Volume 32 - Número 6

Introduction: Most risk stratification scores used in surgery do not include external and non-technical factors as predictors of morbidity and mortality.
Objective: The present study aimed to translate and adapt transculturally the Brazilian version of the Disruptions in Surgery Index (DiSI) questionnaire, which was developed to capture the self-perception of each member of the surgical team regarding the disruptions that may contribute to error and obstruction of safe surgical flow.
Methods: A universalist approach was adopted to evaluate the conceptual equivalence of items and semantics, which included the following stages: (1) translation of the questionnaire into Portuguese; (2) back translation into English; (3) panel of experts to draft the preliminary version; and (4) pre-test for evaluation of verbal comprehension by the target population of 43 professionals working in cardiothoracic surgery.
Results: The questionnaire was translated into Portuguese and its final version with 29 items obtained 89.6% approval from the panel of experts. The target population evaluated all items as easy to understand. The mean overall clarity and verbal comprehension observed in the pre-test reached 4.48 ± 0.16 out of the maximum value of 5 on the psychometric Likert scale.
Conclusion: Based on the methodology used, the experts' analysis and the results of the pre-test, it is concluded that the essential stages of translation and cross-cultural adaptation of DiSI to the Portuguese language were satisfactorily fulfilled in this study.

Objective: The present study refers to a determination of the preoperative B-type natriuretic peptide is a predictor of short-term all-cause mortality in patients undergoing on-pump coronary artery bypass graft surgeries.
Methods: Two hundred and twenty-one patients undergoing on-pump coronary artery bypass graft surgeries were evaluated prospectively during a 30-day postoperative follow-up period. Serum B-type natriuretic peptide concentration was measured without a 24-hour period prior to the surgical procedure and the value obtained was correlated with a short-term all-cause mortality.
Results: Data analysis showed that all-cause mortality rates were equal to 9.5% in 30 days. Accuracy analysis by the receiver operating characteristic curve found an ideal cut-off value of B-type natriuretic peptide equal to 150 pg/mL in relation to mortality (AUC=0.82, 95% CI=0.71-0.87, P<0.001). Multivariate analysis showed that B-type natriuretic peptide value greater than or equal to 150 pg/mL (P=0.030, HR=3.99, 95% CI=1.14-13.98) was an independent predictor of all-cause mortality in a 30-day follow-up period.
Conclusion: Preoperative serum B-type natriuretic peptide concentration is an independent predictor of short-term all-cause mortality in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.

Introduction: Extracorporeal membrane oxygenation (ECMO) has become a standard technique over the past few decades in intensive care unit (ICU).
Objective: A review of pediatric patients who received ECMO support in the pediatric cardiac ICU was conducted to determine the incidence, risk factors and causal organisms related to acquired infections and assess the survival rates of ECMO patients with nosocomial infections.
Methods: Sixty-six patients who received ECMO support in the pediatric cardiac ICU between January 2011 and June 2014 were included in the study. Demographic, echocardiographic, hemodynamic features and surgical procedures were reviewed.
Results: Sixty-six patients received a total of 292.5 days of venoarterial ECMO support. Sixty were postoperative patients. Forty-five patients were weaned from ECMO support with an ECMO survival rate of 68.2%. The rate of infection was 116.2/1000 ECMO days. Prolonged ICU stay, duration of ventilation and ECMO were found associated with development of nosocomial infection and only the duration of ECMO was an independent risk factor for nosocomial infections in ECMO patients.
Conclusion: The correction of the underlying process leading to ECMO support and shortening the length of ECMO duration together with stricter application of ECMO indications would improve the infection incidence and hospital surveillance of the patient group.

Introduction: Few reports in the world have shown a differential effect of hypothyroidism in relation to morbidity and mortality following cardiac surgery.
Objective: To determine the association between preoperative hypothyroidism, composite and disaggregated outcomes of mortality and complications in patients undergoing first-time isolated myocardial revascularization surgery.
Methods: Historical cohort of patients undergoing myocardial revascularization between January 2008 and December 2014, with 626 patients included for evaluation of the composite and disaggregated outcomes of in-hospital mortality and complications (atrial fibrillation, surgical site infection and reoperation due to bleeding). A logistic regression model was used to determine the association between hypothyroidism and the onset of those outcomes.
Results: Cohort of 1696 eligible patients for the study, with 1.8 mortality. Median age, female gender and prevalence of arterial hypertension were all significantly higher among hypothyroid patients. No differences were found in other preoperative or intraoperative characteristics. Hypothyroidism was associated with the presence of the composite outcome, RR 1.6 (1.04-2.4) and atrial fibrillation 1.9 (1.05-3.8). No association with mortality, infections or reoperation due to bleeding was found.
Conclusion: Hypothyroidism is a disease that affects females predominantly and does not determine the presence of other comorbidities. Hypothyroidism is a risk factor for the onset of postoperative fibrillation in patients undergoing myocardial revascularization surgery. Postoperative care protocols focused on the prevention of these complications in this type of patients must be instituted.

