Volume 36 - Issue 6
EDITORIAL
The Keys to Unleashing Potential
Braz J Cardiovasc Surg. 2021;36(6):1-2
COVID-19 and Cardiovascular Surgery. Do We Know What We Are Dealing With?
Braz J Cardiovasc Surg. 2021;36(6):3-4
ORIGINAL ARTICLE
COVID-19 in the Perioperative Period of Cardiovascular Surgery: the Brazilian Experience
Braz J Cardiovasc Surg. 2021;36(6):725-735
Introduction: We investigated the clinical course and outcomes of patients submitted to cardiovascular surgery in Brazil and who had developed symptoms/signs of coronavirus disease 2019 (COVID-19) in the perioperative period.
Methods: A retrospective multicenter study including 104 patients who were allocated in three groups according to time of positive real time reverse transcriptase-polymerase chain reaction (RT-PCR) for the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2): group 1, patients who underwent cardiac surgery > 10 days after positive RT-PCR; group 2, patients with a positive RT-PCR within 10 days before or after surgery; group 3, patients who presented positive RT-PCR > 10 days after surgery. The primary outcome was mortality and secondary outcomes were postoperative complications, intensive care unit (ICU) length of stay, and postoperative days of hospitalization.
Results: The three groups were similar with respect to age, the European System of Cardiac Operative Risk Evaluation score, and comorbidities, except hypertension. Postoperative complications and death were significantly higher in groups 2 and 3 than in group 1, and no significant difference between groups 2 and 3 was seen. Group 2 showed a high prevalence of surgery performed as an urgent procedure. Although no significant differences were observed in ICU length of stay, total postoperative hospitalization time was significantly higher in group 3 than in groups 1 and 2.
Conclusion: COVID-19 affecting the postoperative period of patients who underwent cardiovascular surgery is associated with a higher rate of morbidity and mortality. Delaying procedures in RT-PCR-positive patients may help reduce risks of perioperative complications and death.
Keywords: COVID-19; SARS-Cov-2; Cardiac surgical procedures; Thoracic Surgery; Comorbidity
Methods: A retrospective multicenter study including 104 patients who were allocated in three groups according to time of positive real time reverse transcriptase-polymerase chain reaction (RT-PCR) for the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2): group 1, patients who underwent cardiac surgery > 10 days after positive RT-PCR; group 2, patients with a positive RT-PCR within 10 days before or after surgery; group 3, patients who presented positive RT-PCR > 10 days after surgery. The primary outcome was mortality and secondary outcomes were postoperative complications, intensive care unit (ICU) length of stay, and postoperative days of hospitalization.
Results: The three groups were similar with respect to age, the European System of Cardiac Operative Risk Evaluation score, and comorbidities, except hypertension. Postoperative complications and death were significantly higher in groups 2 and 3 than in group 1, and no significant difference between groups 2 and 3 was seen. Group 2 showed a high prevalence of surgery performed as an urgent procedure. Although no significant differences were observed in ICU length of stay, total postoperative hospitalization time was significantly higher in group 3 than in groups 1 and 2.
Conclusion: COVID-19 affecting the postoperative period of patients who underwent cardiovascular surgery is associated with a higher rate of morbidity and mortality. Delaying procedures in RT-PCR-positive patients may help reduce risks of perioperative complications and death.
Keywords: COVID-19; SARS-Cov-2; Cardiac surgical procedures; Thoracic Surgery; Comorbidity
Central Venous Oxygen Saturation/Lactate Ratio and Prediction of Major Adverse Events after Pediatric Heart Surgery
Braz J Cardiovasc Surg. 2021;36(6):736-742
Introduction: Major adverse events (MAE) are unexpected but undesirably frequent after
pediatric congenital heart surgery and contribute to poorer outcomes. The
aim of this study was to test the predictive value of a ratio between
central venous oxygen saturation and arterial lactate (ScvO2/lactate) for
MAE after pediatric congenital heart surgery in a Brazilian university
hospital.
