Volume 35 - Número 1
EDITORIAL
The Brazilian Contributions to Congenital Cardiac Surgery
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Heart Transplantation: New Decade, New Perspectives
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Reasons to Keep “Case Reports” Alive
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
ORIGINAL ARTICLE
Does Prior Percutaneous Coronary Intervention Influence the Outcomes of Coronary Artery Bypass Surgery?
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Introduction: Percutaneous coronary intervention (PCI) has been increasingly performed to treat coronary artery disease. The performance of multiple PCI has also been increasing. Consequently, the percentage of patients presenting for coronary artery bypass graft (CABG) surgery is reported to vary from 13 to 40%. The influence of previous PCI on CABG outcomes has been studied in single center, regional studies, registries and meta-analyses. Some reports showed a negative effect on mortality and morbidity in early or long-term follow-up, but others did not find this influence.
Methods and Results: A cohort of 3007 patients consecutively operated for CABG, 261 of them with previous PCI, were included in this analysis. Comparison of the groups "previous PCI" and "primary CABG" was made in the original cohort and in a propensity score matched cohort of 261 patients. There were some differences in preoperative clinical characteristics in both types of cohort, even in the matched one. Outcomes were compared at 30 days, 1 year and 5 years of follow-up. There were no statistically significant differences in mortality in any period or cohort. There were some differences in other outcomes as readmission and composite events, including cardiovascular death at 1 and 5 years of follow-up. These differences, neverthless, were not confirmed in comparison with the matched cohort.
Conclusion: Although there are some limitations in this study, it was not found consistent negative influence of previous PCI on CABG.
Keywords: Coronary Artery Disease; Propensity Score; Patient Readmission; Coronary artery bypass; Percutaneous Coronary Intervation; Registries
Methods and Results: A cohort of 3007 patients consecutively operated for CABG, 261 of them with previous PCI, were included in this analysis. Comparison of the groups "previous PCI" and "primary CABG" was made in the original cohort and in a propensity score matched cohort of 261 patients. There were some differences in preoperative clinical characteristics in both types of cohort, even in the matched one. Outcomes were compared at 30 days, 1 year and 5 years of follow-up. There were no statistically significant differences in mortality in any period or cohort. There were some differences in other outcomes as readmission and composite events, including cardiovascular death at 1 and 5 years of follow-up. These differences, neverthless, were not confirmed in comparison with the matched cohort.
Conclusion: Although there are some limitations in this study, it was not found consistent negative influence of previous PCI on CABG.
Keywords: Coronary Artery Disease; Propensity Score; Patient Readmission; Coronary artery bypass; Percutaneous Coronary Intervation; Registries
Coronary Endarterectomy: a Case Control Study and Evaluation of Early Patency Rate of Endarterectomized Arteries
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Objective: To compare two groups of patients - the coronary endarterectomy group, with patients undergoing coronary artery bypass grafting (CABG) with coronary endarterectomy (CE), and the control group, with patients undergoing CABG without CE. We analyzed the rate of major outcomes (perioperative acute myocardial infarction [AMI], stroke, and mortality) and minor outcomes (time of cardiopulmonary bypass [CPB], time of aortic clamp, and postoperative length of hospital stay). We also determined the rates of early graft patency in patients undergoing CE.
Methods: We reviewed a database of patients submitted to CABG, with or without associated CE, between January 2011 and June 2017. Twenty-five patients submitted to CE were compared with 201 patients submitted only to conventional surgery; the two groups presented similar preoperative characteristics and all the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II variables did not presented statistically significant difference. We considered statistically significant values of P< 0.05.
Results: There was no statistically significant difference in relation to time of post-surgical hospitalization (P=0.8139), incidence of perioperative AMI (P=0.2976), stroke (P=0,2976), and mortality rate (P=1.0000), but endarterectomy was associated with longer aortic clamping time (P=0.0004) and CPB time (P=0.0030). The rate of patency evaluated in patients submitted to endarterectomy (78,95%) was compatible with that described in the literature.
Conclusion: In this sample, coronary endarterectomy was associated with the rate of early graft patency similar to that of the literature, with morbidity and mortality rates similar to those of conventional surgery.
Keywords: Cardiopulmonary bypass; Coronary artery bypass; Endarterectomy; Morbity; Myocardial Infarctation; Stroke; Length of stay
Methods: We reviewed a database of patients submitted to CABG, with or without associated CE, between January 2011 and June 2017. Twenty-five patients submitted to CE were compared with 201 patients submitted only to conventional surgery; the two groups presented similar preoperative characteristics and all the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II variables did not presented statistically significant difference. We considered statistically significant values of P< 0.05.
Results: There was no statistically significant difference in relation to time of post-surgical hospitalization (P=0.8139), incidence of perioperative AMI (P=0.2976), stroke (P=0,2976), and mortality rate (P=1.0000), but endarterectomy was associated with longer aortic clamping time (P=0.0004) and CPB time (P=0.0030). The rate of patency evaluated in patients submitted to endarterectomy (78,95%) was compatible with that described in the literature.
Conclusion: In this sample, coronary endarterectomy was associated with the rate of early graft patency similar to that of the literature, with morbidity and mortality rates similar to those of conventional surgery.
