. Regular follow-up of these patients with computed tomography aortogram can lead to timely detection of these sequalae and intervention as needed.
Keywords: Abdominal aorta; Thoracic Aorta; Aortic Dissection; Aneurysm; Pathologic Dilatation; Thrombosis; Tomography
Methods: Patients who had undergone surgery for type A aortic dissection from January 2015 till December 2022 were recruited into the study. Two follow-up computed tomography scans were performed at least six months apart, the first one at least one month after the surgery.
Results: A persistent dissection flap was found in 34 (68%) patients. All segments of residual distal aorta showed dilatation with time. Growth rate was maximum for abdominal aorta - 3.1 (1.6 - 5.4) mm/year. Patency of false lumen was the only significant factor associated with growth of lower descending thoracic aorta and abdominal aorta (P<0.05). Maximum growth was seen in the patients with partial thrombosis of the false lumen, followed by those with patent false lumen. Two patients with partially thrombosed false lumens required reintervention in the form of endovascular stenting.
Conclusion: Patients after surgery for type A aortic dissection with partially thrombosed false lumens are more prone to aortic dilatation. Regular follow-up of these patients with computed tomography aortogram can lead to timely detection of these sequalae and intervention as needed.
Keywords: Abdominal aorta; Thoracic Aorta; Aortic Dissection; Aneurysm; Pathologic Dilatation; Thrombosis; Tomography
Surgical Treatment of Pulmonary Artery Angiosarcoma - A Ten-Year Experience
Braz J Cardiovasc Surg 2025;
e20230441
Publish in: 7/31/2025
Introduction: Pulmonary artery angiosarcoma is a rare and extremely severe tumor. Our study summarizes the clinical data of patients treated for pulmonary artery angiosarcoma over the period of 2010-2020.
Methods: We retrospectively analyzed cases of surgical treatment of patients with diagnosis of pulmonary artery angiosarcoma at our center. Data of operative findings, short-term follow-up, and the long-term results were reviewed where available.
Results: The 30-day mortality rate was six (67%) out of nine patients. Three (33%) patients were discharged. Data on pulmonary vascular resistance in the earlyand long-term postoperative periods were assessed if possible. Certain computed tomography signs have been identified that can be used to suspect pulmonary artery angiosarcoma and make a differential diagnosis with chronic thromboembolic pulmonary hypertension.
Conclusion: The surgical treatment of choice is pneumonectomy with contralateral pulmonary endarterectomy. Oncological vigilance regarding angiosarcoma in occlusive-stenotic lesions of the pulmonary artery is extremely important. Patients’ assessment must be carried out in an expert cardiothoracic surgery center with the involvement of an oncological crew.
Keywords: Pulmonary artery. Pulmonary hypertension. Endarterectomy. Pneumonectomy. Vascular Resistence.
Methods: We retrospectively analyzed cases of surgical treatment of patients with diagnosis of pulmonary artery angiosarcoma at our center. Data of operative findings, short-term follow-up, and the long-term results were reviewed where available.
Results: The 30-day mortality rate was six (67%) out of nine patients. Three (33%) patients were discharged. Data on pulmonary vascular resistance in the earlyand long-term postoperative periods were assessed if possible. Certain computed tomography signs have been identified that can be used to suspect pulmonary artery angiosarcoma and make a differential diagnosis with chronic thromboembolic pulmonary hypertension.
Conclusion: The surgical treatment of choice is pneumonectomy with contralateral pulmonary endarterectomy. Oncological vigilance regarding angiosarcoma in occlusive-stenotic lesions of the pulmonary artery is extremely important. Patients’ assessment must be carried out in an expert cardiothoracic surgery center with the involvement of an oncological crew.
Keywords: Pulmonary artery. Pulmonary hypertension. Endarterectomy. Pneumonectomy. Vascular Resistence.
The Role of Preoperative Chronic Hypertension in Neurocognitive Decline after Cardiac Surgery: A Retrospective Cohort Study
Braz J Cardiovasc Surg 2025;
e20230470
Publish in: 7/31/2025
Introduction: Patients frequently experience transient postoperative neurocognitive decline
(NCD) after cardiac surgery with cardiopulmonary bypass. The goal of this
study is to describe preoperative high blood pressure as a risk factor for
NCD and use genomic expression to uncover its contribution to the
pathophysiology of NCD.
Methods: This is a retrospective analysis of cohort study at a single academic center. Patients undergoing cardiac surgery with the use of cardiopulmonary bypass were administered the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) preoperatively, at postoperative day four, and four weeks postoperatively. Electronic medical records were reviewed for all recorded blood pressure from the year preceding surgery and intraoperative blood pressures. Blood samples were collected six hours preoperatively and six hours postoperatively to assess messenger ribonucleic acid expression.
Results: Eighty-seven patients completed postoperative day four testing, of whom thirty-seven experienced NCD (42.5%). Chronically elevated systolic blood pressure over the year preceding surgery was correlated with greater negative change in RBANS score at postoperative day four (P=0.03). Upon genomic analysis, macrophage markers were upregulated preoperatively, and anti-inflammatory and neuroprotective genes were downregulated postoperatively among patients who had a mean systolic blood pressure ≥ 130 mmHg.
Conclusion: Chronic exposure to elevated preoperative systolic blood pressure may increase the risk of NCD. The contributing role of preoperative hypertension in NCD may be partly explained by reduced attenuation of oxidative stress, increased inflammation, and reduced neuroprotection and heme metabolism postoperatively. This must be considered when assessing patient risks for cardiac surgery.
Keywords: Cardiac surgery; Neurocognitive Decline; Cognitive Dysfunction; Postoperative Cognitive Complications; Neuropsychological Tests
Methods: This is a retrospective analysis of cohort study at a single academic center. Patients undergoing cardiac surgery with the use of cardiopulmonary bypass were administered the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) preoperatively, at postoperative day four, and four weeks postoperatively. Electronic medical records were reviewed for all recorded blood pressure from the year preceding surgery and intraoperative blood pressures. Blood samples were collected six hours preoperatively and six hours postoperatively to assess messenger ribonucleic acid expression.
Results: Eighty-seven patients completed postoperative day four testing, of whom thirty-seven experienced NCD (42.5%). Chronically elevated systolic blood pressure over the year preceding surgery was correlated with greater negative change in RBANS score at postoperative day four (P=0.03). Upon genomic analysis, macrophage markers were upregulated preoperatively, and anti-inflammatory and neuroprotective genes were downregulated postoperatively among patients who had a mean systolic blood pressure ≥ 130 mmHg.
Conclusion: Chronic exposure to elevated preoperative systolic blood pressure may increase the risk of NCD. The contributing role of preoperative hypertension in NCD may be partly explained by reduced attenuation of oxidative stress, increased inflammation, and reduced neuroprotection and heme metabolism postoperatively. This must be considered when assessing patient risks for cardiac surgery.
Keywords: Cardiac surgery; Neurocognitive Decline; Cognitive Dysfunction; Postoperative Cognitive Complications; Neuropsychological Tests
Use of Antegrade Coronary Oxygen Persufflation as a Strategy for Donor Heart Preservation
Braz J Cardiovasc Surg 2025;
e20230469
Publish in: 7/31/2025
Objective: To assess the technical feasibility and functional, metabolic, and structural myocardial
integrity of the donor heart after four hours of direct coronary oxygen persufflation
(COP).
Methods: This research was carried out on three-month-old minipig siblings weighing 23-36 kg. Cardiac arrest was achieved by administrating two liters of Bretschneider’s cardioplegic solution (histidine-tryptophan-ketoglutarate [HTK]) (Custodiol®, Germany) into the aortic root. Orthotopic heart transplantation was performed after three hours of cardiac arrest.
Results: A statistically significant decrease in cardiac output was observed in both groups (from 3.36 ± 0.36 l/min and 3.72 ± 0.52 l/min in the HTK group and modified HTK + COP to 2.35 ± 0.52 l/min and 2.15 ± 0.34 l/min, respectively) (Р<0.05). Differences between both groups were insignificant (P>0.05). Cardiac output was 2.99 ± 0.45 l/min and 2.48 ± 0.58 l/min (Р>0.05) in both groups after 120 min of cardiac recovery. Lactate dehydrogenase, creatine phosphokinase-MB, and troponin I changes in coronary sinus blood were significantly higher in the early reperfusion period. Statistical insignificance was observed between both groups (P>0.05). Myocardial oxygen consumption was 8.2 [7.35; 9.35] ml-О2/min/100 g and 7.7 [6.75; 10.12] ml-О2/min/100g in both groups (P>0.05). Histological examinations demonstrate no significant myocardial ischemic injury in the persufflation group.
Conclusion: The study demonstrated technical feasibility and safety of direct coronary persufflation for four hours during ex vivo donor heart conditioning. However, no significant advantages of direct COP were observed over the standard cold preservation protocol.
Keywords: Oxygen Consumption; Organ preservation; Cardioplegic solutions; Heart transplantation; Feasibility Studies; Siblings; Tissue donors; Heart Arrest; Cardiac output; Reperfusion
Methods: This research was carried out on three-month-old minipig siblings weighing 23-36 kg. Cardiac arrest was achieved by administrating two liters of Bretschneider’s cardioplegic solution (histidine-tryptophan-ketoglutarate [HTK]) (Custodiol®, Germany) into the aortic root. Orthotopic heart transplantation was performed after three hours of cardiac arrest.
Results: A statistically significant decrease in cardiac output was observed in both groups (from 3.36 ± 0.36 l/min and 3.72 ± 0.52 l/min in the HTK group and modified HTK + COP to 2.35 ± 0.52 l/min and 2.15 ± 0.34 l/min, respectively) (Р<0.05). Differences between both groups were insignificant (P>0.05). Cardiac output was 2.99 ± 0.45 l/min and 2.48 ± 0.58 l/min (Р>0.05) in both groups after 120 min of cardiac recovery. Lactate dehydrogenase, creatine phosphokinase-MB, and troponin I changes in coronary sinus blood were significantly higher in the early reperfusion period. Statistical insignificance was observed between both groups (P>0.05). Myocardial oxygen consumption was 8.2 [7.35; 9.35] ml-О2/min/100 g and 7.7 [6.75; 10.12] ml-О2/min/100g in both groups (P>0.05). Histological examinations demonstrate no significant myocardial ischemic injury in the persufflation group.
Conclusion: The study demonstrated technical feasibility and safety of direct coronary persufflation for four hours during ex vivo donor heart conditioning. However, no significant advantages of direct COP were observed over the standard cold preservation protocol.
Keywords: Oxygen Consumption; Organ preservation; Cardioplegic solutions; Heart transplantation; Feasibility Studies; Siblings; Tissue donors; Heart Arrest; Cardiac output; Reperfusion
Evaluation of Systemic Microcirculatory Vessel Density in the Early Postoperative Period of Heart Valve Surgery: an Observational Study
Braz J Cardiovasc Surg 2025;
e20240039
Publish in: 7/31/2025
Introduction: The present study evaluated systemic microcirculatory alterations occurring in the early postoperative period of cardiopulmonary bypass-assisted heart valve surgery compared to preoperative parameters through noninvasive point-of-care microcirculatory imaging of the sublingual area using incident dark field imaging.
Methods: This was a single-center cross-sectional observational study that included 23 patients aged 49 ± 13 years. Sublingual microcirculatory density and perfusion were evaluated using a handheld camera based on incident dark field imaging before surgery and in the early postoperative period.
Results: The total number of capillary vessels (1029 ± 13, P=0.0006), total length of capillary vessels (29.4 ± 3.2 mm, P=0.0005), and capillary vessel density (16.8 ± 1.8 mm/mm2, P=0.0005) were all higher after surgery. On the other hand, the total number of noncapillary vessels (85 ± 34, P=0.05), total length of noncapillary vessels (1.9 ± 0.8 mm, P=0.07), and noncapillary vessel density (1.1 ± 0.5 mm/mm2, P=0.07) were similar before and after surgery. The total number of capillary vessels was higher after surgery (1109 ± 92) in patients who received milrinone infusion (P=0.002) but not in patients who did not receive milrinone (986 ± 129, P=0.05).
Conclusion: After cardiac valve surgery, there was an improvement in microvascular parameters concerning capillary vessels and in the total number of microvessels. Moreover, significant positive correlations were found between the use of milrinone and these parameters. The study demonstrated the usefulness of handheld cameras for bedside evaluation of the microcirculation.
Keywords: Capillares. Milronone. Reference Standards. Microcirculation. Cardiopulmonary bypass. Microvessels. Point-of-Care-Systems.
Methods: This was a single-center cross-sectional observational study that included 23 patients aged 49 ± 13 years. Sublingual microcirculatory density and perfusion were evaluated using a handheld camera based on incident dark field imaging before surgery and in the early postoperative period.
Results: The total number of capillary vessels (1029 ± 13, P=0.0006), total length of capillary vessels (29.4 ± 3.2 mm, P=0.0005), and capillary vessel density (16.8 ± 1.8 mm/mm2, P=0.0005) were all higher after surgery. On the other hand, the total number of noncapillary vessels (85 ± 34, P=0.05), total length of noncapillary vessels (1.9 ± 0.8 mm, P=0.07), and noncapillary vessel density (1.1 ± 0.5 mm/mm2, P=0.07) were similar before and after surgery. The total number of capillary vessels was higher after surgery (1109 ± 92) in patients who received milrinone infusion (P=0.002) but not in patients who did not receive milrinone (986 ± 129, P=0.05).
Conclusion: After cardiac valve surgery, there was an improvement in microvascular parameters concerning capillary vessels and in the total number of microvessels. Moreover, significant positive correlations were found between the use of milrinone and these parameters. The study demonstrated the usefulness of handheld cameras for bedside evaluation of the microcirculation.
Keywords: Capillares. Milronone. Reference Standards. Microcirculation. Cardiopulmonary bypass. Microvessels. Point-of-Care-Systems.
Identification of TGFBR1 Gene Variants in Two Chinese Pedigrees with Loeys-Dietz Syndrome
Braz J Cardiovasc Surg 2025;
e20230495
Publish in: 7/31/2025
Objective: To investigate a precise treatment and related gene variants in some Loeys-Dietz syndrome (LDS) patients with vascular disease.
Methods: Two probands (JX001-II1 and JX002-II1) diagnosed with LDS and their families were recruited. Routine blood test, antiphospholipid antibodies, immune globulins, nuclear antibodies (ANAs) and biochemical tests, and computed tomography angiography (CTA) were performed for probands. Deoxyribonucleic acid was collected from the two families and was sequenced by the next-generation sequencing employing the Ion Torrent platform (Life Technologies); the variants were confirmed by Sanger sequencing.
Results: Two probands’ antiphospholipid antibodies, immune globulins, and ANAs were near normal. CTA showed that both probands had an LDS patient typical arterial change: aortic aneurysm. Genetic testing of the 10 LDS-associated genes in the two probands showed that c.605C>T (JX001-II1) and c.679G>A (JX002-II1) variants were both positioned in exon 1 of TGFBR1 and it results in the substitution of highly conserved 202 alanine (Ala) for valine (Val) ( P. Ala 202Val, JX001-II1) and 227 glutamic acids (Glu) for lysine (Lys) ( P. Glu 227Lys, JX002-II1). However, the parents of both patients did not have similar symptoms and did not carry such gene variants. Proband 1 (JX001-II1) died unexpectedly during the operation preparations, whereas proband 2 (JX002-II1) underwent two operations, and the patient is currently in excellent health.
Conclusion: The two TGFBR1 gene variants may be a primary genetic cause of LDS. The results expand the TGFBR1 variant spectrum. Endovascular surgery can be a feasible option for LDS patients.