Objective: To assess the clinical value of four models for the prediction of cardiac surgery-associated acute kidney injury (CSA-AKI) and severe AKI which renal replacement therapy was needed (RRT-AKI) in Chinese patients.
Methods: 1587 patients who underwent cardiac surgery in the department of cardiac surgery in the Zhongshan Hospital, Fudan University, between January 2013 and December 2013 were enrolled in this research. Evaluating the predicting value for cardiac surgery-associated AKI (AKICS score) and RRT-AKI (Cleveland score, SRI and Mehta score) by Hosmer-Lemeshow goodness-of-fit test for the calibration and area under receiver operating characteristic curve (AUROC) for the discrimination.
Results: Based on 2012 KDIGO (Kidney Disease: Improving Global Outcomes) AKI definition, the incidence of AKI and RRT-AKI was 37.4% (594/1587) and 1.1% (18/1587), respectively. The mortality of AKI and RRT-AKI was 6.1% (36/594) and 66.7% (12/18), respectively, while the total mortality was 2.8% (44/1587). The discrimination (AUROC=0.610) for the prediction of CSA-AKI of AKICS was low, while the calibration (x2=7.55, P=0.109) was fair. For the prediction of RRT-AKI, the discrimination of Cleveland score (AUROC=0.684), Mehta score (AUROC=0.708) and SRI (AUROC=0.622) were not good; while the calibration of them were fair (Cleveland score x2=1.918, P=0.166; Mehta score x2=9.209, P=0.238; SRI x2=2.976, P=0.271).
Conclusion: In our single-center study, based upon valve surgery dominant and less diabetes mellitus patients, according to KDIGO AKI definition, the predictive value of the four models, combining discrimination and calibration, for respective primary event, were not convincible.

Introduction: Tissue adhesives can be used as adjacent to sutures to drop or avoid bleeding in cardiovascular operations.
Objective: To verify the efficiency of fibrin and cyanoacrylate adhesive to seal arterial sutures and if the adhesives penetrate through suture line to the inner of arteries.
Methods: 20 abdominal aorta segments of pigs were divided into two groups according to the adhesive which would be used as adjacent to the suture. In every arterial segment an arteriotomy was done, followed by a conventional artery closure. Afterwards a colloidal fluid was injected inside the arterial segment with a simultaneous intravascular pressure monitoring up to a fluid leakage through the suture. This procedure was repeated after application of one of the adhesives on the suture in order to check if the bursting pressure increases. The inner aorta segments also were analyzed in order to check if there was intraluminal adhesive penetration.
Results: In Suture 1 group, the mean arterial pressure sustained by the arterial suture reached 86±5.35 mmHg and after the fibrin adhesive application reached 104±11.96 (P<0.002). In the Suture 2 group, the mean arterial pressure sustained by the suture reached 83±2.67 mmHg and after the cyanoacrylate adhesive application reached 152±14.58 mmHg (P<0.002). Intraluminal adhesive penetration has not been noticed.
Conclusion: There was a significant rise in the bursting pressure when tissue adhesives were used as adjacent to arterial suture, and this rise was higher if the cyanoacrylate adhesive was used. In addition, the adhesives do not penetrate through the suture line into the arteries.

Introduction: Chronic stimulation of the right ventricle with pacemaker is associated with ventricular dyssynchrony and loss of contractility, even in subjects without previous dysfunction. In these patients, there is a debate of which pacing site is less associated with loss of ventricular function.
Objective: To compare pacemaker-induced dyssynchrony among different pacing sites in right ventricular stimulation.
Methods: Cross-sectional study of outpatients with right ventricle stimulation higher than 80% and preserved left ventricular ejection fraction. Pacing lead position (apical, medial septum or free wall) was assessed through chest X-rays. Every patient underwent echocardiogram to evaluate for dyssynchrony according to CARE-HF criteria: aortic pre-ejection time, interventricular delay and septum/posterior wall delay on M mode.
Results: Forty patients were included. Fifty-two percent had apical electrode position, 42% mid septum and 6% free wall. Mean QRS time 148.97±15.52 milliseconds. A weak correlation between the mean QRS width and pre-aortic ejection time (r=0.32; P=0.04) was found. No difference in QRS width among the positions could be noted. Intraventricular delay was lower in apical patients against mid septal (34.4±17.2 vs. 54.3±19.1 P<0.05) - no difference with those electrode on the free wall. No difference was noted in the pre-aortic ejection time (P=0.9).
Conclusion: Apical pacing showed a lower interventricular conduction delay when compared to medial septum site. Our findings suggest that apical pacing dyssynchrony is not ubiquitous, as previously thought, and that it should remain an option for lead placement.