Keywords: Cardiopulmonary bypass; Coronary artery bypass; Endarterectomy; Morbity; Myocardial Infarctation; Stroke; Length of stay
Bioelectrical Impedance Analysis for Monitoring Fluid and Body Cell Mass Changes in Patients Undergoing Cardiopulmonary Bypass
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Objective: To evaluate preoperative and postoperative body fluid distribution with a bioelectrical impedance analyzer in patients undergoing cardiopulmonary bypass.
Methods: Fifteen adult patients undergoing cardiopulmonary bypass were included in this study. Total body fluid changes, basal metabolism rates, body fat masses, lean body masses, and total cell masses were recorded. The patients’ values were measured before anesthesia, after anesthesia, after sternotomy, at the 5th, 30th, and 60th minutes of cardiopulmonary bypass, and on the 1st, 3rd, and 5th postoperative days. All values were compared with preoperative values.
Results: Total body fluid changed significantly after cardiopulmonary bypass (P<0.01). Metabolic velocity significantly changed compared to preoperative measurements (P<0.05). Fat mass and lean body mass also changed significantly. Body mass index and phase angle did not change significantly (P>0.05).
Conclusion: Changes in body fluids during and after cardiopulmonary bypass are inevitable. The increase in total body weight shows that this fluid load shifts to the extracellular space during bypass and the fluid load in this area passes into the intravascular area in the early postoperative period. This may cause edema and dysfunction in the major organs. Therefore, the fluid balance should be adjusted very carefully, especially during the bypass phase and the early postoperative period.
Keywords: Bioelectrical Impedance; Fat Mass; Lean Body Mass; Total Body Water; Cardiopulmonary bypass
Methods: Fifteen adult patients undergoing cardiopulmonary bypass were included in this study. Total body fluid changes, basal metabolism rates, body fat masses, lean body masses, and total cell masses were recorded. The patients’ values were measured before anesthesia, after anesthesia, after sternotomy, at the 5th, 30th, and 60th minutes of cardiopulmonary bypass, and on the 1st, 3rd, and 5th postoperative days. All values were compared with preoperative values.
Results: Total body fluid changed significantly after cardiopulmonary bypass (P<0.01). Metabolic velocity significantly changed compared to preoperative measurements (P<0.05). Fat mass and lean body mass also changed significantly. Body mass index and phase angle did not change significantly (P>0.05).
Conclusion: Changes in body fluids during and after cardiopulmonary bypass are inevitable. The increase in total body weight shows that this fluid load shifts to the extracellular space during bypass and the fluid load in this area passes into the intravascular area in the early postoperative period. This may cause edema and dysfunction in the major organs. Therefore, the fluid balance should be adjusted very carefully, especially during the bypass phase and the early postoperative period.
Keywords: Bioelectrical Impedance; Fat Mass; Lean Body Mass; Total Body Water; Cardiopulmonary bypass
Thoracoscopic Pulmonary Vein and Left Atrial Posterior Wall Isolation Combined with Left Atrial Appendage Resection in Patients with Long-Standing Persistent Atrial Fibrillation
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Objective: To evaluate the efficacy and safety of a modified technique for totally thoracoscopic left atrial posterior wall and pulmonary vein isolation in patients with long-standing persistent atrial fibrillation.
Methods: From April 2017 to December 2018, we included in this study 28 consecutive patients who underwent thoracoscopic left atrial posterior wall and pulmonary vein radiofrequency isolation combined with left atrial appendage resection. We used a device with irrigated electrodes (Medtronic Cardioblate Gemini-s). The original surgical technique “GALAXY” proposed by Doty in 2012 was modified. The number of ablations was significantly increased, and frequent position changing of the ablation device and change of device angulation were added.
Results: Sinus rhythm was restored in all patients. There was no operative mortality, no myocardial infarction, and no stroke or transient ischemic attack. One patient required sternotomy and another survived left anterolateral thoracotomy due to bleeding. A 180-day follow-up (24-hour Holter monitoring) revealed no sign of recurrence of atrial fibrillation or other supraventricular arrhythmia in any patient. Mean follow-up was nine months (range: 6-16 months). At the last follow-up, 26 patients (92,9%) were in sinus rhythm (24-hour Holter monitoring).
Conclusion: A frequent ablation device position changing during the surgery makes it possible to achieve complete left atrial posterior wall and pulmonary veins isolation. An increased number of applications allows to avoid a false positive transmural damage assessment showed by impedance drop. Also, frequent position changing of the ablation device and increased number of applications do not affect the number of postoperative complications.
Keywords: Atrial fibrillation; Pulmonary veins; Ischemic Attack, Transient; Sternotomy; Thoracotomy; Myocardial infarction; Postoperative complications
Methods: From April 2017 to December 2018, we included in this study 28 consecutive patients who underwent thoracoscopic left atrial posterior wall and pulmonary vein radiofrequency isolation combined with left atrial appendage resection. We used a device with irrigated electrodes (Medtronic Cardioblate Gemini-s). The original surgical technique “GALAXY” proposed by Doty in 2012 was modified. The number of ablations was significantly increased, and frequent position changing of the ablation device and change of device angulation were added.