Keywords: Loeys-Dietz Syndrome; Transforming Growth Factor-beta Type 1; Lysine; Computed Tomography Angiography; Exons; Genetic Testing; High-Throughput Nucleotide Sequencing; DNA
Methods: Two probands (JX001-II1 and JX002-II1) diagnosed with LDS and their families were recruited. Routine blood test, antiphospholipid antibodies, immune globulins, nuclear antibodies (ANAs) and biochemical tests, and computed tomography angiography (CTA) were performed for probands. Deoxyribonucleic acid was collected from the two families and was sequenced by the next-generation sequencing employing the Ion Torrent platform (Life Technologies); the variants were confirmed by Sanger sequencing.
Results: Two probands’ antiphospholipid antibodies, immune globulins, and ANAs were near normal. CTA showed that both probands had an LDS patient typical arterial change: aortic aneurysm. Genetic testing of the 10 LDS-associated genes in the two probands showed that c.605C>T (JX001-II1) and c.679G>A (JX002-II1) variants were both positioned in exon 1 of TGFBR1 and it results in the substitution of highly conserved 202 alanine (Ala) for valine (Val) ( P. Ala 202Val, JX001-II1) and 227 glutamic acids (Glu) for lysine (Lys) ( P. Glu 227Lys, JX002-II1). However, the parents of both patients did not have similar symptoms and did not carry such gene variants. Proband 1 (JX001-II1) died unexpectedly during the operation preparations, whereas proband 2 (JX002-II1) underwent two operations, and the patient is currently in excellent health.
Conclusion: The two TGFBR1 gene variants may be a primary genetic cause of LDS. The results expand the TGFBR1 variant spectrum. Endovascular surgery can be a feasible option for LDS patients.
Keywords: Loeys-Dietz Syndrome; Transforming Growth Factor-beta Type 1; Lysine; Computed Tomography Angiography; Exons; Genetic Testing; High-Throughput Nucleotide Sequencing; DNA
The Effect of Prognostic Nutritional Index in Predicting Clinical Outcomes in Valve Replacement Patients
Braz J Cardiovasc Surg 2025;
e20230503
Publish in: 7/31/2025
Introduction: Cardiopulmonary bypass is known to be a cause of systemic inflammatory
response. The systemic inflammatory response affects albumin and lymphocyte
levels and is associated with the development of complications. Serum
albumin and lymphocyte concentrations have been used to create
inflammation-based risk scores, which predict prognosis in different patient
groups. One of these risk scores is called the Prognostic Nutritional Index
(PNI). In this study, our objective was to examine how changes in PNI
values, measured at different times before and after surgery, impact
clinical outcomes and hospital mortality.
Methods: One hundred and sixty-four patients were retrospectively scanned and included in the study. Patients were divided into aortic valve replacement (AVR) and mitral valve replacement (MVR) groups. The patient's preoperative and postoperative PNI values were examined. Duration of cross-clamping, cardiopulmonary bypass time, length of hospital and intensive care unit stay, postoperative mortality, atrial fibrillation, and acute kidney injury (AKI) development were evaluated.
Results: Preoperative and second PNI values were lower in the patients that developed AKI and non-survivors. The PNI cutoff value was ≤ 28.01 in non-survivors (P=0.001). In the MVR group, the decrease in PNI value over time was statistically significant (P<0.001). There was a negative correlation between preoperative PNI value and length of stay in intensive care unit, cross-clamping, and cardiopulmonary bypass duration (P<0.05, P<0.01).
Conclusion: A correlation was determined between the PNI value and development of postoperative AKI and mortality. PNI value, an easy method to use, can be used in the follow-up of these patients.
Keywords: Atrial fibrillation; Nutritional Assessment; Hospital mortality; Cardiopulmonary bypass; Aortic valve; Constriction; Inflammation; Intensive care units
Methods: One hundred and sixty-four patients were retrospectively scanned and included in the study. Patients were divided into aortic valve replacement (AVR) and mitral valve replacement (MVR) groups. The patient's preoperative and postoperative PNI values were examined. Duration of cross-clamping, cardiopulmonary bypass time, length of hospital and intensive care unit stay, postoperative mortality, atrial fibrillation, and acute kidney injury (AKI) development were evaluated.
Results: Preoperative and second PNI values were lower in the patients that developed AKI and non-survivors. The PNI cutoff value was ≤ 28.01 in non-survivors (P=0.001). In the MVR group, the decrease in PNI value over time was statistically significant (P<0.001). There was a negative correlation between preoperative PNI value and length of stay in intensive care unit, cross-clamping, and cardiopulmonary bypass duration (P<0.05, P<0.01).
Conclusion: A correlation was determined between the PNI value and development of postoperative AKI and mortality. PNI value, an easy method to use, can be used in the follow-up of these patients.
Keywords: Atrial fibrillation; Nutritional Assessment; Hospital mortality; Cardiopulmonary bypass; Aortic valve; Constriction; Inflammation; Intensive care units
Technical Performance Score: A Robust Predictor of Morbidity Following the Norwood Procedure at a Developing Country Institution
Braz J Cardiovasc Surg 2025;
e20240442
Publish in: 7/31/2025
Introduction: The Norwood operation has transformed the approach to hypoplastic left heart syndrome and its variants. Given the complexity of this procedure, postoperative residual injuries are prevalent.
Objective: To evaluate the impact of significant residual injuries on clinical outcomes and mortality in Norwood procedure patients at a high-volume tertiary center in a developing nation using the technical performance score (TPS).
Methods: This single-center, retrospective study included patients who underwent the Norwood procedure between December 2018 and February 2023. Data on demographics, echocardiograms, complications, intensive care unit stay, and mortality were collected. Logistic regression and linear analyses assessed the impact of TPS on outcomes.
Results: Of 69 patients, nine (13%) were excluded due to incomplete echocardiographic data, leaving 60 (87%) for TPS classification. Among them, 28 (47%) were male. TPS classification was as follows: 40 (66%) in class 1 (excellent), five (8.3%) in class 2 (adequate), and 15 (25%) in class 3 (inadequate), indicating significant residual lesions or need for reintervention. The 30-day mortality rate was 21.6%, increasing to 41.6% before the next stage. In TPS class 3, 30-day mortality was 33% vs. 17% in classes 1 and 2 (P = 0.27). Interstage mortality was 60% in class 3 compared to 35% in other groups (P = 0.13). Major complications were significantly higher in TPS class 3 (93% vs. 55.5%, P = 0.04).
Conclusion: TPS effectively predicts major complications post-Norwood and serves as a valuable tool for improving patient outcomes.
Keywords: Hypoplastic left heart syndrome. Norwood Procedure. Surgery For Congenital Heart Diseases. Reference Standards. Hospital Mortality.
Objective: To evaluate the impact of significant residual injuries on clinical outcomes and mortality in Norwood procedure patients at a high-volume tertiary center in a developing nation using the technical performance score (TPS).
Methods: This single-center, retrospective study included patients who underwent the Norwood procedure between December 2018 and February 2023. Data on demographics, echocardiograms, complications, intensive care unit stay, and mortality were collected. Logistic regression and linear analyses assessed the impact of TPS on outcomes.
Results: Of 69 patients, nine (13%) were excluded due to incomplete echocardiographic data, leaving 60 (87%) for TPS classification. Among them, 28 (47%) were male. TPS classification was as follows: 40 (66%) in class 1 (excellent), five (8.3%) in class 2 (adequate), and 15 (25%) in class 3 (inadequate), indicating significant residual lesions or need for reintervention. The 30-day mortality rate was 21.6%, increasing to 41.6% before the next stage. In TPS class 3, 30-day mortality was 33% vs. 17% in classes 1 and 2 (P = 0.27). Interstage mortality was 60% in class 3 compared to 35% in other groups (P = 0.13). Major complications were significantly higher in TPS class 3 (93% vs. 55.5%, P = 0.04).
Conclusion: TPS effectively predicts major complications post-Norwood and serves as a valuable tool for improving patient outcomes.
Keywords: Hypoplastic left heart syndrome. Norwood Procedure. Surgery For Congenital Heart Diseases. Reference Standards. Hospital Mortality.
The Konno-Rastan Procedure in the Current Era: Still A Feasible Option?
Braz J Cardiovasc Surg 2025;
e20240002
Publish in: 7/31/2025
Introduction: The Konno-Rastan procedure is a commonly used surgical technique to address complicated subaortic stenosis and to enlarge the aorta via an anterior route. The objective of this report is to describe the experience of our unit with this procedure.
Methods: Between 2002 and 2022, we identified pediatric patients who underwent the Konno-Rastan procedure. Relevant information was retrospectively collected.
Results: There were 16 patients who underwent the Konno-Rastan procedure. The median follow-up was nine years (4 - 16 years), and there was no operative mortality. All patients had a straightforward recovery, and five patients required reoperation at follow-up, none of which was related to the left ventricular outflow tract. The median echocardiographic indices at the most recent follow-up were not significantly different from the preoperative values, with a median peak gradient across the left ventricular outflow tract of 25 mmHg. In their most recent follow-up, 81% of the patients were New York Heart Association class 1. No bleeding, thromboembolic, or infective complications were encountered.
Conclusion: We concluded that the Konno-Rastan procedure can be regarded as a definitive alternative to other surgical interventions for left ventricular outflow tract obstructions. Although reoperations are still necessary, particularly in patients with additional mitral valve disease, the Konno-Rastan procedure is still a viable option in patients with complex left ventricular disease.
Keywords: Mitral Valve; Left Ventricular Outflow Obstruction; Pathologic Constriction; Hear Valve Diseases; Subvalvular Aortic Stenosis; Hypertrophic Cardiomyopathy
Methods: Between 2002 and 2022, we identified pediatric patients who underwent the Konno-Rastan procedure. Relevant information was retrospectively collected.
Results: There were 16 patients who underwent the Konno-Rastan procedure. The median follow-up was nine years (4 - 16 years), and there was no operative mortality. All patients had a straightforward recovery, and five patients required reoperation at follow-up, none of which was related to the left ventricular outflow tract. The median echocardiographic indices at the most recent follow-up were not significantly different from the preoperative values, with a median peak gradient across the left ventricular outflow tract of 25 mmHg. In their most recent follow-up, 81% of the patients were New York Heart Association class 1. No bleeding, thromboembolic, or infective complications were encountered.
Conclusion: We concluded that the Konno-Rastan procedure can be regarded as a definitive alternative to other surgical interventions for left ventricular outflow tract obstructions. Although reoperations are still necessary, particularly in patients with additional mitral valve disease, the Konno-Rastan procedure is still a viable option in patients with complex left ventricular disease.
Keywords: Mitral Valve; Left Ventricular Outflow Obstruction; Pathologic Constriction; Hear Valve Diseases; Subvalvular Aortic Stenosis; Hypertrophic Cardiomyopathy
Penetrating Cardiac Injury: A 20-Year Retrospective Analysis at a High-Complexity University Center
Braz J Cardiovasc Surg 2025;
e20240049
Publish in: 7/31/2025
Introduction: Penetrating cardiac injury, though infrequent, is associated with substantial
mortality. In 2005, our research team conducted a comprehensive
retrospective analysis of penetrating cardiac injuries managed at our
facility from 1990 to 2003. Now, two decades later, we conducted the present
study on penetrating cardiac injuries attended in our hospital over the last
20 years.
Methods: This is a retrospective analysis of medical records and trauma database data, with a focus on survivors of penetrating cardiac trauma, excluding those deceased upon arrival.
Results: Out of 1,093 cases, 25 had penetrating cardiac injuries with an overall mortality rate of 36%. Hemorrhage was the leading cause of death, and survival was correlated with higher systolic blood pressure upon admission and the level of consciousness.
Conclusion: The study highlights the need for rapid intervention and emphasizes the importance of managing bleeding and supporting hemodynamics. It also points to areas for improvement in emergency care and the benefits of interdisciplinary collaboration.
Keywords: Blood Pressure; Cause of Death; Consciousness; Emergency Medical Services; Hemodynamics; Hemorrhage; Hospitals; Medical Records; Mortality
Methods: This is a retrospective analysis of medical records and trauma database data, with a focus on survivors of penetrating cardiac trauma, excluding those deceased upon arrival.
Results: Out of 1,093 cases, 25 had penetrating cardiac injuries with an overall mortality rate of 36%. Hemorrhage was the leading cause of death, and survival was correlated with higher systolic blood pressure upon admission and the level of consciousness.
Conclusion: The study highlights the need for rapid intervention and emphasizes the importance of managing bleeding and supporting hemodynamics. It also points to areas for improvement in emergency care and the benefits of interdisciplinary collaboration.
Keywords: Blood Pressure; Cause of Death; Consciousness; Emergency Medical Services; Hemodynamics; Hemorrhage; Hospitals; Medical Records; Mortality
Echocardiographic Anatomical Risk Factors for Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement: A Retrospective Cohort Study
Braz J Cardiovasc Surg 2025;
e20240127
Publish in: 7/31/2025
Introduction: Transcatheter aortic valve replacement (TAVR) has revolutionized the
management of patients with aortic valve disease. However, the need for
pacemaker implantation remains a frequent complication. The objectives of
this study were to estimate the incidence of permanent pacemaker
implantation and to determine the associated risk factors.
Methods: This is a retrospective cohort study of adults who underwent TAVR, developed cardiac conduction disease, and required permanent pacemaker implantation during hospitalization. Groups were compared according to post procedure pacemaker implantation or not; and recognized preoperative and echocardiographically identified anatomic factors related to the procedure were evaluated. A predictive model was generated using multiple logistic regression.
Results: A total of 234 patients were included. The pacemaker implantation rate was 14%, and risk factors associated with this procedure were age (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.01 - 1.22), female sex (OR 0.11, 95% CI 0.01 - 0.61), body surface area > 1.51 m2 (OR 9.78, 95% CI 2.13 - 73.6), right bundle branch block (OR 22.5, 95% CI 2.62 - 242), first-degree atrioventricular block (OR 18.8, 95% CI 3.04 - 150), and implantation depth measured via echocardiography (OR 1.76, 95% CI 1.26 - 2.64). The model demonstrated good predictive capability with an area under the receiver operating characteristic curve of 0.934 (P < 0.001, 95% CI 0.878 - 0.988).
Conclusion: A well-performing predictive model was developed with six independent risk factors for the need for pacemaker implantation after TAVR, based on factors related to anatomic echocardiographic measurements associated with classic risk factors.
Keywords: Atrioventricular block. Transcatheter Aortic Valve Replacement. Artificial pacemaker. Risk factors.
Methods: This is a retrospective cohort study of adults who underwent TAVR, developed cardiac conduction disease, and required permanent pacemaker implantation during hospitalization. Groups were compared according to post procedure pacemaker implantation or not; and recognized preoperative and echocardiographically identified anatomic factors related to the procedure were evaluated. A predictive model was generated using multiple logistic regression.
Results: A total of 234 patients were included. The pacemaker implantation rate was 14%, and risk factors associated with this procedure were age (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.01 - 1.22), female sex (OR 0.11, 95% CI 0.01 - 0.61), body surface area > 1.51 m2 (OR 9.78, 95% CI 2.13 - 73.6), right bundle branch block (OR 22.5, 95% CI 2.62 - 242), first-degree atrioventricular block (OR 18.8, 95% CI 3.04 - 150), and implantation depth measured via echocardiography (OR 1.76, 95% CI 1.26 - 2.64). The model demonstrated good predictive capability with an area under the receiver operating characteristic curve of 0.934 (P < 0.001, 95% CI 0.878 - 0.988).