Introduction: The implantable cardioverter defibrillator had been increasing the survival of patients at high risk for sudden cardiac death. The subcutaneous implantable cardioverter defibrillator was developed to mitigate the complications inherent to lead placement into cardiovascular system.
Objective: To report the initial experience of 18 consecutive cases of subcutaneous implantable cardioverter defibrillator implantation showing the indications, potential pitfalls and perioperative complications.
Methods: Between September 2016 and March 2017, 18 patients with indication for primary and secondary prevention of sudden cardiac death, with no concomitant indication for artificial cardiac pacing, were included.
Results: The implantation of the subcutaneous implantable cardioverter defibrillator successfully performed in 18 patients. It was difficult to place the subcutaneous lead at the parasternal line in two patients. One patient returned a week after the procedure complaining about an increase in pain intensity at pulse generator pocket site, which was associated with edema, temperature rising and hyperemia. Two patients took antialgic medication for five days after surgery. A reintervention was necessary in one patient to replace the lead in order to correct inappropriate shocks caused by myopotential oversensing.
Conclusion: In our initial experience, although the subcutaneous implantable cardioverter defibrillator implantation is a less-invasive, simple-accomplishment procedure, it resulted in a bloodier surgery perhaps requiring an operative care different from the conventional. Inappropriate shock by oversensing is a reality in this system, which should be overcame in order not to become a limiting issue for its indication.

Introduction: The superior cavopulmonary connection operation is one of the stages of the palliative surgical management for patients with functionally single ventricle. After surviving this stage, the patients are potential candidates for the final palliative procedure: the Fontan operation.
Objectives: This study aimed to analyze the outcomes of superior cavopulmonary connection operations in our center and to identify factors affecting the survival and the progression to Fontan stage.
Methods: The outcomes of 161 patients were retrospectively analyzed after undergoing superior cavopulmonary connection operation in our center between 2005 and 2015.
Results: The early mortality rate was 2.5%. Five (3.1%) patients underwent takedown of the superior cavopulmonary connection. The rate of exclusion from the Fontan stage was 8.3%. Statistical analysis revealed that elevated mean pulmonary artery pressure preoperatively and the prior palliation with pulmonary artery banding were risk factors for both early mortality and takedown; however, the age, the morphology of the single ventricle and the type of operation were not considered risk factors.
Conclusion: The superior cavopulmonary connection operation can be performed with low rate mortality and morbidity; however, the elevated mean pulmonary artery pressure preoperatively and the prior pulmonary artery banding are associated with poor outcomes.

Objective: To investigate the mid- and long-term outcomes of case-based selective strategy of mitral ring annuloplasty during coronary artery bypass grafting in patients with coronary artery disease accompanied by chronic ischemic mitral regurgitation.
Methods: 132 patients who were diagnosed ischemic moderate to severe mitral regurgitation undergoing coronary artery bypass grafting in the same center with the same surgical team were divided into 2 groups and investigated retrospectively. Patients undergoing simultaneous mitral ring annuloplasty and coronary artery bypass grafting were enrolled to group 1 (n=58), patients undergoing isolated coronary artery bypass grafting were enrolled in group 2 (n=74).
Results: The mean age of the patients were 65.0 ± 9.4 years and 39 (29.5%) of them were female. Preoperative New York Heart Association (NHYA) class (P=0.0001), atrial fibrillation (P=0.006) and the grade of mitral regurgitation (P=0.0001) were significantly different between the groups. Hospitalization for heart failure was required in 6 (10.6%) patients in group 1 and 19 (27.1%) patients in Group 2 (P=0.02). Hospital mortality and one-month postoperative mortality occurred in 2 (3.4%) patients in Group 1 and in 4 (5.4%) patients in Group 2 (P=0.69). Clinical follow-up was completed with 117 (88.6%) patients.
Conclusion: Mitral ring annuloplasty in addition to the coronary artery bypass grafting is associated with improved NYHA functional class, increased ejection fraction, decreased residual mitral regurgitation. Further studies are needed to clarify the role of combined surgery on long-term outcomes. With proper tools and according to the decisions made by heart teams, both management strategies can be safely performed.