Results: Sinus rhythm was restored in all patients. There was no operative mortality, no myocardial infarction, and no stroke or transient ischemic attack. One patient required sternotomy and another survived left anterolateral thoracotomy due to bleeding. A 180-day follow-up (24-hour Holter monitoring) revealed no sign of recurrence of atrial fibrillation or other supraventricular arrhythmia in any patient. Mean follow-up was nine months (range: 6-16 months). At the last follow-up, 26 patients (92,9%) were in sinus rhythm (24-hour Holter monitoring).
Conclusion: A frequent ablation device position changing during the surgery makes it possible to achieve complete left atrial posterior wall and pulmonary veins isolation. An increased number of applications allows to avoid a false positive transmural damage assessment showed by impedance drop. Also, frequent position changing of the ablation device and increased number of applications do not affect the number of postoperative complications.
Keywords: Atrial fibrillation; Pulmonary veins; Ischemic Attack, Transient; Sternotomy; Thoracotomy; Myocardial infarction; Postoperative complications
Comparison of Femoral and Axillary Artery Cannulation in Acute Type A Aortic Dissection Surgery
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Introduction: One of the most important points of the acute type A aortic dissection surgery is how to perform cannulation regarding cerebral protection concerns and the conditions of arterial structures as a pathophysiological consequence of the disease.
Objective: In this study, femoral and axillary cannulation methods were compared in acute type A aortic dissection operations.
Methods: The study retrospectively evaluated 52 patients who underwent emergency surgery for acute type A aortic dissection. Patients without malperfusion according to Penn Aa classification were chosen for preoperative standardization of the study groups. The femoral arterial cannulation group was group 1 (n=22) and the axillary arterial cannulation group was group 2 (n=30). The groups were compared in terms of perioperative and postoperative results.
Results: There was no statistically significant difference in terms of preoperative data. In terms of postoperative parameters, especially early mortality and new-onset cerebrovascular event, there was no statistically significant difference. Mortality rates in group 1 and group 2 were 13.6% (n=3) and 10% (n=3), respectively (P=0.685). Postoperative new-onset cerebral events ratio was found in 5 (22.7%) in the femoral cannulation group and 6 (20%) in the axillary cannulation group (P=0.812).
Conclusion: Both femoral and axillary arterial cannulation methods can be safely performed in patients with acute type A aortic dissection, provided that cerebral protection strategies should be considered in the first place. The method to be performed may vary depending on the patient’s current medical condition or the surgeon's preference.
Keywords: Aneurysm; Dissecting; Catheterization; Vascular surgical procedures; Surgeons
Objective: In this study, femoral and axillary cannulation methods were compared in acute type A aortic dissection operations.
Methods: The study retrospectively evaluated 52 patients who underwent emergency surgery for acute type A aortic dissection. Patients without malperfusion according to Penn Aa classification were chosen for preoperative standardization of the study groups. The femoral arterial cannulation group was group 1 (n=22) and the axillary arterial cannulation group was group 2 (n=30). The groups were compared in terms of perioperative and postoperative results.
Results: There was no statistically significant difference in terms of preoperative data. In terms of postoperative parameters, especially early mortality and new-onset cerebrovascular event, there was no statistically significant difference. Mortality rates in group 1 and group 2 were 13.6% (n=3) and 10% (n=3), respectively (P=0.685). Postoperative new-onset cerebral events ratio was found in 5 (22.7%) in the femoral cannulation group and 6 (20%) in the axillary cannulation group (P=0.812).
Conclusion: Both femoral and axillary arterial cannulation methods can be safely performed in patients with acute type A aortic dissection, provided that cerebral protection strategies should be considered in the first place. The method to be performed may vary depending on the patient’s current medical condition or the surgeon's preference.
Keywords: Aneurysm; Dissecting; Catheterization; Vascular surgical procedures; Surgeons
Influence of Bentall Procedure on Left Ventricular Function
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Objective: To evaluate the influence of Bentall procedure on left ventricular function and condition on long-term follow-up.
Methods: Seventy-three consecutive patients who underwent an aortic root and ascending aorta replacement with composite valve button Bentall or flanged Bentall technique, from January 2007 to November 2018, were included in this retrospective study.
Results: Postoperative left ventricular ejection fraction significantly increased (52.14±11.38 vs. 56.79±11.36; P=0.041), left ventricular end-systolic diameter significantly reduced (38.25±9.31 mm vs. 34.17±9.15 mm; P=0.027), left ventricular end-diastolic diameter significantly reduced (56.42±9.72 mm vs. 51.58±9.03 mm; P=0.01), and left atrial diameter significantly reduced (45.33±12.77 mm vs. 39.25±12.41 mm; P=0.01), compared to preoperative values. Our long-term survival results are comparable with previous studies in which survival rates in 5 years and 10 years were 83.5% and 69.8%, respectively. In comparing patients according to their New York Heart Association (NYHA) functional class, it was shown that their postoperative functional capacity was improved during the follow-up period (2.1±0.56 vs. 1.2±0.42; P=0.001).
Conclusion: The Bentall procedure significantly improved the left ventricular systolic function and condition and decreased the left ventricular end-systolic and end-diastolic diameters and the left atrial diameter on long-term follow-up, based on the transthoracic echocardiography. Bentall procedure can be performed with acceptable mortality and morbidity rates on long-term follow-up.