Conclusion: A well-performing predictive model was developed with six independent risk factors for the need for pacemaker implantation after TAVR, based on factors related to anatomic echocardiographic measurements associated with classic risk factors.
Keywords: Atrioventricular block. Transcatheter Aortic Valve Replacement. Artificial pacemaker. Risk factors.
Optimal Concentration of Papaverine for the Inhibition of Internal Thoracic Artery Vasospasm during Coronary Artery Bypass Graft Surgery
Braz J Cardiovasc Surg 2025;
e20240058
Publish in: 7/31/2025
Introduction: The internal thoracic artery is commonly used as a graft in coronary artery bypass grafting. In this study, we aimed to investigate whether papaverine prevents vasoconstriction caused by various vasospasm inducers, including 5-hydroxytriptamine or serotonin, in endothelium-denuded internal thoracic artery at concentrations as low as 1.25 mM used for radial arteries.
Methods: Human internal thoracic artery tissue was obtained from patients (n=6) undergoing coronary artery bypass grafting. The organ bath technique was used to determine the inhibitory effects of papaverine on vasoconstriction induced by ergonovine, adenosine diphosphate, 5-hydroxytriptamine, noradrenaline, and angiotensin II in isolated endothelium-denuded internal thoracic artery. Moreover, the inhibitory effect of papaverine on collagen-stimulated human platelet aggregation was examined at the same concentration.
Results: Papaverine inhibited ergonovine-induced vasoconstriction in a concentration-dependent manner. Papaverine at concentrations > 30 μM not only blocked ergonovine-induced vasoconstriction but also induced vasodilation. Papaverine at 30 μM significantly suppressed the vasoconstriction induced by 5-hydroxytriptamine or noradrenaline and completely blocked that induced by adenosine diphosphate or angiotensin II. However, 100 μM papaverine completely blocked the vasoconstriction induced by adenosine diphosphate, 5-hydroxytriptamine, noradrenaline, and angiotensin II. Additionally, papaverine significantly inhibited collagen-stimulated human platelet aggregation in a concentration-dependent manner.
Conclusion: Overall, 100 μM papaverine prevented vasoconstriction by various vasospasm inducers, such as 5-hydroxytriptamine, and significantly suppressed collagen-stimulated platelet aggregation. These results suggest that papaverine at 100 μM, which is 1/10th the concentration used for radial artery, is sufficient to prevent vasospasm in internal thoracic artery during coronary artery bypass grafting.
Keywords: Coronary artery bypass; Thoracic Artery; Papaverine; Vasoconstriction
Methods: Human internal thoracic artery tissue was obtained from patients (n=6) undergoing coronary artery bypass grafting. The organ bath technique was used to determine the inhibitory effects of papaverine on vasoconstriction induced by ergonovine, adenosine diphosphate, 5-hydroxytriptamine, noradrenaline, and angiotensin II in isolated endothelium-denuded internal thoracic artery. Moreover, the inhibitory effect of papaverine on collagen-stimulated human platelet aggregation was examined at the same concentration.
Results: Papaverine inhibited ergonovine-induced vasoconstriction in a concentration-dependent manner. Papaverine at concentrations > 30 μM not only blocked ergonovine-induced vasoconstriction but also induced vasodilation. Papaverine at 30 μM significantly suppressed the vasoconstriction induced by 5-hydroxytriptamine or noradrenaline and completely blocked that induced by adenosine diphosphate or angiotensin II. However, 100 μM papaverine completely blocked the vasoconstriction induced by adenosine diphosphate, 5-hydroxytriptamine, noradrenaline, and angiotensin II. Additionally, papaverine significantly inhibited collagen-stimulated human platelet aggregation in a concentration-dependent manner.
Conclusion: Overall, 100 μM papaverine prevented vasoconstriction by various vasospasm inducers, such as 5-hydroxytriptamine, and significantly suppressed collagen-stimulated platelet aggregation. These results suggest that papaverine at 100 μM, which is 1/10th the concentration used for radial artery, is sufficient to prevent vasospasm in internal thoracic artery during coronary artery bypass grafting.
Keywords: Coronary artery bypass; Thoracic Artery; Papaverine; Vasoconstriction
Fontan Surgical Planning: Numerical Simulations Reveal Efficient Geometries Predicting Post-Surgical Outcomes
Braz J Cardiovasc Surg 2025;
e20240217
Publish in: 7/31/2025
Introduction: Computational fluid dynamics has the potential to assist cardiovascular surgeons in making more accurate decisions, allowing the prediction of post-surgical outcomes, provided that pre-surgical conditions are well established. However, the application of current techniques, which are based on volume methods, is still limited to a few specialized centers. Lack of knowledge, coupled with the need for advanced computational resources, can serve as obstacles to implementation. Objective: This study aimed to develop a replicable surgical planning procedure for a simplified and clinically feasible total cavopulmonary geometry.
Methods: The finite volume method was used to simulate different configurations of cavopulmonary anastomosis under continuous and pulsatile flow and thus gain a better understanding of blood behavior, energy efficiency, and shear stress in the studied regions.
Results: Two geometries were found to be efficient in distributing blood flow in a physiological manner, with adequate shear stress and energy loss. In addition to the correct placement of the anastomosis, the results underscored the need for attention regarding potential stenoses in pulmonary arteries to obtain adequate geometries.
Conclusion: The developed method proved to be effective for early visualization of post-surgical results, particularly in complex clinical cases. Furthermore, the method contributes to a comprehensive understanding of hemodynamics in the studied area, improving the accuracy of cardiovascular surgical planning.
Keywords: Hydrodynamics; Pulsative Flow; Pulonary Artery; Pathologic Constriction; Surgical Anastomosis; Right Heart Bypass; Surgeons
Methods: The finite volume method was used to simulate different configurations of cavopulmonary anastomosis under continuous and pulsatile flow and thus gain a better understanding of blood behavior, energy efficiency, and shear stress in the studied regions.
Results: Two geometries were found to be efficient in distributing blood flow in a physiological manner, with adequate shear stress and energy loss. In addition to the correct placement of the anastomosis, the results underscored the need for attention regarding potential stenoses in pulmonary arteries to obtain adequate geometries.
Conclusion: The developed method proved to be effective for early visualization of post-surgical results, particularly in complex clinical cases. Furthermore, the method contributes to a comprehensive understanding of hemodynamics in the studied area, improving the accuracy of cardiovascular surgical planning.
Keywords: Hydrodynamics; Pulsative Flow; Pulonary Artery; Pathologic Constriction; Surgical Anastomosis; Right Heart Bypass; Surgeons
Left Anterior Mini-Thoracotomy vs. Conventional Sternotomy in On-Pump Multivessel Coronary Revascularization
Braz J Cardiovasc Surg 2025;
e20230299
Publish in: 7/31/2025
Objective: In this study, we aimed to compare the outcomes of left anterior
mini-thoracotomy and conventional sternotomy in on-pump multivessel coronary
revascularization.
Methods: Two hundred sixty-two patients who underwent minimally invasive coronary artery bypass grafting through the left anterior mini-thoracotomy and conventional coronary artery bypass grafting with full sternotomy were included. All patients were divided into two groups - 132 patients who underwent minimally invasive multivessel coronary artery bypass grafting in Group I, and 130 patients with full sternotomy in Group II. Intraoperative variables (cross-clamping time, cardiopulmonary bypass time, etc.), postoperative parameters (drainage amount, revision, intensive care and hospital stay times, etc.), and mortality were analyzed retrospectively.
Results: Cardiopulmonary bypass time (152.24 ± 36.4 minutes) was significantly longer in Group I than in Group II (102.24 ± 19.4 minutes) (P<0.001). Cross-clamping time (86 ± 13.2 minutes) was significantly longer in Group I than in Group II (62 ± 21.4 minutes) (P<0.001). And intensive care stay time (P=0.005) and hospital stay time (P=0.004) were significantly shorter in Group I. In the postoperative period, six patients in Group I and seven patients in Group II were revised due to bleeding. Total perioperative mortality was one patient in both groups (P=0.82).
Conclusion: Multivessel coronary artery bypass grafting through the left anterior mini-thoracotomy is an effective, reliable, and successful method, due to less drainage amount and less blood transfusion need, shorter intensive care and hospital stays, faster return to daily life, and better cosmetic results compared to conventional methods.
Keywords: Sternotomy. Thoracotomy. Length of stay. Cardiopulomnary Bypass. Constriction. Drainage.
Methods: Two hundred sixty-two patients who underwent minimally invasive coronary artery bypass grafting through the left anterior mini-thoracotomy and conventional coronary artery bypass grafting with full sternotomy were included. All patients were divided into two groups - 132 patients who underwent minimally invasive multivessel coronary artery bypass grafting in Group I, and 130 patients with full sternotomy in Group II. Intraoperative variables (cross-clamping time, cardiopulmonary bypass time, etc.), postoperative parameters (drainage amount, revision, intensive care and hospital stay times, etc.), and mortality were analyzed retrospectively.
Results: Cardiopulmonary bypass time (152.24 ± 36.4 minutes) was significantly longer in Group I than in Group II (102.24 ± 19.4 minutes) (P<0.001). Cross-clamping time (86 ± 13.2 minutes) was significantly longer in Group I than in Group II (62 ± 21.4 minutes) (P<0.001). And intensive care stay time (P=0.005) and hospital stay time (P=0.004) were significantly shorter in Group I. In the postoperative period, six patients in Group I and seven patients in Group II were revised due to bleeding. Total perioperative mortality was one patient in both groups (P=0.82).
Conclusion: Multivessel coronary artery bypass grafting through the left anterior mini-thoracotomy is an effective, reliable, and successful method, due to less drainage amount and less blood transfusion need, shorter intensive care and hospital stays, faster return to daily life, and better cosmetic results compared to conventional methods.
Keywords: Sternotomy. Thoracotomy. Length of stay. Cardiopulomnary Bypass. Constriction. Drainage.
Comparison of Two Coronary Anastomosis Techniques in Terms of Flow Rate in Porcine Hearts
Braz J Cardiovasc Surg 2025;
e20240073
Publish in: 7/31/2025
Introduction: The quality of coronary anastomoses is one of the important parameters that may affect graft patency in coronary artery bypass grafting patients. Therefore, we compared two different anastomotic techniques to improve graft flow and patency rates.
Methods: This study was conducted by performing two different fashions of anastomosis with a human saphenous vein graft on 24 various coronary segments of five postmortem porcine hearts. Each arteriotomy was used for both anastomotic techniques. In the first method, epicardial fat tissue around the coronary artery was involved to the saphenous vein anastomosis line (coronary wall and epicardial fat tissue [CWE] technique). In the second method, the saphenous vein graft was sutured to the coronary wall only, without involving epicardial fat tissue (only coronary wall [OCW] technique).The time it tookfor 30 cc of 0.9% isotonic saline solution to pass through the anastomosis in a free-flow fashion by gravity was measured following each technique. Additionally, the anastomotic areas in mm2 were measured and compared between the two techniques.
Results: The mean flow time for the CWE technique was 77.5 ± 21.4 seconds, whereas for the OCW technique, it was 87.2 ± 19.5 seconds (P<0.001). The flow rates were 23.2 ml/min and 20.6 ml/min, respectively. The anastomotic area was 3.947 mm2 for the CWE technique and 1.430 mm2 for the OCW technique.
Conclusion: When the sutures penetrate both the epicardial fat tissue and the coronary artery wall simultaneously, a larger anastomosis area can be created. Consequently, potentially better graft flow and hemodynamic performance could be achieved.
Keywords: Coronary Anastomosis Technique; Hemodynamic Performance; Graft Flow; Coronary artery bypass; Graft Patency
Methods: This study was conducted by performing two different fashions of anastomosis with a human saphenous vein graft on 24 various coronary segments of five postmortem porcine hearts. Each arteriotomy was used for both anastomotic techniques. In the first method, epicardial fat tissue around the coronary artery was involved to the saphenous vein anastomosis line (coronary wall and epicardial fat tissue [CWE] technique). In the second method, the saphenous vein graft was sutured to the coronary wall only, without involving epicardial fat tissue (only coronary wall [OCW] technique).The time it tookfor 30 cc of 0.9% isotonic saline solution to pass through the anastomosis in a free-flow fashion by gravity was measured following each technique. Additionally, the anastomotic areas in mm2 were measured and compared between the two techniques.
Results: The mean flow time for the CWE technique was 77.5 ± 21.4 seconds, whereas for the OCW technique, it was 87.2 ± 19.5 seconds (P<0.001). The flow rates were 23.2 ml/min and 20.6 ml/min, respectively. The anastomotic area was 3.947 mm2 for the CWE technique and 1.430 mm2 for the OCW technique.
Conclusion: When the sutures penetrate both the epicardial fat tissue and the coronary artery wall simultaneously, a larger anastomosis area can be created. Consequently, potentially better graft flow and hemodynamic performance could be achieved.
Keywords: Coronary Anastomosis Technique; Hemodynamic Performance; Graft Flow; Coronary artery bypass; Graft Patency
Cardiopulmonary Bypass and Cross-Clamping Times in Aortic Valve Replacement Surgery by Ministernotomy with Sutureless Prosthesis Implantation Compared to Conventional Prosthesis: A Cross-Sectional Study
Braz J Cardiovasc Surg 2025;
e20240290
Publish in: 7/31/2025
Introduction: Valve replacement is one of the effective treatments for aortic valve
disease. This study aims to compare cardiopulmonary bypass and ischemia
times in aortic valve replacement surgeries using stented biological and
sutureless prostheses (PERCEVAL®) through a minimally invasive
ministernotomy approach. Methods: This single-center
cross-sectional study, conducted from February 2015 to February 2021,
assessed clinical and epidemiological characteristics in aortic valve
replacement patients. It analyzed factors including hospital stay, early
outcomes, valve etiology, intraoperative diagnosis, systolic gradients, left
ventricular ejection fraction, and left ventricular mass. Two groups were
studied: 12 patients with PERCEVAL® prostheses and 81 with
conventional bioprostheses.
Results: This study included 93 patients (age: 59 ± 16 years), 61.3% were male, and 80.2% had hypertension; dyslipidemias were present in 34.1% and 25.3% were diabetic. Cardiopulmonary bypass and cross-clamping times were 61 minutes and 41 minutes in the conventional bioprostheses group and 59.5 minutes and 39.5 minutes in the PERCEVAL® group (P=0.143 and P=0.058, respectively). Intensive care unit and overall hospital stays were statistically comparable between both groups (P=0.662 and P=0.599, respectively). All participants survived the 30-day postoperative period, with minimal complications, no significant differences in echocardiographic parameters were observed, yet higher values for certain cardiac function indicators were noted in the conventional bioprostheses group.
Conclusion: The groups with conventional bioprostheses and sutureless prostheses (PERCEVAL®) didn't display significant differences in the analyzed variables for ministernotomy aortic valve replacement surgery. They exhibited similar results in terms of hospital stay duration, 30-day outcomes, and cardiac function values.
Keywords: Aortic valve; Bioprosthesis; Cardiopulmonary bypass; Constriction; Left Ventricular Function; Aortic Valve Disease; Ischemia
Results: This study included 93 patients (age: 59 ± 16 years), 61.3% were male, and 80.2% had hypertension; dyslipidemias were present in 34.1% and 25.3% were diabetic. Cardiopulmonary bypass and cross-clamping times were 61 minutes and 41 minutes in the conventional bioprostheses group and 59.5 minutes and 39.5 minutes in the PERCEVAL® group (P=0.143 and P=0.058, respectively). Intensive care unit and overall hospital stays were statistically comparable between both groups (P=0.662 and P=0.599, respectively). All participants survived the 30-day postoperative period, with minimal complications, no significant differences in echocardiographic parameters were observed, yet higher values for certain cardiac function indicators were noted in the conventional bioprostheses group.