Nonvalvular atrial fibrillation is associated with a 4- to 5-fold strokes increase and may be responsible for 15% to 20% of all strokes in the elderly. In this scenario, the left atrial appendage thrombus would be the associated with 90% of cases. The use of anticoagulants, percutaneous devices, and the left atrial appendage surgical exclusion is still an open discussion. For left atrial appendage procedures, relevant anatomic spatial relationships have to be emphasized, besides the chance of the normal physiological functioning would be eliminated with the proceedings. There are evidences that the left atrial appendage closure during routine cardiac surgery is significantly associated with an increased risk of early postoperative atrial fibrillation. Therefore, the purpose of this review is to focus basic aspects for continuous medical education. In summary, the rationale of this text is to emphasize anatomical and pharmacological aspects involved in the simple surgical exclusion of left atrial appendage under cardiopulmonary bypass. There are several operative techniques, but to conclude this revision it will present one of them based on the discussed basic sciences.

This article describes our proposal for routine anesthesia, intraoperative medical management, cerebral and physiological monitoring during pediatric cardiac surgery with cardiopulmonary bypass that intend to provide appropriate anesthesia (analgesia, hypnosis), neuroprotection, adequate cerebral and systemic oxygen supply, and preventing against drugs neurotoxicity. A concise retrospective data is presented.

Objective: To investigate the relationship between brain natriuretic peptide and recurrence of atrial fibrillation after successful electrical cardioversion.
Methods: Medline and Embase databases were used to identify publications evaluating BNP/N-Terminal (NT)-proBNP levels in association with atrial fibrillation recurrence after successful electrical cardioversion. Nineteen studies that fulfilled the specified criteria of our analysis were found.
Results: Baseline BNP/NT-proBNP levels of the atrial fibrillation recurrence group were significantly higher than those of the sinus rhythm maintaining group (SMD -0.70, CI [-0.82, -0.58]).
Conclusion: Our analysis suggests that low BNP/NT-proBNP levels are associated with sinus rhythm maintenance, and baseline BNP/NT-proBNP concentrations may be a predictor of atrial fibrillation recurrence after successful electrical cardioversion.

Introduction: Spontaneous coronary artery dissection is a sudden separation between the layers of a coronary artery wall, non-iatrogenic or trauma related, that has been recognized as an important cause of myocardial infarction.
Objective: To report an emblematic case, in terms of angiographic images, clinical presentation and predisposing factors, whose clinical management failure led to surgical intervention.
Methods: A previously healthy 48-year-old male farmer was admitted to the emergency room complaining of anterior chest pain described as "tearing", which started after physical exertion. Anterior wall ST-segment depression was observed in the electrocardiogram and troponin levels were increased. The patient then underwent coronary catheterization. Angiography showed a tortuous left anterior descending coronary artery with a dissection line involving proximal and middle segments, resulting in mild to moderate luminal stenosis. At first, a conservative approach was chosen. Control cardiac catheterization, 3 months later, showed dissection progression to the distal segment.
Results: The patient was referred to surgical treatment. Internal thoracic artery and a great saphenous vein graft were used to revascularize the target vessels. He had an uneventful postoperative course.
Conclusion: In this report, we describe a typical clinical manifestation of an uncommon cause of acute myocardial infarction. The dissection was started by an extreme physical effort, which is a known triggering factor. Management of these cases is always challenging because there are no evidence-based therapies or guideline-based recomendations.

Embolization by a dislodged projectile is a rare complication that may occur in cases of gunshot cardiac injuries. We report a case of a firearm projectile cardiac injury that evolved, with dislocation of the projectile during cardiac surgery, into embolization of the right external carotid artery.

Left atrial dissection is a rare factor that may cause left ventricular assist device obstruction. Prompt diagnosis and surgical repair are essential. This case report describes our experience and a successful surgical management in a patient after HeartMate 3 implantation and mitral valve inflow obstruction due to a left atrial dissection.

Stent-graft migration and type I endoleaks are associated with a higher rate of reintervention and increased mortality and morbidity. This article describes a patient presented with an infrarenal aortic stent-graft which had migrated into the aortic sac with loss of all aortic neck attachment. The acutely expanding abdominal aortic aneurysm was treated by placing a second modular endograft within and above the migrated stentgraft. The patient returned 36 months later, with features of an acute myocardial infarction, severe bilateral lower limb ischemia, and renal failure. He was too ill for intervention and demised within 48 hours.