Keywords: Ventricular function; Left; Survival rate; Atrial Fibrilation; Aortic Valce; Echocardiography; Diastole
Methods: Seventy-three consecutive patients who underwent an aortic root and ascending aorta replacement with composite valve button Bentall or flanged Bentall technique, from January 2007 to November 2018, were included in this retrospective study.
Results: Postoperative left ventricular ejection fraction significantly increased (52.14±11.38 vs. 56.79±11.36; P=0.041), left ventricular end-systolic diameter significantly reduced (38.25±9.31 mm vs. 34.17±9.15 mm; P=0.027), left ventricular end-diastolic diameter significantly reduced (56.42±9.72 mm vs. 51.58±9.03 mm; P=0.01), and left atrial diameter significantly reduced (45.33±12.77 mm vs. 39.25±12.41 mm; P=0.01), compared to preoperative values. Our long-term survival results are comparable with previous studies in which survival rates in 5 years and 10 years were 83.5% and 69.8%, respectively. In comparing patients according to their New York Heart Association (NYHA) functional class, it was shown that their postoperative functional capacity was improved during the follow-up period (2.1±0.56 vs. 1.2±0.42; P=0.001).
Conclusion: The Bentall procedure significantly improved the left ventricular systolic function and condition and decreased the left ventricular end-systolic and end-diastolic diameters and the left atrial diameter on long-term follow-up, based on the transthoracic echocardiography. Bentall procedure can be performed with acceptable mortality and morbidity rates on long-term follow-up.
Keywords: Ventricular function; Left; Survival rate; Atrial Fibrilation; Aortic Valce; Echocardiography; Diastole
Infra-Abdominal Muscles Activation Brings Benefits to the Pulmonary Function of Patients with Sternal Instability after Cardiac Surgery
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Objective: To compare physical therapy strategies involving abdominal muscle stabilization, with and without upper limb movement, in patients with sternal instability after heart surgery and during in-hospital care.
Methods: This prospective, longitudinal, randomized, and comparative clinical study included 20 patients, which were divided into two groups: ARM, the arm group (n=10), and LEG, the leg group (n=10). The study involved the evaluation of scores of visual analog scales for sternal instability, pain, discomfort, functional impairment, lung function, and maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) before and after the interventions. Two protocols consisting of abdominal exercises in both groups with upper limb movements (ARM) and just abdominal activation with leg movements (LEG) were used for three weeks.
Results: There were statistically significant (P≤0.01) improvements in pain, discomfort, and functional impairment scores, and in MIP (P=0.04) and MEP (P≤0.01) after intervention in both groups and just LEG showed improvement in forced vital capacity (P=0.043) and forced expiratory volume in one second (P=0.011).
Conclusion: Both strategies promoted improvement in pain, discomfort, and functional impairment scores and in the values of inspiratory and expiratory pressures. Perhaps they were influenced by the time and resolution of the infection process, although exercises with upper limb movements seem to be safe in this population. The activation of the infra-abdominal muscles through leg movements seems to bring more benefits to lung function.
Keywords: Mediastinitis; Surgical wound infection; Sternum; Muscle Strengthening; Exercises
Methods: This prospective, longitudinal, randomized, and comparative clinical study included 20 patients, which were divided into two groups: ARM, the arm group (n=10), and LEG, the leg group (n=10). The study involved the evaluation of scores of visual analog scales for sternal instability, pain, discomfort, functional impairment, lung function, and maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) before and after the interventions. Two protocols consisting of abdominal exercises in both groups with upper limb movements (ARM) and just abdominal activation with leg movements (LEG) were used for three weeks.
Results: There were statistically significant (P≤0.01) improvements in pain, discomfort, and functional impairment scores, and in MIP (P=0.04) and MEP (P≤0.01) after intervention in both groups and just LEG showed improvement in forced vital capacity (P=0.043) and forced expiratory volume in one second (P=0.011).
Conclusion: Both strategies promoted improvement in pain, discomfort, and functional impairment scores and in the values of inspiratory and expiratory pressures. Perhaps they were influenced by the time and resolution of the infection process, although exercises with upper limb movements seem to be safe in this population. The activation of the infra-abdominal muscles through leg movements seems to bring more benefits to lung function.
Keywords: Mediastinitis; Surgical wound infection; Sternum; Muscle Strengthening; Exercises
Sternal Wound Complications: Results of Routine Use of Negative Pressure Wound Therapy
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Introduction: Negative pressure wound therapy (NPWT) has significantly improved outcomes in individuals with superficial and deep sternal wound dehiscence (SWD). We report our experience with NPWT to evaluate factors influencing effectiveness, duration of treatment and postoperative hospital stay.
Methods: We reviewed 92 patients with postoperative SWD following a median sternotomy. Patients were divided into 2 groups: those with a superficial SWD (Group 1; 72, 78%) and those with a deep SWD (Group 2; 20, 28%). Group 1 was further divided into 3 subgroups based on NPWT duration.