Conclusion: The groups with conventional bioprostheses and sutureless prostheses (PERCEVAL®) didn't display significant differences in the analyzed variables for ministernotomy aortic valve replacement surgery. They exhibited similar results in terms of hospital stay duration, 30-day outcomes, and cardiac function values.
Keywords: Aortic valve; Bioprosthesis; Cardiopulmonary bypass; Constriction; Left Ventricular Function; Aortic Valve Disease; Ischemia
Del Nido vs. Blood Cardioplegia: A Comparative Analysis of Postoperative Atrial Fibrillation in Coronary Artery Bypass Grafting Patients
Braz J Cardiovasc Surg 2025;
e20240071
Publish in: 7/31/2025
Introduction: Cardioplegia solution, also called the del Nido solution, has been widely used in pediatric cardiac surgeries, and has recently started to be used in adult cardiac surgeries. In this context, this study aimed to investigate the relationship between the use of del Nido and blood cardioplegia solutions and postoperative atrial fibrillation rates in our clinic.
Methods: The study sample comprised 140 patients who underwent coronary artery bypass grafting. The del Nido and blood cardioplegia solutions were used in 70 (50%) patients. The postoperative atrial fibrillation rates of both groups were compared. Additionally, patients’ preoperative, intraoperative, and postoperative data were evaluated.
Results: The cardiopulmonary bypass duration and defibrillation rate were lower in the del Nido cardioplegia group than in the blood cardioplegia group (P < 0.001). Atrial fibrillation rates on postoperative days one, five, and 30 were significantly lower in the del Nido cardioplegia group than in the blood cardioplegia group (P < 0.001, P < 0.001, and P = 0.007, respectively).
Conclusion: The postoperative atrial fibrillation rate was significantly lower in the del Nido cardioplegia group than in the blood cardioplegia group. In addition, the del Nido cardioplegia solution did not interrupt the surgical flow, thus resulting in less total perfusion, shorter cross-clamping durations, and fewer defibrillation needs. In conclusion, the del Nido cardioplegia solution can be used safely and effectively in coronary artery bypass grafting surgeries.
Keywords: Cardiopulmonary bypass. Cardioplegia Solution. Atrial fibrillation. Del Nido cardioplegia solution. Perfusion.
Methods: The study sample comprised 140 patients who underwent coronary artery bypass grafting. The del Nido and blood cardioplegia solutions were used in 70 (50%) patients. The postoperative atrial fibrillation rates of both groups were compared. Additionally, patients’ preoperative, intraoperative, and postoperative data were evaluated.
Results: The cardiopulmonary bypass duration and defibrillation rate were lower in the del Nido cardioplegia group than in the blood cardioplegia group (P < 0.001). Atrial fibrillation rates on postoperative days one, five, and 30 were significantly lower in the del Nido cardioplegia group than in the blood cardioplegia group (P < 0.001, P < 0.001, and P = 0.007, respectively).
Conclusion: The postoperative atrial fibrillation rate was significantly lower in the del Nido cardioplegia group than in the blood cardioplegia group. In addition, the del Nido cardioplegia solution did not interrupt the surgical flow, thus resulting in less total perfusion, shorter cross-clamping durations, and fewer defibrillation needs. In conclusion, the del Nido cardioplegia solution can be used safely and effectively in coronary artery bypass grafting surgeries.
Keywords: Cardiopulmonary bypass. Cardioplegia Solution. Atrial fibrillation. Del Nido cardioplegia solution. Perfusion.
Total Arch Replacement is Safe as Hemiarch Repair in Acute Type A Aortic Dissection in a Middle-Income Country Setting
Braz J Cardiovasc Surg 2025;
e20240088
Publish in: 7/31/2025
Objectiver: The aim of this study was to determine the clinical outcomes of patients with
acute type A aortic dissection comparing proximal aortic repair
vs. total arch replacement.
Methods: This was a retrospective cohort study. We included all acute type A aortic dissection procedures from January 2002 to November 2022. Groups were defined according to the extent of aortic replacement (hemiarch repair vs. total arch replacement). We collected data from pre, intra, and postoperative variables. Our main endpoints were stroke rate, spinal cord injury, and in-hospital mortality. We performed a statistical analysis for between-group comparisons according to the nature and distribution of variables. Bivariate analyses were done using the Mann-Whitney U test and for categorical variables, the Chi-square test or Fisher’s exact test. Significance was established at alpha level of 0.05.
Results: We identified 107 acute type A aortic dissection procedures (69 hemiarch repairs vs. 38 total arch replacements). There were no differences in postoperative outcomes such as surgical site infection or acute kidney injury. Bleeding reoperation was more frequent in the hemiarch group (30% vs. 11 %). We did not find statistically significant differences in stroke rate, spinal cord injury, or in-hospital mortality.
Conclusion: Acute type A aortic dissection treatment is still a challenge. Total arch replacement does not increase the risk of major early postoperative complications in comparison to hemiarch repair. The extended repair seems to provide benefits such as a lower risk of reoperation. Total arch replacement should be performed in selected patients, as it may improve long-term outcomes
Keywords: Surgical wound infection; Reoperation; Hospital mortality; Aortic Dissection; Spinal Cord Injuries; Stroke; Acute kidney injury
Methods: This was a retrospective cohort study. We included all acute type A aortic dissection procedures from January 2002 to November 2022. Groups were defined according to the extent of aortic replacement (hemiarch repair vs. total arch replacement). We collected data from pre, intra, and postoperative variables. Our main endpoints were stroke rate, spinal cord injury, and in-hospital mortality. We performed a statistical analysis for between-group comparisons according to the nature and distribution of variables. Bivariate analyses were done using the Mann-Whitney U test and for categorical variables, the Chi-square test or Fisher’s exact test. Significance was established at alpha level of 0.05.
Results: We identified 107 acute type A aortic dissection procedures (69 hemiarch repairs vs. 38 total arch replacements). There were no differences in postoperative outcomes such as surgical site infection or acute kidney injury. Bleeding reoperation was more frequent in the hemiarch group (30% vs. 11 %). We did not find statistically significant differences in stroke rate, spinal cord injury, or in-hospital mortality.
Conclusion: Acute type A aortic dissection treatment is still a challenge. Total arch replacement does not increase the risk of major early postoperative complications in comparison to hemiarch repair. The extended repair seems to provide benefits such as a lower risk of reoperation. Total arch replacement should be performed in selected patients, as it may improve long-term outcomes
Keywords: Surgical wound infection; Reoperation; Hospital mortality; Aortic Dissection; Spinal Cord Injuries; Stroke; Acute kidney injury
Comparative Study on the Outcomes of Right Ventricular Outflow Tract Stenting vs. Modified Blalock-Taussig Shunt in Patients with Tetralogy of Fallot: A Prospective Randomized Trial
Braz J Cardiovasc Surg 2025;
e20230478
Publish in: 7/31/2025
Objective: To evaluate pulmonary vascular development and outcomes of complete
correction following palliative treatment in infants with critical tetralogy
of Fallot.
Methods: This prospective, randomized, two-center study included infants with tetralogy of Fallot who underwent surgery between June 2018 and 2022. The patients were divided into two groups - those who underwent stenting of the right ventricular outflow tract (stent group, n=21) and those who underwent modified Blalock-Taussig shunt placement (shunt group, n=21).
Results: In the stent group, a significantly greater increase in Nakata index was observed, with mean values rising from 104.2 to 208.6 mm2/m2, compared to an increase from 107.3 to 169.4 mm2/m2 in the shunt group (P<0.01). According to the mixed model analysis, the rate of growth of the right pulmonary artery in the stent group was 2.05*10-2 z score/day, which was 3.01 times greater than that in the shunt group (P<0.01). The rate of growth of the left pulmonary artery in the stent group was 2.3*10-2 z score/day, which was 1.47 times greater than that in the shunt group (P<0.01). In one patient (4.8%), after 76 days following the stenting of the RVOT, a severe infectious process with sepsis occurred, leading to a fatal outcome. Complete correction in the stent group involved transannular patch repair of the right ventricular outflow tract to the pulmonary artery in 12 patients (60%), while the same procedure was performed in 15 patients (71.4%) in the shunt group (P=0.52).
Conclusion: Stenting of the right ventricular outflow tract provides hemodynamic stabilization and symmetric growth of the pulmonary vascular bed compared to the formation of a modified Blalock-Taussig shunt.
Keywords: Tetralogy of Fallot; Pulmonary artery; Blalock-Taussig Procedure; Stents; Sepsis
Methods: This prospective, randomized, two-center study included infants with tetralogy of Fallot who underwent surgery between June 2018 and 2022. The patients were divided into two groups - those who underwent stenting of the right ventricular outflow tract (stent group, n=21) and those who underwent modified Blalock-Taussig shunt placement (shunt group, n=21).
Results: In the stent group, a significantly greater increase in Nakata index was observed, with mean values rising from 104.2 to 208.6 mm2/m2, compared to an increase from 107.3 to 169.4 mm2/m2 in the shunt group (P<0.01). According to the mixed model analysis, the rate of growth of the right pulmonary artery in the stent group was 2.05*10-2 z score/day, which was 3.01 times greater than that in the shunt group (P<0.01). The rate of growth of the left pulmonary artery in the stent group was 2.3*10-2 z score/day, which was 1.47 times greater than that in the shunt group (P<0.01). In one patient (4.8%), after 76 days following the stenting of the RVOT, a severe infectious process with sepsis occurred, leading to a fatal outcome. Complete correction in the stent group involved transannular patch repair of the right ventricular outflow tract to the pulmonary artery in 12 patients (60%), while the same procedure was performed in 15 patients (71.4%) in the shunt group (P=0.52).
Conclusion: Stenting of the right ventricular outflow tract provides hemodynamic stabilization and symmetric growth of the pulmonary vascular bed compared to the formation of a modified Blalock-Taussig shunt.
Keywords: Tetralogy of Fallot; Pulmonary artery; Blalock-Taussig Procedure; Stents; Sepsis
Effects of Harvesting Site and Incision Method on Surgical Wound Complications of No-Touch Saphenous Vein Grafts: A Retrospective Observational Study
Braz J Cardiovasc Surg 2025;
e20240098
Publish in: 7/31/2025
Introduction: Saphenous vein grafts are frequently used for coronary artery revascularization. However, harvesting veins is associated with infected surgical sites and other complications. The no-touch technique that includes harvesting saphenous vein grafts along with surrounding tissues improves graft patency but increases the frequency of wound complications. We harvested saphenous vein grafts using the no-touch technique and devised other options for sites and incision methods to prevent wound complications. This study aimed to determine the clinical outcomes of no-touch saphenous vein grafts as well as associations between harvesting methods and wound complications.
Methods: We enrolled 132 patients who underwent isolated coronary artery bypass surgery with saphenous vein grafts harvested using the no-touch technique. Wound condition, general status, and graft patency were assessed during clinical follow-up.
Results: We harvested 180 veins (lower legs, n = 69 veins; upper legs, n = 111) using longitudinal and skip incisions at 100 and 80 sites, respectively. Wound complications occurred at 35 sites. The frequency of complications was significantly lower in the upper, than in the lower legs (14.4% vs. 27.5%). Furthermore, wound complications were reduced more by skip, than by longitudinal skin incisions (16.3% vs. 20.0%).
Conclusion: We devised a method to harvest no-touch saphenous vein grafts and determined the clinical outcomes of saphenous vein grafts and harvesting sites. Harvesting from the upper leg and via skip incisions reduced the frequency of wound complications.
Keywords: Coronary artery bypass. Saphenous vein. Wounds and Injuries. Coronary Vessels.
Methods: We enrolled 132 patients who underwent isolated coronary artery bypass surgery with saphenous vein grafts harvested using the no-touch technique. Wound condition, general status, and graft patency were assessed during clinical follow-up.
Results: We harvested 180 veins (lower legs, n = 69 veins; upper legs, n = 111) using longitudinal and skip incisions at 100 and 80 sites, respectively. Wound complications occurred at 35 sites. The frequency of complications was significantly lower in the upper, than in the lower legs (14.4% vs. 27.5%). Furthermore, wound complications were reduced more by skip, than by longitudinal skin incisions (16.3% vs. 20.0%).
Conclusion: We devised a method to harvest no-touch saphenous vein grafts and determined the clinical outcomes of saphenous vein grafts and harvesting sites. Harvesting from the upper leg and via skip incisions reduced the frequency of wound complications.
Keywords: Coronary artery bypass. Saphenous vein. Wounds and Injuries. Coronary Vessels.
Thiol/Disulfide Homeostasis in Pericardial Fluid and Plasma of Patients Undergoing Coronary Artery Bypass Surgery
Braz J Cardiovasc Surg 2025;
e20220367
Publish in: 7/31/2025
Introduction: On-pump coronary artery bypass grafting (CABG) method affect almost
allbiochemicalreactions by disrupting the patient’s redox homeostasis.
Detection of systemic redox hemostasis in the patient is critical for the
CABG method’s success and the prognosis of the disease. In this study,
thiol/disulfide parameters, which are indicators of redox homeostasis, and
ischemia-modified albumin levels in the plasma and pericardial fluid of
patients who underwent CABG were investigated.
Methods: Sixty patients who underwent an on-pump CABG operation with the cardiopulmonary bypass method were included in this study. Blood samples were taken from the patients before and after cardiopulmonary bypass. Pericardia fluid samples were taken before cardiopulmonary bypass. Then, thiol/disulfide homeostasis, albumin, and ischemia-modified albumin levels in the pericardial fluid and the patients’ plasma levels were compared.
Results: Albumin and ischemia-modified albumin levels were significantly higher in the postoperative period compared to the preoperative one (P<0.001). Thiol/disulfide parameters were higher and statistically significant in preoperative than in postoperative examinations (P<0.001). A negative correlation was found between pericardial fluid ischemia-modified albumin and thiol-disulfide parameters (P<0.001).
Conclusion: Changes in thiol/disulfide homeostasis, albumin, and ischemia-modified albumin levels at different times during the on-pump CABG may be caused by foreign non-endothelial surfaces, filters, the reperfusion process, and pharmacological effects in the extracorporeal circulation. Thiol/disulfide homeostasis, albumin, and ischemia-modified albumin levels should be monitored during the on-pump CABG and should be intervened with appropriate therapeutic strategies. In this way, secondary pathologies can be avoided by preventing cellular damage and excessive inflammatory responses.
Keywords: Coronary artery bypass; Disulfides; Extracorporeal circulation; Pericardia Fluid; Homeostasis; Indicators and Reagents; Ischemia; Oxidation-Reduction; Reperfusion; Sulfhydryl Compounds
Methods: Sixty patients who underwent an on-pump CABG operation with the cardiopulmonary bypass method were included in this study. Blood samples were taken from the patients before and after cardiopulmonary bypass. Pericardia fluid samples were taken before cardiopulmonary bypass. Then, thiol/disulfide homeostasis, albumin, and ischemia-modified albumin levels in the pericardial fluid and the patients’ plasma levels were compared.
Results: Albumin and ischemia-modified albumin levels were significantly higher in the postoperative period compared to the preoperative one (P<0.001). Thiol/disulfide parameters were higher and statistically significant in preoperative than in postoperative examinations (P<0.001). A negative correlation was found between pericardial fluid ischemia-modified albumin and thiol-disulfide parameters (P<0.001).