Results: In both groups, none of the preoperative characteristics examined showed a significant association with longer NPWT duration. In Group 2, there was a trend for postoperative bleeding and neurological complications to be associated with longer treatment duration. In the entire series, staph infection resulted a weak predictor of NPWT duration. In each Group 1 subgroup and in Group 2, treatment days were compared with duration of hospitalization until discharge. Mean post-NPWT hospital stay was 6 days in subgroup 1, 12 days in subgroup 2 and 20 days in subgroup 3 (P<0.0001). At a median 3-year follow-up, there were 4 late deaths, none related to wound complications. No cases of SWD recurrence were observed.
Conclusion: Our results confirm the effectiveness of NPWT in SWD management, while excessive treatment duration might have a negative impact on the length of hospital stay. Further studies are needed to define an optimal use of NPWT protocol.
Keywords: Sternotom; Patient discharge; Duration of Therapy; Sternum; Hospitalization; Infections; Postoperative complications
Methods: We reviewed 92 patients with postoperative SWD following a median sternotomy. Patients were divided into 2 groups: those with a superficial SWD (Group 1; 72, 78%) and those with a deep SWD (Group 2; 20, 28%). Group 1 was further divided into 3 subgroups based on NPWT duration.
Results: In both groups, none of the preoperative characteristics examined showed a significant association with longer NPWT duration. In Group 2, there was a trend for postoperative bleeding and neurological complications to be associated with longer treatment duration. In the entire series, staph infection resulted a weak predictor of NPWT duration. In each Group 1 subgroup and in Group 2, treatment days were compared with duration of hospitalization until discharge. Mean post-NPWT hospital stay was 6 days in subgroup 1, 12 days in subgroup 2 and 20 days in subgroup 3 (P<0.0001). At a median 3-year follow-up, there were 4 late deaths, none related to wound complications. No cases of SWD recurrence were observed.
Conclusion: Our results confirm the effectiveness of NPWT in SWD management, while excessive treatment duration might have a negative impact on the length of hospital stay. Further studies are needed to define an optimal use of NPWT protocol.
Keywords: Sternotom; Patient discharge; Duration of Therapy; Sternum; Hospitalization; Infections; Postoperative complications
Thoracic Aortic Aneurysm Surgery in Marfan Patients: a Perspective from the UK
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Objective: Cardiovascular complications in Marfan patients include progressive aortic root dilation which can precipitate acute aortic dissection, ruptured aorta, severe aortic regurgitation, or all the aforementioned. Such complications can be fatal and the cause of death prior to any surgical intervention. We set out to identify the Marfan population in England and Wales and present their surgical outcomes.
Methods: A total of 306 patients with Marfan syndrome who underwent aortic root surgery were identified between April 2007 and March 2013 from NICOR database. We examined the perioperative characteristics of such cohort along with in-hospital outcomes and survival.
Results: Root and ascending segment procedures on Marfan patients performed in 3.3% of the total cohort by NICOR root surgery patients. The median reported age was 40 years (IQR = 29-49 years) and 100 (32.7%) were female. Of the patients analysed, 17.3% were treated non-electively and 68.6% of them received concomitant valve procedure. The in-hospital mortality was 2.0%. Reoperation for bleeding was required in 8.2% of patients and 1.3% of them suffered a cerebrovascular accident (CVA). Mortality at 1 year was reported as 5.5%.
Conclusion: The outcomes of surgery on the root and ascending aorta in Marfan patients in the United Kingdom are satisfactory; however, the overall complexities of this patient population are not well understood and would benefit from further investigations.
Keywords: Marfan syndrome; Aortic Valve Insufficuency; Aneurysm; Dissecting; Hemorrhage; Treatment outcome
Methods: A total of 306 patients with Marfan syndrome who underwent aortic root surgery were identified between April 2007 and March 2013 from NICOR database. We examined the perioperative characteristics of such cohort along with in-hospital outcomes and survival.
Results: Root and ascending segment procedures on Marfan patients performed in 3.3% of the total cohort by NICOR root surgery patients. The median reported age was 40 years (IQR = 29-49 years) and 100 (32.7%) were female. Of the patients analysed, 17.3% were treated non-electively and 68.6% of them received concomitant valve procedure. The in-hospital mortality was 2.0%. Reoperation for bleeding was required in 8.2% of patients and 1.3% of them suffered a cerebrovascular accident (CVA). Mortality at 1 year was reported as 5.5%.
Conclusion: The outcomes of surgery on the root and ascending aorta in Marfan patients in the United Kingdom are satisfactory; however, the overall complexities of this patient population are not well understood and would benefit from further investigations.
Keywords: Marfan syndrome; Aortic Valve Insufficuency; Aneurysm; Dissecting; Hemorrhage; Treatment outcome
National Trends in Utilization and In-Hospital Outcomes of Surgical Aortic Valve Replacements in Spain, 2001-2015
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Objective: The aims of this study were to examine the incidence and in-hospital outcomes of surgical aortic valve replacement (SAVR) and to identify factors associated with in-hospital mortality (IHM) among patients according to the type of implanted valve used in SAVR.
Methods: We performed a retrospective study using the Spanish National Hospital Discharge Database, 2001-2015. We included patients who had SAVR listed as a procedure in their discharge report.
Results: We identified 86,578 patients who underwent SAVR (52.78% mechanical and 47.22% bioprosthetic). Incidence of SAVR coding increased significantly from 11.95 cases per 100,000 inhabitants in 2001 to 17.92 in 2015 (P<0.001). Age and comorbidities increased over time (P<0.001). There was a significant increase in the frequency of concomitant coronary artery bypass grafting (CABG) and in the use of pacemaker implantation. The use of mechanical SAVR decreased and the use of bioprosthetic valves increased over time. IHM decreased over time (from 8.13% in 2001-05 to 5.39% in 2011-15). Patients who underwent mechanical SAVR had higher IHM than those who underwent bioprosthetic SAVR (7.44% vs. 6%; P<0.05). Higher IHM rates were associated with advanced age, female sex, comorbidities, concomitant CABG, and the use of mechanical SAVR (OR 1.67; 95% CI 1.57-1.77).
Conclusion: The number of SAVRs performed in Spain has increased since 2001. The use of mechanical SAVR has decreased and the use of bioprosthetic valves has increased over time. IHM has decreased over time for both types of valves and despite a concomitant increase in age and comorbidities of patients during the same period.
Keywords: Aortic valve; Hospital mortality; Incidence; Spain; Heart valve prosthesis; Coronary artery bypass; Pacemarker Artificial
Methods: We performed a retrospective study using the Spanish National Hospital Discharge Database, 2001-2015. We included patients who had SAVR listed as a procedure in their discharge report.
Results: We identified 86,578 patients who underwent SAVR (52.78% mechanical and 47.22% bioprosthetic). Incidence of SAVR coding increased significantly from 11.95 cases per 100,000 inhabitants in 2001 to 17.92 in 2015 (P<0.001). Age and comorbidities increased over time (P<0.001). There was a significant increase in the frequency of concomitant coronary artery bypass grafting (CABG) and in the use of pacemaker implantation. The use of mechanical SAVR decreased and the use of bioprosthetic valves increased over time. IHM decreased over time (from 8.13% in 2001-05 to 5.39% in 2011-15). Patients who underwent mechanical SAVR had higher IHM than those who underwent bioprosthetic SAVR (7.44% vs. 6%; P<0.05). Higher IHM rates were associated with advanced age, female sex, comorbidities, concomitant CABG, and the use of mechanical SAVR (OR 1.67; 95% CI 1.57-1.77).
Conclusion: The number of SAVRs performed in Spain has increased since 2001. The use of mechanical SAVR has decreased and the use of bioprosthetic valves has increased over time. IHM has decreased over time for both types of valves and despite a concomitant increase in age and comorbidities of patients during the same period.
Keywords: Aortic valve; Hospital mortality; Incidence; Spain; Heart valve prosthesis; Coronary artery bypass; Pacemarker Artificial
Are Standard Follow-Up Parameters Sufficient to Protect Neurocognitive Functions in Patients with Diabetes Mellitus who Underwent Coronary Artery Bypass Grafting?
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Objective: We aimed to compare the effectiveness of cognitive function protection between the standard follow-up parameters and advanced neuromonitoring methods in diabetic patients who underwent coronary artery bypass grafting during cardiopulmonary bypass.
Methods: Study design was prospective and observational. Patients were separated into two groups, treated only with standard follow-up parameters (Group 1) and followed up with the change of regional cerebral tissue oxygenation (rSO2) by near-infrared spectroscopy (Group 2). Neurocognitive functions were evaluated preoperatively and postoperatively before discharge in all patients using the Montreal Cognitive Assessment (MoCA) test.
Results: Cognitive functions of Group 2 patients in the postoperative period were significantly higher than Group 1 patients (P=0.001). The mean postoperative MoCA score of patients was significantly lower than the mean preoperative MoCA score in Group 1 (24.8±2.2 vs. 23.6±2.6, P=0.02). However, mild cognitive dysfunction was significantly lower in Group 2, compared to Group 1 (P=0.02).
Conclusion: In patients followed up with standard parameters, a significant decrease in cognitive function was observed in the early period. However, the use of advanced neuromonitoring methods can significantly prevent this decrease in cognitive functions.
Keywords: Cardiopulmonary bypass; Cognitive Dysfunction; Spectroscopy; Near-Infrared; Coronary artery bypass
Methods: Study design was prospective and observational. Patients were separated into two groups, treated only with standard follow-up parameters (Group 1) and followed up with the change of regional cerebral tissue oxygenation (rSO2) by near-infrared spectroscopy (Group 2). Neurocognitive functions were evaluated preoperatively and postoperatively before discharge in all patients using the Montreal Cognitive Assessment (MoCA) test.
Results: Cognitive functions of Group 2 patients in the postoperative period were significantly higher than Group 1 patients (P=0.001). The mean postoperative MoCA score of patients was significantly lower than the mean preoperative MoCA score in Group 1 (24.8±2.2 vs. 23.6±2.6, P=0.02). However, mild cognitive dysfunction was significantly lower in Group 2, compared to Group 1 (P=0.02).
Conclusion: In patients followed up with standard parameters, a significant decrease in cognitive function was observed in the early period. However, the use of advanced neuromonitoring methods can significantly prevent this decrease in cognitive functions.