Conclusion: Changes in thiol/disulfide homeostasis, albumin, and ischemia-modified albumin levels at different times during the on-pump CABG may be caused by foreign non-endothelial surfaces, filters, the reperfusion process, and pharmacological effects in the extracorporeal circulation. Thiol/disulfide homeostasis, albumin, and ischemia-modified albumin levels should be monitored during the on-pump CABG and should be intervened with appropriate therapeutic strategies. In this way, secondary pathologies can be avoided by preventing cellular damage and excessive inflammatory responses.
Keywords: Coronary artery bypass; Disulfides; Extracorporeal circulation; Pericardia Fluid; Homeostasis; Indicators and Reagents; Ischemia; Oxidation-Reduction; Reperfusion; Sulfhydryl Compounds
Predictors of Postoperative Hospital-Acquired Infection and Mortality Following Cardiac Surgery in a Low-Income Country: A Retrospective Cohort Study
Braz J Cardiovasc Surg 2025;
e20240111
Publish in: 7/31/2025
Introduction: Recognizing the risk factors for postoperative hospital-acquired infection
and mortality is crucial for better outcomes. We aimed to determine the risk
predictors for postoperative hospital-acquired infection and death following
cardiac surgery.
Methods: This is a retrospective cohort study that included 880 consecutive adult patients who underwent cardiac surgery between 2015 and 2021. Multivariable logistic regression was performed to assess the predictors of postoperative hospital-acquired infection and mortality.
Results: Patients who developed postoperative hospital-acquired infection had higher values on European System for Cardiac Operative Risk Evaluation score (4.01% vs. 2.51%; P=0.001), as well as longer hospital preoperative stay (9.44 vs. 8.28 days; P=0.049) and hospital length of stay (28.41 vs. 16.16 days; P<0.001). After multivariable analysis, predictors of postoperative hospital-acquired infection were longer hospital preoperative stay (odds ratio 1.024; 95% confidence interval 1.005-1.044; P=0.009), higher body mass index (odds ratio 1.043; 95% confidence interval 1.008-1.079; P=0.015), and longer extracorporeal circulation time (odds ratio 1.007; 95% confidence interval 1.003-1.012; P<0.001). Both longer extracorporeal circulations time and postoperative hospital-acquired infection were significantly associated with higher mortality before hospital discharge (odds ratio 1.012; 95% confidence interval 1.006-1.019; P<0.001; and odds ratio 2.418; 95% confidence interval 1.385-4.233; P=0.001, respectively).
Conclusion: Extended preoperative hospitalization, body mass index, and extracorporeal circulation time are correlated with heightened postoperative hospital-acquired infection rates. Moreover, longer extracorporeal circulation time and postoperative hospital-acquired infection incidence emerged as significant predictors of mortality following cardiac surgery.
Keywords: Cardiac surgical procedures; Hospitalization Infection; Mortality
Methods: This is a retrospective cohort study that included 880 consecutive adult patients who underwent cardiac surgery between 2015 and 2021. Multivariable logistic regression was performed to assess the predictors of postoperative hospital-acquired infection and mortality.
Results: Patients who developed postoperative hospital-acquired infection had higher values on European System for Cardiac Operative Risk Evaluation score (4.01% vs. 2.51%; P=0.001), as well as longer hospital preoperative stay (9.44 vs. 8.28 days; P=0.049) and hospital length of stay (28.41 vs. 16.16 days; P<0.001). After multivariable analysis, predictors of postoperative hospital-acquired infection were longer hospital preoperative stay (odds ratio 1.024; 95% confidence interval 1.005-1.044; P=0.009), higher body mass index (odds ratio 1.043; 95% confidence interval 1.008-1.079; P=0.015), and longer extracorporeal circulation time (odds ratio 1.007; 95% confidence interval 1.003-1.012; P<0.001). Both longer extracorporeal circulations time and postoperative hospital-acquired infection were significantly associated with higher mortality before hospital discharge (odds ratio 1.012; 95% confidence interval 1.006-1.019; P<0.001; and odds ratio 2.418; 95% confidence interval 1.385-4.233; P=0.001, respectively).
Conclusion: Extended preoperative hospitalization, body mass index, and extracorporeal circulation time are correlated with heightened postoperative hospital-acquired infection rates. Moreover, longer extracorporeal circulation time and postoperative hospital-acquired infection incidence emerged as significant predictors of mortality following cardiac surgery.
Keywords: Cardiac surgical procedures; Hospitalization Infection; Mortality
Intrapericardial Extra-Anatomic Aorto-Aortic Bypass for Aortic Coarctation in Adults
Braz J Cardiovasc Surg 2025;
e20240185
Publish in: 7/31/2025
Introduction: The preferred treatment for aortic coarctation is direct repair during childhood. However, some patients reach adulthood without being diagnosed. For these patients, an extra-anatomic bypass offers an alternative solution.
Objective: To evaluate the surgical outcomes of adult patients with aortic coarctation treated with an extra-anatomic aorto-aortic bypass.
Methods: This retrospective study includes adult patients who underwent an intrapericardial extra-anatomic bypass using a Dacron® tube from 2013 to 2021 (n=8). Clinical characteristics, surgical outcomes, survival rates, and the need for reinterventions were assessed up to March 31, 2024.
Results: All patients were male, with an average age of 39.9 ± 10.8 years (range 23-51). All were hypertensive. Four patients had associated aortic valve disease, and one had coronary artery disease. The operative risk, calculated using the European System for Cardiac Operative Risk Evaluation II score, was 1.65%. Four patients underwent concurrent valve surgeries (two valve replacements, one David procedure, and one Bentall procedure), and one had coronary artery surgery. The average pump time was 119 minutes, with longer times for those undergoing additional procedures (157 vs. 82.5 minutes). There was no operative mortality. The mean follow-up period was 107.1 ± 32 months, during which all patients survived. One patient required reintervention on the 118th postoperative month due to aortic stenosis, necessitating valve replacement with a biological prosthesis.
Conclusion: Intrapericardial extra-anatomic bypass is a viable option for treating aortic coarctation in adults, demonstrating excellent shortand long-term outcomes. It can be effectively combined with other surgical procedures.
Keywords: Coronary Artery Disease. Aortic valve. Polyethylene Terephthalates. Aortic coarctation. Survival rate. Follow-up studies. Aortic valve stenosis. Aortic Valve Disease. Prostheses and implants. Coronary Artery Bypass.
Objective: To evaluate the surgical outcomes of adult patients with aortic coarctation treated with an extra-anatomic aorto-aortic bypass.
Methods: This retrospective study includes adult patients who underwent an intrapericardial extra-anatomic bypass using a Dacron® tube from 2013 to 2021 (n=8). Clinical characteristics, surgical outcomes, survival rates, and the need for reinterventions were assessed up to March 31, 2024.
Results: All patients were male, with an average age of 39.9 ± 10.8 years (range 23-51). All were hypertensive. Four patients had associated aortic valve disease, and one had coronary artery disease. The operative risk, calculated using the European System for Cardiac Operative Risk Evaluation II score, was 1.65%. Four patients underwent concurrent valve surgeries (two valve replacements, one David procedure, and one Bentall procedure), and one had coronary artery surgery. The average pump time was 119 minutes, with longer times for those undergoing additional procedures (157 vs. 82.5 minutes). There was no operative mortality. The mean follow-up period was 107.1 ± 32 months, during which all patients survived. One patient required reintervention on the 118th postoperative month due to aortic stenosis, necessitating valve replacement with a biological prosthesis.
Conclusion: Intrapericardial extra-anatomic bypass is a viable option for treating aortic coarctation in adults, demonstrating excellent shortand long-term outcomes. It can be effectively combined with other surgical procedures.
Keywords: Coronary Artery Disease. Aortic valve. Polyethylene Terephthalates. Aortic coarctation. Survival rate. Follow-up studies. Aortic valve stenosis. Aortic Valve Disease. Prostheses and implants. Coronary Artery Bypass.
Clinical Impact of New-Onset Left Bundle Branch Block After Transcatheter Aortic Valve Replacement: Data from a Single-Center Retrospective Registry
Braz J Cardiovasc Surg 2025;
e20240187
Publish in: 7/31/2025
Introduction: The clinical significance of new-onset left bundle branch block (LBBB) after
transcatheter aortic valve replacement (TAVR) remains controversial. In the
presented study, we aimed to assess the impact of new LBBB on clinical
outcomes after TAVR.
Methods: A total of 473 patients underwent TAVR for severe aortic stenosis between 2015 and 2023. According to the exclusion criteria, the study cohort comprised of 322 patients for analysis. The primary endpoint was cardiovascular death, with secondary endpoints including all-cause mortality and permanent pacemaker implantation (PPI) during follow-up.
Results: Patients with new LBBB had a significantly smaller indexed aortic valve area (0.3 ± 0.1 vs. 0.4 ± 0.1, P < 0.01) and interventricular membranous septum length (6.2 ± 1.6 vs. 6.9 ± 1.8, P < 0.01). By multivariable analysis, new LBBB remained an independent predictor of cardiovascular death (hazard ratio [HR] 7.09, 95% confidence interval [CI] 1.16 - 43.50, P = 0.03) during the 2.9-year follow-up period. There were no significant differences in the incidence of all-cause mortality (HR 0.48, 95% CI 0.17 - 1.37, P = 0.16) and PPI (HR 2.61, 95% CI 0.85 - 0.80, P = 0.08) between patients with new LBBB compared to those without it.
Conclusion: New LBBB after TAVR procedure is associated with an increased risk of death from cardiovascular causes, but it did not increase the risk of all-cause mortality and PPI over the long-term period.
Keywords: Aortic Stenosis. Transcatheter Aortic Valve Replacement. Left Bundle Branch Block. Permanent Pacemaker Implantation.
Methods: A total of 473 patients underwent TAVR for severe aortic stenosis between 2015 and 2023. According to the exclusion criteria, the study cohort comprised of 322 patients for analysis. The primary endpoint was cardiovascular death, with secondary endpoints including all-cause mortality and permanent pacemaker implantation (PPI) during follow-up.
Results: Patients with new LBBB had a significantly smaller indexed aortic valve area (0.3 ± 0.1 vs. 0.4 ± 0.1, P < 0.01) and interventricular membranous septum length (6.2 ± 1.6 vs. 6.9 ± 1.8, P < 0.01). By multivariable analysis, new LBBB remained an independent predictor of cardiovascular death (hazard ratio [HR] 7.09, 95% confidence interval [CI] 1.16 - 43.50, P = 0.03) during the 2.9-year follow-up period. There were no significant differences in the incidence of all-cause mortality (HR 0.48, 95% CI 0.17 - 1.37, P = 0.16) and PPI (HR 2.61, 95% CI 0.85 - 0.80, P = 0.08) between patients with new LBBB compared to those without it.
Conclusion: New LBBB after TAVR procedure is associated with an increased risk of death from cardiovascular causes, but it did not increase the risk of all-cause mortality and PPI over the long-term period.
Keywords: Aortic Stenosis. Transcatheter Aortic Valve Replacement. Left Bundle Branch Block. Permanent Pacemaker Implantation.
Short-Term Outcomes of Patients with Non-Metastatic Malignant Solid Tumor after Coronary Artery Bypass Grafting: A Population-Based Study of National/Nationwide Inpatient Sample From 2015 To 2020
Braz J Cardiovasc Surg 2025;
e20240202
Publish in: 7/31/2025
Introduction: Previous studies found that patients with a history of cancer either have
similar outcomes or face an increased risk of early morbidity following
cardiac surgery. However, the applicability of these findings to clinical
practice may be constrained by the heterogeneity of cancer patients. To
refine our understanding, this study focuses specifically on the in-hospital
outcomes of patients with non-metastatic malignant solid tumors (NMST)
undergoing coronary artery bypass grafting (CABG).
Methods: Patients who underwent CABG were identified in National/Nationwide Inpatient Sample from Q4 2015-2020. Exclusion criteria included age < 18 years, concomitant procedures, and other malignancies. A 1:3 propensity-score matching was employed to address differences in demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and admission status between patients with and without NMST. In-hospital outcomes after CABG were evaluated.
Results: There were 2,139 patients with NMST who underwent CABG and who were matched to 6,580 out of 164,351 patients without NMST. Patients with and without NMST had comparable mortality (2.25% vs. 2.16%, P=0.80). However, NMST patients have a higher risk of hemorrhage/hematoma (63.48% vs. 58.27%, P<0.01) and a higher rate of transfer out (28.75% vs. 25.36%, P<0.01). In addition, patients with NMST had longer time from admission to operation (P<0.01), a longer length of stay (P<0.01), and higher hospital charges (P<0.01).
Conclusion: Patients with NMST have comparable short-term outcomes after CABG, except for a higher risk of postoperative bleeding. Thus, CABG could be performed safely for NMST patients, despite long-term prognosis of these patients may require further investigation.
Keywords: Coronary artery bypass; Thoracic Surgery; Neoplasms; Risk; Mortality; Morbidity; Length of Stay
Methods: Patients who underwent CABG were identified in National/Nationwide Inpatient Sample from Q4 2015-2020. Exclusion criteria included age < 18 years, concomitant procedures, and other malignancies. A 1:3 propensity-score matching was employed to address differences in demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and admission status between patients with and without NMST. In-hospital outcomes after CABG were evaluated.
Results: There were 2,139 patients with NMST who underwent CABG and who were matched to 6,580 out of 164,351 patients without NMST. Patients with and without NMST had comparable mortality (2.25% vs. 2.16%, P=0.80). However, NMST patients have a higher risk of hemorrhage/hematoma (63.48% vs. 58.27%, P<0.01) and a higher rate of transfer out (28.75% vs. 25.36%, P<0.01). In addition, patients with NMST had longer time from admission to operation (P<0.01), a longer length of stay (P<0.01), and higher hospital charges (P<0.01).
Conclusion: Patients with NMST have comparable short-term outcomes after CABG, except for a higher risk of postoperative bleeding. Thus, CABG could be performed safely for NMST patients, despite long-term prognosis of these patients may require further investigation.
Keywords: Coronary artery bypass; Thoracic Surgery; Neoplasms; Risk; Mortality; Morbidity; Length of Stay
Evaluation of Intraoperative and Postoperative Blood Cell Salvage Use in Cardiac Surgery with Cardiopulmonary Bypass
Braz J Cardiovasc Surg 2025;
e20240244
Publish in: 7/31/2025
Introduction: Blood transfusion is associated with adverse clinical and surgical outcomes.
Strategies like the Patient Blood Management program, which includes blood
cell salvage, contribute to reducing the use of blood components. Blood cell
salvage is very useful in heart surgeries where the patient's blood loss can
be massive.
Objective: The present study aimed to evaluate the impact of using the blood cell salvage in the intraoperative and postoperative periods (up to 24 hours) on the hemoglobin and hematocrit values, transfusion of red blood cells, infection rates, and postoperative length of stay in patients undergoing cardiac surgery with cardiopulmonary bypass.
Methods: Forty-one patients who underwent cardiac surgery with cardiopulmonary bypass according to the inclusion criteria were selected in an observational study and separated into two groups: with the use of the blood cell salvage group (BCS, n = 21) and without the use of the blood cell salvage (WBCS, n = 20).
Results: Patients in the group using blood cell salvage had higher postoperative hemoglobin (P = 0.018) and postoperative hematocrit levels (P = 0.009), lower consumption of red blood cells in the postoperative period and hospital discharge (P < 0.001), shorter postoperative length of stay (P = 0.020), and lower infection rates (P = 0.009).