Keywords: Cardiopulmonary bypass; Cognitive Dysfunction; Spectroscopy; Near-Infrared; Coronary artery bypass
Valve Heart Surgery in Brazil – The BYPASS Registry Analysis
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Objective: To analyze the profile and outcomes of patients who underwent valve heart surgery in Brazil, using information retrieved from the Brazilian Registry of Cardiovascular Surgeries in Adults (BYPASS Registry) database.
Methods: This is a multicenter cohort study, evaluating 920 patients submitted to heart valve surgery. Demographics and postoperative clinical outcomes were assessed and compared to estimate mortality risk using the European System for Cardiac Operative Risk Evaluation (EuroSCORE).
Results: Isolated aortic valve replacement was the most frequently performed surgery (34%), followed by isolated mitral valve replacement (24.9%). Valve repair was performed in 21% of mitral procedures. Minimally invasive access was performed in 1.6% and the most frequent postoperative complications were arrhythmias (22.6%), infections (5.7%), and low-output syndrome (5.1%). Operations covered by the public health system accounted for 80.8% and the hospital mortality rate was 7.3%.
Conclusion: The most frequent isolated valve surgery in Brazil is the aortic valve replacement by conventional open access and the rheumatic disease is still the main etiology for valve surgery. The BYPASS Registry has a fundamental role to provide information on the profile of patients with valve heart disease in our country in order to delineate adequate strategies for health promotion and resource allocation for cardiac surgery.
Keywords: Aortic valve; Hospital mortality; Public Health; Access to Information; Heart valve diseases; Cardiac surgical procedures
Methods: This is a multicenter cohort study, evaluating 920 patients submitted to heart valve surgery. Demographics and postoperative clinical outcomes were assessed and compared to estimate mortality risk using the European System for Cardiac Operative Risk Evaluation (EuroSCORE).
Results: Isolated aortic valve replacement was the most frequently performed surgery (34%), followed by isolated mitral valve replacement (24.9%). Valve repair was performed in 21% of mitral procedures. Minimally invasive access was performed in 1.6% and the most frequent postoperative complications were arrhythmias (22.6%), infections (5.7%), and low-output syndrome (5.1%). Operations covered by the public health system accounted for 80.8% and the hospital mortality rate was 7.3%.
Conclusion: The most frequent isolated valve surgery in Brazil is the aortic valve replacement by conventional open access and the rheumatic disease is still the main etiology for valve surgery. The BYPASS Registry has a fundamental role to provide information on the profile of patients with valve heart disease in our country in order to delineate adequate strategies for health promotion and resource allocation for cardiac surgery.
Keywords: Aortic valve; Hospital mortality; Public Health; Access to Information; Heart valve diseases; Cardiac surgical procedures
REVIEW ARTICLE
Twenty-Five Years of No-Touch Saphenous Vein Harvesting for Coronary Artery Bypass Grafting: Structural Observations and Impact on Graft Performance
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
The saphenous vein is the most common conduit used in coronary artery bypass grafting (CABG) yet its failure rate is higher compared to arterial grafts. An improvement in saphenous vein graft performance is therefore a major priority in CABG. No-touch harvesting of the saphenous vein is one of the few interventions that has shown improved patency rates, comparable to that of the left internal thoracic artery. After more than two decades of no-touch research, this technique is now recognized as a Class IIa recommendation in the 2018 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization. In this review, we describe the structural alterations that occur in conventional versus no-touch saphenous vein grafts and how these changes affect graft patency. In addition, we discuss various strategies aimed at repairing saphenous vein grafts prepared at conventional CABG.
Keywords: Coronary artery bypass; Guidelines; Myocardial Revascularization; Saphenous vein; Mammary arteries; CardiologyShould Doctors Know Their Patients’ Attachment Style? A Psychological Perspective and its Impact on Cardiac Surgery Outcomes
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Objective: To increase our understanding of the psychological attachment styles in order to develop a preventative strategy that could potentially improve patients’ perioperative outcomes.
Methods: A comprehensive literature search was performed utilizing major electronic databases. The search was done from inception to January 2019. All of the relevant papers have been extracted and critically appraised in this review.
Results: Understanding the psychological aspects of patients is crucial for a satisfactory postoperative outcome. Depression and anxiety have been shown to increase both mortality and morbidity after coronary artery bypass graft surgery, independently of medical factors, although the behavioural and biological mechanisms are poorly understood. Psychosocial assessment is an important part of the pre-transplant evaluation process. The majority of individuals undergoing a transplant have significant psychosocial problems and can either be deferred or denied the transplant until these psychosocial issues are approached and managed. Psychological distress has been shown to affect long-term prognosis of cardiac patients and as a result, it should be addressed during follow-up of cardiac arrest survivors due to cardiac cause. Several studies have considered different approaches and analyses of different psychological attachments, and the understanding of such parameters perioperatively could possibly minimise perioperatively complications.
Conclusion: Since psychological distress affects long-term prognosis of cardiac surgery patients, it should be addressed during follow-up of cardiac arrest survivors due to cardiac cause.
Keywords: Depression; Stress; Psychological; Coronary Artery Bypass; Cardiac Surgical Procedures; Anxiety; Morbidity; Survivors
Methods: A comprehensive literature search was performed utilizing major electronic databases. The search was done from inception to January 2019. All of the relevant papers have been extracted and critically appraised in this review.
Results: Understanding the psychological aspects of patients is crucial for a satisfactory postoperative outcome. Depression and anxiety have been shown to increase both mortality and morbidity after coronary artery bypass graft surgery, independently of medical factors, although the behavioural and biological mechanisms are poorly understood. Psychosocial assessment is an important part of the pre-transplant evaluation process. The majority of individuals undergoing a transplant have significant psychosocial problems and can either be deferred or denied the transplant until these psychosocial issues are approached and managed. Psychological distress has been shown to affect long-term prognosis of cardiac patients and as a result, it should be addressed during follow-up of cardiac arrest survivors due to cardiac cause. Several studies have considered different approaches and analyses of different psychological attachments, and the understanding of such parameters perioperatively could possibly minimise perioperatively complications.
Conclusion: Since psychological distress affects long-term prognosis of cardiac surgery patients, it should be addressed during follow-up of cardiac arrest survivors due to cardiac cause.
Keywords: Depression; Stress; Psychological; Coronary Artery Bypass; Cardiac Surgical Procedures; Anxiety; Morbidity; Survivors
MULTIMEDIA
Post-Traumatic Giant Left Ventricular Pseudoaneurysm: a Multimedia Presentation
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Traumatic left ventricular pseudoaneurysms are rare and surgical correction is the treatment of choice. In this article, it is reported a case of a myocardial stab injury with primary suture and development of a giant pseudoaneurysm, five years later, that underwent surgical repair.
Keywords: Aneurysm; False; Wounds; Stab; Heart Ventricules; Myocardium; Sutures
CASE REPORT
Late Arterial Switch Surgery Under ECMO Support in a Patient with Transposition of the Great Arteries with Intact Ventricular Septum: a Case Report
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
A 30-month-old male patient with transposition of the great arteries with intact ventricular septum (TGA/IVS) is presented. Arterial switch operation (ASO) was performed in the light of echocardiographic and angiographic findings. The patient remained under extracorporeal membrane oxygenation support for seven days postoperatively, and his cardiac functions returned to normal at the postoperative 10th day. He was discharged at the postoperative 20th day. The present case, which presents one of the most advanced ages at operation for TGA/IVS among previously reported cases, is used to discuss late ASO in this study.
Keywords: Transposition of the Great Vessels; Arterial Switch Operation; Ventricular septum; Extracorporeal membrane oxygenation; AngiographyCongenital Supravalvar Mitral Ring – A Case Report
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Congenital mitral valve stenosis is a rare and severe disease, usually associated with other heart defects. The appropriate intervention depends on the site and mechanism of valvular obstruction and the aim is to avoid or delay valve replacement since it is associated with significant morbidity and mortality. Early single-stage complete repair is associated with better prognosis. We report the case of a 20-month-old child with a supravalvar mitral ring combined with a ventricular septal defect; pulmonary arterial systolic pressure before the surgery was 79 mmHg. The patient underwent a successful surgical repair with good clinical resolution.
Keywords: Mitral Valve Stenosis; Heart Defects; Congenital; Systole; Arteries; Mitral Valve Stenosis; Blood Pressure; PrognosisApproach to An Unusual Cardiac Mass: Mitral Annulus Caseoma
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Caseous calcification of the mitral annulus (CCMA) is known to be a rare variant of mitral annulus calcification, a chronic and degenerative process of the mitral valve fibrous ring. It usually carries a benign prognosis. The following case demonstrates a huge mitral annulus caseoma that complicated with severe mitral regurgitation and was treated with a successful surgery. The common consensus on the optimal management of CCMA is conservative medical management and avoiding unnecessary surgery. Therewithal, the current indications for surgical intervention include mitral valve dysfunction, strokes and uncertain diagnosis. Aggressive debridement, risk of left ventricular perforation and exposure of caseous debris to the systemic blood flow may increase the risk of a standard mitral valve surgery. Mitral valve replacement should be preferred compared with mitral valve repair.
Keywords: Mitral Valve; Mitral valve insufficiency; Debridement; Heart valve diseases; Cardiac surgical proceduresPrimary Mediastinal Hydatid Cyst Causing Diaphragmatic Palsy
Braz J Cardiovasc Surg 35;
Publish in: 8/1/2025
Hydatid cystic disease is a significant clinical problem in endemic countries. Hydatid cysts are most commonly located in the liver and lungs. Primary mediastinal hydatid cyst is a rare clinical entity. The diagnosis must be considered in a patient with a mediastinal mass, particularly in endemic regions. Mediastinal hydatid cysts causing paralysis of phrenic and recurrent laryngeal nerves have been rarely reported. We describe a rare case of primary mediastinal hydatid cyst associated with diaphragmatic palsy caused by compression of the left phrenic nerve, which was successfully treated with partial cystectomy and capitonnage with hemidiaphragmatic plication.
Keywords: Pulmonary Echinococcosis; Mediastinal cyst; Diaphragmatic Palsy; Recurrent Laryngeal Nerve