Conclusion: Patient Blood Management strategies, particularly the use of blood cell salvage in the intraoperative and immediate postoperative periods of patients undergoing cardiac surgery with cardiopulmonary bypass, are associated with less use of blood components and consequently better clinical outcomes.
Keywords: Cardiopulmonary bypass; Erythrocytes; Infections; Hemoglobins; Length of stay; Hematocrit
Objective: The present study aimed to evaluate the impact of using the blood cell salvage in the intraoperative and postoperative periods (up to 24 hours) on the hemoglobin and hematocrit values, transfusion of red blood cells, infection rates, and postoperative length of stay in patients undergoing cardiac surgery with cardiopulmonary bypass.
Methods: Forty-one patients who underwent cardiac surgery with cardiopulmonary bypass according to the inclusion criteria were selected in an observational study and separated into two groups: with the use of the blood cell salvage group (BCS, n = 21) and without the use of the blood cell salvage (WBCS, n = 20).
Results: Patients in the group using blood cell salvage had higher postoperative hemoglobin (P = 0.018) and postoperative hematocrit levels (P = 0.009), lower consumption of red blood cells in the postoperative period and hospital discharge (P < 0.001), shorter postoperative length of stay (P = 0.020), and lower infection rates (P = 0.009).
Conclusion: Patient Blood Management strategies, particularly the use of blood cell salvage in the intraoperative and immediate postoperative periods of patients undergoing cardiac surgery with cardiopulmonary bypass, are associated with less use of blood components and consequently better clinical outcomes.
Keywords: Cardiopulmonary bypass; Erythrocytes; Infections; Hemoglobins; Length of stay; Hematocrit
The Ticking Clock of Aortic Root Replacement - Single-Center Experience After Urgent and Emergent Aortic Root Replacement Using the BioIntegral and Freestyle™ Bioconduits
Braz J Cardiovasc Surg 2025;
e20240307
Publish in: 7/31/2025
Introduction: Aortic root pathologies needing full aortic root replacement are challenging
entities correlated to high morbidity and mortality due to their complexity
and mostly refer to high-risk patients. In this retrospective study, we
report our surgical experience and clinical results of patients undergoing a
Bentall procedure as primary or reoperative surgery with the application of
aortic bioconduits.
Methods: Patients who underwent full aortic root replacement utilizing either BioIntegral (BI) or Medtronic Freestyle™ (FS) bioconduit in the Cardiothoracic Surgery Department of the University Hospital Aachen RWTH from January 2015 until September 2020, in an urgent or emergency setting, were analyzed and followed up until December 2023.
Results: Twenty-six patients underwent aortic root replacement with bioconduits (N=11 with BI, N=15 with FS) in our center. Twenty-three cases were of infective cause, and three were of noninfective cause; 30.76% were urgent, and 69.23% were emergency cases. Two (7.70%) patients died during operation due to irreversible aortic root damage. In-hospital and 30-day mortality rates were four out 26 (15.4%) patients. The mean follow-up time for all the patients was 52.01 ± 39.41 months. Patients who received a primary aortic root replacement had significantly higher survival than redo cases. BI surgery needed longer cardiopulmonary bypass times.
Conclusion: Clinical outcome was equal for both bioconduits. Further studies with larger cohorts are needed for deeper insights into this complex entity.
Keywords: Thoracic Aorta; Cardiopulmonary bypass; Aortic valve; Bioprosthesis; Hospitals; Outpatients
Methods: Patients who underwent full aortic root replacement utilizing either BioIntegral (BI) or Medtronic Freestyle™ (FS) bioconduit in the Cardiothoracic Surgery Department of the University Hospital Aachen RWTH from January 2015 until September 2020, in an urgent or emergency setting, were analyzed and followed up until December 2023.
Results: Twenty-six patients underwent aortic root replacement with bioconduits (N=11 with BI, N=15 with FS) in our center. Twenty-three cases were of infective cause, and three were of noninfective cause; 30.76% were urgent, and 69.23% were emergency cases. Two (7.70%) patients died during operation due to irreversible aortic root damage. In-hospital and 30-day mortality rates were four out 26 (15.4%) patients. The mean follow-up time for all the patients was 52.01 ± 39.41 months. Patients who received a primary aortic root replacement had significantly higher survival than redo cases. BI surgery needed longer cardiopulmonary bypass times.
Conclusion: Clinical outcome was equal for both bioconduits. Further studies with larger cohorts are needed for deeper insights into this complex entity.
Keywords: Thoracic Aorta; Cardiopulmonary bypass; Aortic valve; Bioprosthesis; Hospitals; Outpatients
CASE REPORT
Repair of Left Ventricular Pseudoaneurysm Due to Systemic Lupus Erythematosus
Braz J Cardiovasc Surg 2025;
e20240038
Publish in: 7/31/2025
Systemic lupus erythematosus is a clinically heterogeneous autoimmune disease that frequently affects young women. The risk of cardiovascular events is higher in patients with this disease than in the general population. In this study, we report a patient who developed a left ventricular pseudoaneurysm with no etiological factor other than systemic lupus erythematosus. Dor ventriculoplasty and mitral ring replacement were performed as surgical treatment. The case is shared because of the rarity of left ventricular pseudoaneurysm due to systemic lupus erythematosus and successful pseudoaneurysm repair.
Keywords: Left Ventricular Pseudo-Aneurysm; Systemic Lupus Erythematosus; Ventriculoplasty
Triple Arterial Minimally Invasive Direct Coronary Artery Bypass Grafting: Step-By-Step Technique Report
Braz J Cardiovasc Surg 2025;
e20240193
Publish in: 7/31/2025
Minimally invasive direct coronary artery bypass grafting (MIDCAB) has considerable benefits over the conventional coronary artery bypass grafting procedure. This case report presents the MIDCAB procedure in a multivessel coronary disease using triple arterial grafts and four arterial anastomoses. The initial anastomosis was made between the left intrathoracic mammary artery (LIMA) and the radial artery (RA), as an end-to-side "T" graft. Next, the RIMA was used to left anterior descending anastomosis. The first obtuse marginal (OM1) branch was grafted to allow LIMA-OM1 side-to-side anastomosis. Then, with the diagonal branch (Dg) opened, the formation of a "jumping" anastomosis was made using LIMA-OM1-Dg. The posterior descending artery (PDA) was used to create a LIMA-RA-PDA.
Keywords: Coronary artery bypass; Coronary Artery Disease; Surgical Anastomosis; Mammary arteries; Radial arteryOccurrence of Acute Aortic Dissection Twice During the Same Pregnancy
Braz J Cardiovasc Surg 2025;
e20230401
Publish in: 7/31/2025
Pregnancy-related aortic dissection is an uncommon and serious condition since it poses a risk to the lives of both the mother and the fetus. Here, we describe a pregnant woman who suffered from aortic dissection twice during the same pregnancy and whose fetus was safely delivered following aortic root replacement and thoracic aortic stent-graft implantation.
Keywords: Thoracic Aortic; Aortic Dissection; Pregnancy; Marfan syndrome; Stens; Transplants
Robotic-Assisted Minimally Invasive Direct Coronary Artery Bypass Grafting with Concomitant Left Atrial Appendage Exclusion
Braz J Cardiovasc Surg 2025;
e20240198
Publish in: 7/31/2025
Off-pump robotic-assisted minimally invasive direct coronary artery bypass (MIDCAB) achieves revascularization without conventional sternotomy and provides benefit to patients that otherwise may not be ideal surgical candidates. For patients with comorbid atrial fibrillation, left atrial appendage exclusion may reduce stroke risk and is achievable via mini thoracotomy during concomitant MIDCAB. Here, we report four patients who underwent off-pump robotic-assisted MIDCAB and concurrent epicardial left atrial appendage exclusion. Intraoperative transesophageal echocardiography confirmed complete left atrial appendage exclusion in all cases. The concomitant robotic approach proved to be feasible, efficacious, and safe, with no postoperative mortality or stroke events during follow-up.
Keywords: Atrial fibrillation; Coronary artery bypass; Echocardiography; Transesophageal; Mortality; Risk; Sternotomy
Reviving Duran’s Approach to Pericardial Valve Reconstruction in the Pulmonary Position Within the Right Ventricle-to-Pulmonary Artery Conduit: A Compelling Case Report
Braz J Cardiovasc Surg 2025;
e20240123
Publish in: 7/31/2025
Various techniques of conduit repair have been employed during valve reconstruction. While Ozaki conduits have streamlined the procedure, their limited availability poses concerns. This case report presents 14-year-old patient with pulmonary atresia and an anomalous left anterior descending artery arising from the right sinus. A right ventricle-to-pulmonary artery conduit was created using Dacron® graft and a trileaflet valve employing Duran's technique of pericardial valve reconstruction, elucidating surgical methodology. In developing countries, the implementation of Duran's technique presents noteworthy advantage allowing for utilization of autologous tissue, addressing challenges associated with PTFE conduits. Unlike PTFE conduits, the results of Duran’s technique at the pulmonary position needs to be followed up in a large number of cases.
Keywords: Pulmonary atresia; Pulmonary artery; Congenital Heart Defects; Polyethylene Terephthalates; Adolescent;Dacron® Graft Kinking Following Ascending Aorta Replacement Is Not Only a Cosmetic Issue
Braz J Cardiovasc Surg 2025;
e20220468
Publish in: 7/31/2025
A 58-year-old man, who has undergone ascending aorta replacement, started to complain of pain in the lower limbs, shortness of breath, and progressive fatigue a few months after surgery. Transthoracic and transesophageal Doppler echocardiographies revealed a diseased bicuspid aortic valve and a subocclusive mass in the ascending aorta. Thoracic computed tomography angiography confirmed the presence of a subocclusive mass, pseudoaneurysm formation, and a distorted shape of the Dacron® graft. The patient underwent urgent surgery to remove the mass, which appeared to be a thrombus, and aortic valve and ascending aorta replacement. Kinking of vascular graft has been reported including surgical techniques to correct the excessive length to avoid gradients and guarantee laminar flow. When kinking is severe, high gradients and hemolysis can be detected. However, thrombus formation in the ascending aorta segment is less likely, due to the high blood velocity flow. Therefore, several concurrent causes should be considered. In this case, the most probable explanation for thrombus formation was kinking of a too long Dacron® graft, combined with extrinsic compression effect of the graft by the pseudoaneurysm at the anastomosis site and anomalous flow directed from the diseased bicuspid aortic valve. Various grades of Dacron® graft kinking might occur following ascending aorta replacement and undiagnosed at follow-up especially if resulting in mild symptoms, thus, careful visual and echocardiography evaluation should be done at the end of surgery. Finally, distorted Dacron® graft might trigger thrombus formation when inflammation and coagulation processes are set off during bacteria or viral infection.
Keywords: Aortic valve; Bicuspid Aortic Valve Disease; Polyethylene Terephthalates; Hemolysis; Surgical Anastomosis, Bacteria, Fatigue; InflammationMini-Sternotomy for Aortic Valve Replacement with Concomitant Ablation of the Pulmonary Vein and Persistent Left Superior Vena Cava: A Case Report
Braz J Cardiovasc Surg 2025;
e20240053
Publish in: 7/31/2025
A 79-year-old man with severe aortic valve stenosis and atrial fibrillation was referred to our department for surgery. Computed tomography revealed persistent left superior vena cava. Lower mini-sternotomy was performed. The left atrial appendage was amputated before ablation of the persistent left superior vena cava. The jaw of the ablation device was passed behind the pulmonary veins using a tip-lighted articulating dissector. Finally, aortic valve replacement was completed. Aortic valve replacement with concomitant pulmonary vein and persistent left superior vena cava ablation via lower mini-sternotomy is a safe and less invasive alternative.
Keywords: Superior Vena Cava; Persistent Left Superior Vena Cava; Sternotomy; Aortic valve stenosis; Atrial Appendage; Tomography;Catheter for Hemodialysis in Persistent Left Superior Vena Cava in a Patient with Aortic Valve Endocarditis
Braz J Cardiovasc Surg 2025;
e20230266
Publish in: 7/31/2025
Persistent left superior vena cava (PLSVC) is a common congenital venous anomaly, usually associated with other congenital heart diseases (12%). Its incidence in the general population is 0.5%. In cardiac surgery patients, it is suspected when using the left subclavian vein or left internal jugular vein for central venous catheter or hemodialysis catheter placement. Transthoracic ultrasound exam is useful in confirming the position of catheters in the venous system by injecting a 5% glucose solution that can be visualized in the right atrium after administration through the catheter. Hemodialysis catheters can be inserted in the PLSVC with good catheter function and no major risk in increase of complications.
Keywords: Cardiac surgery; Hemodialysis; Central Venous Catheter; Persistent Left Superior Vena Cava
Treatment of Sternocutaneous Fistula Due to Cardiac Surgery Using Extracellular Matrix Patch
Braz J Cardiovasc Surg 2025;
e20240137
Publish in: 7/31/2025
The incidence of sternal wound complications, such as dehiscences, infections, and sternocutaneous fistulas, can reach 10%. Sternocutaneous fistulas are extremely rare, and the only definite therapy is surgical repair. Our experience taught us that combining a traditional approach with an extracellular matrix patch might be a step forward in therapy. We described three examples of surgically reconstructing sternocutaneous fistulas with an extracellular matrix patch (ProxiCor®).
Keywords: Incidence; Sternum/surgery; Surgical wound infection; Cutaneous Fistula; Cardiac Surgical Procedures;
REVIEW ARTICLE
Rheumatic Mitral Valve Surgery: Repair or Replacement?
Braz J Cardiovasc Surg 2025;
e20230294
Publish in: 7/31/2025
Introduction: Rheumatic heart disease remains a public health problem, especially in developing countries. The mitral valve (MV) is the main affected cardiac structure, requiring intervention in many cases. The discussion of which is the best option - repair or replacement - is still a controversy.
Objective: To compare the survival of patients with rheumatic MV submitted to replacement or repair.
Methods: We systematically reviewed the English literature through PubMed®, Literatura Latino-Americana e do Caribe em Ciências da Saúde (or LILACS), Scientific Electronic Library Online (or SciELO), and Google Scholar between January 2021 and February 2022, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (or PRISMA) methodology. Articles with a sample of at least 30 patients who underwent MV replacement or repair were included.
Results: Six studies including 2874 patients were analyzed. Most of the patients were female (2001; 69.6%) with a ratio of 2.3:1. The ages ranged from 11 to 66 years. The mean follow-up varied from six to 106 months. In the MV repair group, mortality was 2.5% (62 of 2473) and reoperation was 3.7% (93 of 2473), while in the MV replacement group, mortality was 8.2% (106 of 1291), and 3.6% (54 of 1475) of the patients required reoperation. The patient's survival was similar (85% for repair and 87% for replacement). The main complications post-MV repair or replacement were stroke (1.8%; 2.5%) and endocarditis (0.5%; 1.3%).
Conclusion: The MV repair had lower mortality and fewer complications compared to MV replacement. Reoperation rate and survival are similar.
Keywords: Rheumatic heart disease; Reoperation; Mitral Valve; Treatment outcome; Review;
Objective: To compare the survival of patients with rheumatic MV submitted to replacement or repair.
Methods: We systematically reviewed the English literature through PubMed®, Literatura Latino-Americana e do Caribe em Ciências da Saúde (or LILACS), Scientific Electronic Library Online (or SciELO), and Google Scholar between January 2021 and February 2022, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (or PRISMA) methodology. Articles with a sample of at least 30 patients who underwent MV replacement or repair were included.
Results: Six studies including 2874 patients were analyzed. Most of the patients were female (2001; 69.6%) with a ratio of 2.3:1. The ages ranged from 11 to 66 years. The mean follow-up varied from six to 106 months. In the MV repair group, mortality was 2.5% (62 of 2473) and reoperation was 3.7% (93 of 2473), while in the MV replacement group, mortality was 8.2% (106 of 1291), and 3.6% (54 of 1475) of the patients required reoperation. The patient's survival was similar (85% for repair and 87% for replacement). The main complications post-MV repair or replacement were stroke (1.8%; 2.5%) and endocarditis (0.5%; 1.3%).
Conclusion: The MV repair had lower mortality and fewer complications compared to MV replacement. Reoperation rate and survival are similar.
Keywords: Rheumatic heart disease; Reoperation; Mitral Valve; Treatment outcome; Review;
Mini-Sternotomy vs. Right Anterior Mini-Thoracotomy for Surgical Aortic Valve Replacement – A Systematic Review and Meta-Analysis
Braz J Cardiovasc Surg 2025;
e20240211
Publish in: 7/31/2025
Introduction: Minimally invasive techniques for aortic valve replacement have become
increasingly popular. The most common minimally invasive approaches are
mini-sternotomy and right anterior mini-thoracotomy. We aimed to review the
literature and compare clinical outcomes for these two approaches.
Methods: Three databases were assessed. The primary endpoint was perioperative mortality. The secondary endpoints were reoperation for bleeding, stroke, operation duration, intensive care unit length of stay, cardiopulmonary bypass time, cross-clamping time, hospital length of stay, paravalvular leak, renal complications, conversion to full sternotomy, permanent pacemaker implantation, and wound infection. Random effects models were performed.
Results: Ten studies were included in the meta-analysis (30,524 patients). There was no difference in perioperative mortality between groups (odds ratio: 0.83; 95% confidence interval 0.57-1.21; P=0.33). In comparison with mini-sternotomy, right anterior mini-thoracotomy showed higher rates of reoperation for bleeding (odds ratio: 0.69; 95% confidence interval 0.50-0.97; P=0.03), lower rates of stroke (odds ratio: 1.27; 95% confidence interval 1.01-1.60; P=0.04), and longer operation duration (standard mean difference: -0.58; 95% confidence interval -1.01 to -0.14; P=0.01). Other secondary endpoints were not statistically significant.
Conclusion: The results suggest that both techniques present similar perioperative mortality rates for aortic valve replacement. However, right anterior mini-thoracotomy is associated with higher rates of reoperation for bleeding, lower rates of stroke, and longer operation duration time.
Keywords: Aortic valve; Sternotomy; Thoracotomy; Reoperation, Aortic Valve; Constriction; Length of stay; Stroke;
Methods: Three databases were assessed. The primary endpoint was perioperative mortality. The secondary endpoints were reoperation for bleeding, stroke, operation duration, intensive care unit length of stay, cardiopulmonary bypass time, cross-clamping time, hospital length of stay, paravalvular leak, renal complications, conversion to full sternotomy, permanent pacemaker implantation, and wound infection. Random effects models were performed.
Results: Ten studies were included in the meta-analysis (30,524 patients). There was no difference in perioperative mortality between groups (odds ratio: 0.83; 95% confidence interval 0.57-1.21; P=0.33). In comparison with mini-sternotomy, right anterior mini-thoracotomy showed higher rates of reoperation for bleeding (odds ratio: 0.69; 95% confidence interval 0.50-0.97; P=0.03), lower rates of stroke (odds ratio: 1.27; 95% confidence interval 1.01-1.60; P=0.04), and longer operation duration (standard mean difference: -0.58; 95% confidence interval -1.01 to -0.14; P=0.01). Other secondary endpoints were not statistically significant.
Conclusion: The results suggest that both techniques present similar perioperative mortality rates for aortic valve replacement. However, right anterior mini-thoracotomy is associated with higher rates of reoperation for bleeding, lower rates of stroke, and longer operation duration time.
Keywords: Aortic valve; Sternotomy; Thoracotomy; Reoperation, Aortic Valve; Constriction; Length of stay; Stroke;
Five-Year Mortality of Surgical and Transcatheter Aortic Valve Replacement in the Real-World Scenario: A Systematic Review and Meta-Analysis of Propensity Score Matching Studies
Braz J Cardiovasc Surg 2025;
e20240048
Publish in: 7/31/2025
Introduction: Randomized controlled trials (RCTs) provide evidence of efficacy, while
real-world data (RWD) demonstrate effectiveness in real-world practice. We
designed a systematic review and meta-analysis of reconstructed
time-to-event (RTE) data from propensity score matching studies comparing
transcatheter aortic valve implantation (TAVI) and surgical aortic valve
replacement (SAVR) to compare their effectiveness and evaluate the
generalizability of TAVI indications.
Methods: Systematic review of literature between 2007 and 2023 including propensity score matching studies comparing TAVI or SAVR that reported at least one-year Kaplan-Meier curves of endpoints.
Results: Twenty-one studies were included (39538 participants). TAVI shows a higher all-cause mortality (hazard ratio [HR] 1.41; 95% confidence interval [CI] 1.34-1.47, P-value < 0.001), with a significant heterogeneity. The analysis of HR trend over time shows that TAVI superiority is limited to the first month with a steep reversal afterwards, when SAVR becomes clearly superior. All-cause mortality is significantly higher in TAVI in low-risk (HR 1.35; 95% CI 1.08-1.69, P-value < 0.001) as well as in intermediate (HR 1.73; 95% CI 1.35-2.22, P-value < 0.001) and high-risk (HR 1.61; 95% CI 1.38-1.88, P-value < 0.001) patients. The HR trend in the subgroups of risk confirms the data from the whole mixed population.
Conclusion: In a real-word setting, TAVI is associated with higher incidence of all-cause death and maintains a survival benefit only in the first month after implantation. These results show that TAVI effectiveness may not reflect the efficacy demonstrated by RCTs and pose a threat to their external validity.
Keywords: Transcatheter Aortic Valve Replacement; Aortic valve; Meta-analysis; Systematic Review
Methods: Systematic review of literature between 2007 and 2023 including propensity score matching studies comparing TAVI or SAVR that reported at least one-year Kaplan-Meier curves of endpoints.
Results: Twenty-one studies were included (39538 participants). TAVI shows a higher all-cause mortality (hazard ratio [HR] 1.41; 95% confidence interval [CI] 1.34-1.47, P-value < 0.001), with a significant heterogeneity. The analysis of HR trend over time shows that TAVI superiority is limited to the first month with a steep reversal afterwards, when SAVR becomes clearly superior. All-cause mortality is significantly higher in TAVI in low-risk (HR 1.35; 95% CI 1.08-1.69, P-value < 0.001) as well as in intermediate (HR 1.73; 95% CI 1.35-2.22, P-value < 0.001) and high-risk (HR 1.61; 95% CI 1.38-1.88, P-value < 0.001) patients. The HR trend in the subgroups of risk confirms the data from the whole mixed population.
Conclusion: In a real-word setting, TAVI is associated with higher incidence of all-cause death and maintains a survival benefit only in the first month after implantation. These results show that TAVI effectiveness may not reflect the efficacy demonstrated by RCTs and pose a threat to their external validity.
Keywords: Transcatheter Aortic Valve Replacement; Aortic valve; Meta-analysis; Systematic Review
Optimizing Antibiotic Therapy and Circuit Management in Extracorporeal Membrane Oxygenation: A Comprehensive Narrative Review of Clinical Strategies and Evidence
Braz J Cardiovasc Surg 2025;
e20240158
Publish in: 7/31/2025
Introduction: Extracorporeal membrane oxygenation (ECMO) has emerged as a life-saving
therapy for patients with severe respiratory and cardiac failure. However,
the management of infections and circuit sequestration remains a significant
challenge in ECMO patients. This narrative review aims to provide a
comprehensive overview of current strategies and evidence related to
antibiotics therapy and circuit management in ECMO.
Methods: A systematic search was conducted in medical databases including PubMed® and Google Scholar to identify relevant studies published up to January 2022. Keywords such as "antibiotics therapy ECMO", "circuit sequestration ECMO", and related terms were used to retrieve articles. Studies focusing on infections acquired during ECMO, antibiotic dosing, circuit optimization, and outcomes were included.
Results: The search yielded a total of 20 relevant studies encompassing various aspects of antibiotics therapy and circuit sequestration in ECMO patients. Key findings include the epidemiology of infections acquired during ECMO, optimal antibiotic dosing strategies, risk factors for circuit-related complications, and the impact of circuit changes on patient outcomes. Effective management of infections and circuit sequestration is essential to improve outcomes in ECMO patients.
Conclusion: This review highlights the importance of tailored antibiotic therapy, vigilant circuit monitoring, and evidence-based practices to mitigate complications and optimize patient care during ECMO support. Further research is needed to refine existing strategies and enhance the overall management of ECMO-associated infections and circuit issues.
Keywords: Extracorporeal membrane oxygenation; Antibiotics Therapy; Circuit Sequestration; Infections; Antibiotic Dosing
Methods: A systematic search was conducted in medical databases including PubMed® and Google Scholar to identify relevant studies published up to January 2022. Keywords such as "antibiotics therapy ECMO", "circuit sequestration ECMO", and related terms were used to retrieve articles. Studies focusing on infections acquired during ECMO, antibiotic dosing, circuit optimization, and outcomes were included.
Results: The search yielded a total of 20 relevant studies encompassing various aspects of antibiotics therapy and circuit sequestration in ECMO patients. Key findings include the epidemiology of infections acquired during ECMO, optimal antibiotic dosing strategies, risk factors for circuit-related complications, and the impact of circuit changes on patient outcomes. Effective management of infections and circuit sequestration is essential to improve outcomes in ECMO patients.
Conclusion: This review highlights the importance of tailored antibiotic therapy, vigilant circuit monitoring, and evidence-based practices to mitigate complications and optimize patient care during ECMO support. Further research is needed to refine existing strategies and enhance the overall management of ECMO-associated infections and circuit issues.
Keywords: Extracorporeal membrane oxygenation; Antibiotics Therapy; Circuit Sequestration; Infections; Antibiotic Dosing
Prevalence of Hearing Loss After Open-Heart Surgery: A Systematic Review
Braz J Cardiovasc Surg 2025;
e20230197
Publish in: 7/31/2025
Introduction: Today, due to the increase in the incidence of heart problems in people, we
see an increase in the number of heart surgeries worldwide. Hearing
disorders in the form of hearing loss have been reported as one of the side
effects of this kind of surgery in some studies. Considering the evidence of
the effect of open-heart surgery on patients’ hearing loss, this systematic
review study was conducted to determine the frequency of hearing loss after
open-heart surgery.
Methods: To carry out this systematic review, studies that investigated hearing loss after open-heart surgery in Iran and the rest of world, published in Persian or English, and various international electronic databases including PubMed®, Web of Science, Scopus®, and authentic Persian sources (e.g., Irandoc and Scientific Information Database) until the end of 2021 have been indexed.
Results: In the initial review, 46 of the 2230 initially searched articles had the conditions for further review. After checking the articles’ title and abstract and the working method of the studies and removing duplicates and incomplete articles, a total of 16 articles were included in the study. Then, their results were analyzed as the frequency of hearing loss after open-heart surgery by age and sex.
Conclusion: The review of various studies confirms the fact that after open-heart surgery, the existence of evidence of hearing changes is not far from expected.
Keywords: Hearing Loss; Deafness; Cardiac surgical procedures; Systematic Review Study
Methods: To carry out this systematic review, studies that investigated hearing loss after open-heart surgery in Iran and the rest of world, published in Persian or English, and various international electronic databases including PubMed®, Web of Science, Scopus®, and authentic Persian sources (e.g., Irandoc and Scientific Information Database) until the end of 2021 have been indexed.
Results: In the initial review, 46 of the 2230 initially searched articles had the conditions for further review. After checking the articles’ title and abstract and the working method of the studies and removing duplicates and incomplete articles, a total of 16 articles were included in the study. Then, their results were analyzed as the frequency of hearing loss after open-heart surgery by age and sex.
Conclusion: The review of various studies confirms the fact that after open-heart surgery, the existence of evidence of hearing changes is not far from expected.
Keywords: Hearing Loss; Deafness; Cardiac surgical procedures; Systematic Review Study
SPECIAL ARTICLE
A Pioneer of Cardiothoracic Surgery — the Brazilian Northeast Heart Transplant Program
Braz J Cardiovasc Surg 2025;
e2024128
Publish in: 7/31/2025
This review highlights the pivotal milestones in the development of cardiac transplantation and related techniques. Beginning with Alexis Carrel's pioneering work on vascular anastomosis and organ preservation, the narrative progresses through groundbreaking achievements such as John Gibbon's invention of the heart-lung machine in 1953 and James Hardy's daring chimpanzee-to-human heart transplant in 1964. The story culminates in Christiaan Barnard’s historic human heart transplant in 1967 and Euryclides Zerbini's leadership in bringing this innovation to Brazil in 1968. Key advancements include the development of orthotopic heart transplantation techniques by Richard Lower and Norman Shumway and the resurgence of heart transplants following the introduction of cyclosporine in 1983, which revolutionized organ rejection management. The collaborative Programa Nordeste de Transplante Cardíaco, initiated in 1986, exemplifies regional innovation in overcoming logistical and financial barriers in Brazil. Recent progress, such as the first successful xenotransplantation using a genetically modified pig heart in 2022, underscores ongoing efforts to address donor shortages and improve transplant outcomes. This narrative is a testament to human ingenuity and perseverance in offering life-saving solutions to end-stage heart disease.
Keywords: Surgery; Pioneer; Heart transplantation; Historical ArticleResearch and Development of Ventricular Assist Devices: Experiences from the Instituto Dante Pazzanese de Cardiologia
Braz J Cardiovasc Surg 2025;
e20240209
Publish in: 7/31/2025
Ventricular assist devices have been widely accepted as an alternative treatment for advanced heart failure, while heart transplantation is a limited procedure because of the shortage of donors. In face of a scarce availability of these devices, many centers around the world have developed their own technologies. We describe historical and general features of the main ventricular assist devices developed at the Instituto Dante Pazzanese de Cardiologia. The auxiliary total artificial heart is an electromechanical pulsatile blood pump with left and right chambers, being originally designed to work as a heterotopic artificial heart. The spiral pump is a disposable device and currently available for clinical use in cardiopulmonary bypass. It works through a combination of centrifugal and axial pumping principles coming from a conically shaped impeller. The implantable centrifugal blood pump was conceived for long-term circulatory assistance with a unique impeller design concept producing a mixed flow. The apico-aortic blood pump consists of a miniaturized centrifugal pump originally conceived for bridge to transplantation strategy. The temporary circulatory support device is a new centrifugal blood pump for temporary ventricular assistance developed with the purpose of bridge-to-decision or recovery strategies. Additionally, the hybrid cardiovascular simulator was developed as a tool to test blood pumps as they minimize the need for animal experiments. Brazil represents an important reference with a few academic groups with a considerable output in ventricular assist devices research and development. Notable devices produced at Instituto Dante Pazzanese de Cardiologia have demonstrated excellent results for clinical application.
Keywords: Engineering; Heart-assist devices; Cardiopulmonary bypass; Animal experimentation; Heart failure; Heart transplantation; Artificial Heart;Off-pump Myocardial Revascularization — From the Beginning Till Now
Braz J Cardiovasc Surg 2025;
e20240993
Publish in: 7/31/2025
BRIEF COMMUNICATION
Simple Endocardial Running Suture Technique for Concealing Prosthetic Material in Mitral Valve Annulus Cerclage to Prevent Hemolysis
Braz J Cardiovasc Surg 2025;
e20240309
Publish in: 7/31/2025
EDITORIAL
Between Science and Humanity: The Journey of Paulo Évora
Braz J Cardiovasc Surg 2025;
e20250902
Publish in: 7/31/2025
A Paradigm Shift in Managing Carotid Artery Disease Associated with Coronary Artery Bypass Grafting
Braz J Cardiovasc Surg 2025;
e20250901
Publish in: 7/31/2025
The Bioartificial Heart: Our Mission to Mars
Braz J Cardiovasc Surg 2025;
e20250044
Publish in: 7/31/2025
Bridging Gaps, Building Legacy: The Role of BJCVS in Latin American Science
Braz J Cardiovasc Surg 2025;
e20250904
Publish in: 7/31/2025
ERRATUM
ORIGINAL ARTICLE
Association Between Suicide Donors and Outcomes in Heart Transplantation: A Retrospective Cohort Study
Braz J Cardiovasc Surg 2025;
e20240299
Publish in: 7/31/2025
Introduction: The use of organs from suicide donors in heart transplantation is controversial due to potential concerns about graft function and recipient outcomes. This study investigates the association between heart transplantation using suicide donors related with the incidence of primary graft dysfunction (PGD) and mortality within 30 days after transplant.
Methods: A retrospective analysis was conducted on 97 adult heart transplant recipients at the Instituto do Coração of São Paulo between 2020 and 2021. Data on donor characteristics (age, sex, mechanism of brain death), recipient preoperative status (age, sex, cardiomyopathy etiology, body mass index, comorbidities, use of intra-aortic balloon pump, extracorporeal membrane oxygenation [ECMO]), intraoperative variables (ischemia time, cardiopulmonary bypass time, implantation time), and postoperative outcomes (use of ECMO, mortality) were analyzed.
Results: Of the 97 transplants analyzed, six were from suicide donors (6.2%). Recipients of hearts from suicide donors had a significantly higher need for ECMO (33.3% vs. 4.4%, P = 0.036), increased PGD (66.7% vs. 19.8%, P < 0.05), and higher 30-day mortality (50% vs. 3.3%, P < 0.05) compared to non-suicide donors. No significant intraoperative time differences were found between the groups.
Conclusion: This study is the first to identify a significant association between heart transplantation from suicide donors and adverse outcomes, including higher rates of PGD and early mortality. These findings suggest possible psychological and biological influences on organ quality and transplantation outcomes. Further research is needed to clarify these associations and inform donor selection criteria.
Keywords: Heart transplantation; Donors; Primary Graft Dysfunction; Organ preservation; Inflammatory Markers;
Methods: A retrospective analysis was conducted on 97 adult heart transplant recipients at the Instituto do Coração of São Paulo between 2020 and 2021. Data on donor characteristics (age, sex, mechanism of brain death), recipient preoperative status (age, sex, cardiomyopathy etiology, body mass index, comorbidities, use of intra-aortic balloon pump, extracorporeal membrane oxygenation [ECMO]), intraoperative variables (ischemia time, cardiopulmonary bypass time, implantation time), and postoperative outcomes (use of ECMO, mortality) were analyzed.
Results: Of the 97 transplants analyzed, six were from suicide donors (6.2%). Recipients of hearts from suicide donors had a significantly higher need for ECMO (33.3% vs. 4.4%, P = 0.036), increased PGD (66.7% vs. 19.8%, P < 0.05), and higher 30-day mortality (50% vs. 3.3%, P < 0.05) compared to non-suicide donors. No significant intraoperative time differences were found between the groups.
Conclusion: This study is the first to identify a significant association between heart transplantation from suicide donors and adverse outcomes, including higher rates of PGD and early mortality. These findings suggest possible psychological and biological influences on organ quality and transplantation outcomes. Further research is needed to clarify these associations and inform donor selection criteria.
Keywords: Heart transplantation; Donors; Primary Graft Dysfunction; Organ preservation; Inflammatory Markers;
Perioperative Neurocognitive Disorder After Cardiac Surgery – A Narrative Study of a Retrospective Casuistic
Braz J Cardiovasc Surg 2025;
e20240216
Publish in: 7/31/2025
Introduction: Delirium is one of the most serious and common neuropsychological complications in the immediate postoperative period of cardiac surgery, always resulting in negative consequences, prolonged hospitalization, and increased early and late morbidity and mortality.
Methods: An active search for acute cognitive dysfunction was performed in the electronic medical records written by the multidisciplinary team about the immediate postoperative period of 262 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass operated on in 2019 at the Instituto do Coração of Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo. To maintain randomness, data were collected from 25 patients per month for a total of 10 months.
Results: Seventy-three patients (27.9%) presented symptoms of delirium or perioperative neurocognitive disorder in the postoperative period, with a median time of four days. The most frequent symptoms were changes in cognition (25.6%), attention (25.2%), and agitation (24.8%). Patients with delirium had a longer intensive care unit stay (median seven days vs. three days, P < 0.001), longer mechanical ventilation (median 977 vs. 535, P < 0.001), longer hospital stay (median 20 days vs. 13 days, P < 0.001), and higher incidence of hospital death (22.2% vs. 3.2%, P < 0.001).
Conclusion: The incidence of delirium immediately after cardiac surgery was high, around 27.9%, which is consistent with values found in the literature. The occurrence of delirium was highly associated with worse outcomes, such as longer hospital stays and mortality.
Characteristics of Hemodialysis Patients and Renal Transplant Recipients Undergoing Cardiovascular Intervention: Is It Possible to Predict Cardiac Risk?
Braz J Cardiovasc Surg 2025;
e20240291
Publish in: 7/31/2025
Introduction: Cardiovascular problems are one of the major causes of morbidity and mortality among renal transplant and hemodialysis patients. This study evaluates the preoperative risk factors and postoperative outcomes in patients undergoing heart surgery.
Methods: A total of 83 patients (47 post-renal transplant recipients and 36 on hemodialysis) who underwent cardiac surgery and percutaneous coronary artery procedures at Dr. Siyami Ersek Heart Hospital between 2015 and 2022 were retrospectively analyzed using hospital electronic records without selection bias. Demographic information, such as age, sex, height, weight, and body mass index, cardiac surgery type, and preoperative laboratory findings were recorded.
Results: Renal transplant recipients and hemodialysis patients undergoing heart surgery showed no significant differences in age, sex, or comorbidities (P > 0.05). Both groups had a high percentage of patients with elevated fasting blood glucose, triglycerides, and low-density lipoprotein levels. Additionally, body mass index and the triglyceride-glucose index were elevated, indicating insulin resistance. Renal transplant recipients with low preoperative glomerular filtration rate and hemoglobin levels < 10 g/dL had a higher risk of developing acute kidney injury. Four patients (9%) experienced graft loss after acute kidney injury, requiring hemodialysis. Mortality rates did not differ significantly between the groups (P > 0.56).
Conclusion: Cardiovascular surgery can be safely performed in both renal transplant recipients with functional allografts and end-stage kidney disease patients on hemodialysis. Identifying and managing risk factors in these patients, who frequently experience cardiovascular complications, will lead to better outcomes.
Keywords: Cardiac surgical procedures; Renal dialysis; Acute kidney injury; Selection Bias; Insulin Resistance;
Methods: A total of 83 patients (47 post-renal transplant recipients and 36 on hemodialysis) who underwent cardiac surgery and percutaneous coronary artery procedures at Dr. Siyami Ersek Heart Hospital between 2015 and 2022 were retrospectively analyzed using hospital electronic records without selection bias. Demographic information, such as age, sex, height, weight, and body mass index, cardiac surgery type, and preoperative laboratory findings were recorded.
Results: Renal transplant recipients and hemodialysis patients undergoing heart surgery showed no significant differences in age, sex, or comorbidities (P > 0.05). Both groups had a high percentage of patients with elevated fasting blood glucose, triglycerides, and low-density lipoprotein levels. Additionally, body mass index and the triglyceride-glucose index were elevated, indicating insulin resistance. Renal transplant recipients with low preoperative glomerular filtration rate and hemoglobin levels < 10 g/dL had a higher risk of developing acute kidney injury. Four patients (9%) experienced graft loss after acute kidney injury, requiring hemodialysis. Mortality rates did not differ significantly between the groups (P > 0.56).
Conclusion: Cardiovascular surgery can be safely performed in both renal transplant recipients with functional allografts and end-stage kidney disease patients on hemodialysis. Identifying and managing risk factors in these patients, who frequently experience cardiovascular complications, will lead to better outcomes.
Keywords: Cardiac surgical procedures; Renal dialysis; Acute kidney injury; Selection Bias; Insulin Resistance;
Impact of Right Coronary Artery Bypass Grafting on Development of Atrial Fibrillation in Coronary Artery Bypass Grafting Surgery: A Retrospective Study
Braz J Cardiovasc Surg 2025;
e20240325
Publish in: 7/31/2025
Introduction: Previous studies suggest that the location of coronary artery disease cannot independently predict atrial fibrillation after coronary artery bypass grafting, but with little information, it has also been thought that simultaneous right coronary endarterectomy may cause this rhythm problem.
Objective: In this study, we aimed to evaluate the effect of right coronary artery bypass grafting on early postoperative atrial fibrillation.
Methods: Patients who underwent elective on-pump coronary artery bypass grafting operations in our hospital were included in the study, and patients who underwent a different open-heart surgery or those who had previously undergone open-heart surgery were not included. Patients included in the study were divided into Group 1 (patients who developed postoperative atrial fibrillation) and Group 2 (patients who did not develop postoperative atrial fibrillation) and compared in terms of right coronary artery bypass grafting and other follow-up parameters.
Results: The mean age of a total of 158 patients included in the study was determined as 63.25 ± 10.07 years (range 44 - 85 years), 120 were male, and 96% of them had hypertension. Postoperative atrial fibrillation developed in 43 patients, and right coronary artery bypass grafting was performed in 123 patients.
Conclusion: We think that the frequency of postoperative atrial fibrillation development may be higher in cases where right coronary artery bypass grafting is performed, as it may play a role in processes related to the conduction system and right ventricular dysfunction, and multicenter studies with a large number of patients would be beneficial on this subject.
HOW I DO IT
Concomitant Box Lesion Ablation for Atrial Fibrillation with a Standard Non-Irrigated Bipolar Radiofrequency Clamp: Simplified Approach Without Left Atriotomy
Braz J Cardiovasc Surg 2025;
e20230432
Publish in: 7/31/2025
In this paper, the authors describe a simplified technique for concomitant left atrial posterior box isolation for atrial fibrillation using a standard nonirrigated bipolar radiofrequency clamp without opening the left atrium.
Keywords: Atrial Fibrillation; Surgical Ablation; Posterior Box Isolation
Reentry to the Mediastinum When the Ascending Aorta Is Adherent to the Sternum: A Two-Stage Sternotomy Approach
Braz J Cardiovasc Surg 2025;
e20230310
Publish in: 7/31/2025
Reentry to the mediastinum when the ascending aorta aneurysm is adherent to the sternum is characterized by high risk of aneurysm rupture during sternum opening. In such cases, often cardiopulmonary bypass via peripheral vessels is instituted, and reentry done in deep hypothermia and circulatory arrest. To reduce both risks of aneurysm rupture during resternotomy and those related to prolonged cardiopulmonary bypass time, we present a surgical approach consisting of a two-stage sternotomy to avoid the risky zone and extra-anatomic epiaortic vessels anastomoses.
Keywords: Ascending Aorta Aneurysm; Cardiopulmonary Bypass; Hypthermia; Mediastinum; Sternotomy; Sternum; Time
LETTER TO THE EDITOR
Bridging the Gap Between Research and Clinical Practice in Cardiac Tumors
Braz J Cardiovasc Surg 2025;
e20240298
Publish in: 7/31/2025
Coronary Artery Bypass Grafting in Patients with Reduced Ventricular Function: The Devil Is in The Details
Braz J Cardiovasc Surg 2025;
e20240052
Publish in: 7/31/2025
Post-Infarction Left Ventricular Aneurysm Repair
Braz J Cardiovasc Surg 2025;
e20230449
Publish in: 7/31/2025
Body Perfusion Management in Aortic Arch Surgery
Braz J Cardiovasc Surg 2025;
e20240054
Publish in: 7/31/2025
Sowing an Idea to Harvest a Better Future
Braz J Cardiovasc Surg 2025;
e20240166
Publish in: 7/31/2025
What Is in a Name?
Braz J Cardiovasc Surg 2025;
e20240221
Publish in: 7/31/2025
Is the Fate of the Internal Mammary Vein in CABG Similar to that of the Saphenous Vein?
Braz J Cardiovasc Surg 2025;
e20230332
Publish in: 7/31/2025
Survival Analysis in Adult Heart Transplantation: Correspondence
Braz J Cardiovasc Surg 2025;
e20240310
Publish in: 7/31/2025
The Ticking Surgical Clock: Outcome, Predictor, or a Bit of Both?
Braz J Cardiovasc Surg 2025;
e20240084
Publish in: 7/31/2025
Trends, Implications, and Outcomes in the Changing Landscape of Cardiac Surgery: Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis and Concomitant Coronary Artery Disease
Braz J Cardiovasc Surg 2025;
e20240050
Publish in: 7/31/2025
Post-Cardiotomy Blood Parameters as a Prognostic Marker in Acute Aortic Dissection Surgery
Braz J Cardiovasc Surg 2025;
e20240087
Publish in: 7/31/2025
Perspectives of Pediatric Cardiology on the Creation of Pediatric Congenital Heart Surgery Subspecialty in Brazil
Braz J Cardiovasc Surg 2025;
e20240200
Publish in: 7/31/2025
EDUCATIONAL FORUM
Therapeutic Considerations of Post-Myocardial Infarction Ventricular Septal Defect in the Elderly - An Educational Presentation
Braz J Cardiovasc Surg 2025;
e20240249
Publish in: 7/31/2025
Post-myocardial infarction ventricular septal defect is an infrequent complication associated with low survival rates in the absence of surgical management. An 80-year-old woman presents to the emergency department with an inferior wall ST-segment elevation myocardial infarction with complete occlusion of the right coronary artery and a rupture of the interventricular septum with rapid deterioration to cardiogenic shock. Advanced age, female sex, and cardiogenic shock are associated with high mortality. The use of intra-aortic balloon pump improves hemodynamic status, allowing stabilization in the preoperative period.
Keywords: Heart Septal Defects. Ventricular. Myocardial infarction. Cardiogenic shock. Hospital Emergency Service. Preoperative Period.Early Acute Aortic Dissection After Coronary Artery Bypass Grafting
Braz J Cardiovasc Surg 2025;
e20230342
Publish in: 7/31/2025
Patients having Stanford type A acute dissection soon after cardiac surgery have a high risk of rupture and death. The presentation, management, and outcome of primary dissection of the ascending aorta (Stanford type A or De Bakey type I or II) are well described. However, patients with Stanford type A acute aortic dissection soon (3-4 weeks) after primary cardiac surgery have distinctly different presentation, management, and postoperative outcome. In this report, we describe the clinical and surgical findings of a patient with early Stanford type A acute aortic dissection four weeks after primary coronary artery bypass grafting.
Keywords: Coronary artery bypass; Aortic Dissection; Cardiac surgical procedures; Thoracic Aorta; Aortic Dissection
EXPERT OPINION
Multisociety endorsement of the 2024 European guideline recommendations on coronary revascularization
Braz J Cardiovasc Surg 2025;
e20250900
Publish in: 7/31/2025