Methods: We conducted a retrospective observational study in a tertiary care university hospital, including 194 infants and children submitted to surgery for congenital heart disease. The predictive value of ScvO2, lactate, and ScvO2/lactate ratio were assessed by the area under the receiver operating characteristics curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
Results: The incidence of MAE was 16% — cardiac arrest/death, unplanned reoperation, and low cardiac output syndrome were the most common events. Overall, ScvO2/lactate ratio discriminated patients with and without MAE very well (AUC 0.842), performing better than either variable alone, with sensitivity of 48%, specificity of 94%, PPV of 60%, and NPV of 91%.
Conclusion: A ScvO2/lactate ratio > 5 can accurately identify patients at low risk of MAE after pediatric congenital heart surgery, with very good specificity and NPV, but poor sensitivity and PPV.
Keywords: Congenital heart disease; Cardiac surgery; Pulmonary gas exchange; Sensitivity and Specificity; Heart Arrest; Incidence
Methods: We conducted a retrospective observational study in a tertiary care university hospital, including 194 infants and children submitted to surgery for congenital heart disease. The predictive value of ScvO2, lactate, and ScvO2/lactate ratio were assessed by the area under the receiver operating characteristics curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
Results: The incidence of MAE was 16% — cardiac arrest/death, unplanned reoperation, and low cardiac output syndrome were the most common events. Overall, ScvO2/lactate ratio discriminated patients with and without MAE very well (AUC 0.842), performing better than either variable alone, with sensitivity of 48%, specificity of 94%, PPV of 60%, and NPV of 91%.
Conclusion: A ScvO2/lactate ratio > 5 can accurately identify patients at low risk of MAE after pediatric congenital heart surgery, with very good specificity and NPV, but poor sensitivity and PPV.
Keywords: Congenital heart disease; Cardiac surgery; Pulmonary gas exchange; Sensitivity and Specificity; Heart Arrest; Incidence
Extracorporeal Membrane Oxygenation-Related Nosocomial Infection after Cardiac Surgery in Adult Patients
Braz J Cardiovasc Surg. 2021;36(6):743-751
Introduction: The evaluation of extracorporeal membrane oxygenation-related nosocomial infection (ECMO-related NI) in a homogeneous cohort remains scarce. This study analyzed ECMO-related NI in adult patients who have undergone cardiac surgery.
Methods: From January 2012 to December 2017, 322 adult patients who have received ECMO support after cardiac surgery were divided into the infection group (n=131) and the non-infection group (n=191). ECMO-related NI was evaluated according to demographic data, surgical procedures, and ECMO parameters.
Results: The incidence of ECMO-related NI was 85.4 cases per 1000 ECMO days. Acinetobacter baumannii was the most common pathogen causing blood stream infection and respiratory tract infection. Prolonged duration of surgery (P=0.042) and cardiopulmonary bypass assist (P=0.044) increased the risk of ECMO-related NI. Body mass index (odds ratio [OR]: 1.077; 95% confidence interval [CI]: 1.004-1.156; P=0.039) and duration of ECMO support (OR: 1.006; 95% CI: 1.003-1.009; P=0.0001) were the independent risk factors for ECMO-related NI. Duration of ECMO support > 144 hours (OR: 2.460; 95% CI: 1.155-7.238; P<0.0001) and ECMO-related NI (OR: 3.726; 95% CI: 1.274-10.895; P=0.016) increased significantly the risk of in-hospital death.
Conclusion: Prolonged duration of ECMO support was an independent risk factor for NI. Surgical correcting latent causes of cardiopulmonary failure and shortening duration of ECMO whenever possible would reduce susceptibility to NI.
Keywords: Cross infection; Extracorporeal membrane oxygenation; Odds Ratio; Incidence; Risk Factors; Body mass index; Hospital mortality; Cardiac surgical procedures
Methods: From January 2012 to December 2017, 322 adult patients who have received ECMO support after cardiac surgery were divided into the infection group (n=131) and the non-infection group (n=191). ECMO-related NI was evaluated according to demographic data, surgical procedures, and ECMO parameters.
Results: The incidence of ECMO-related NI was 85.4 cases per 1000 ECMO days. Acinetobacter baumannii was the most common pathogen causing blood stream infection and respiratory tract infection. Prolonged duration of surgery (P=0.042) and cardiopulmonary bypass assist (P=0.044) increased the risk of ECMO-related NI. Body mass index (odds ratio [OR]: 1.077; 95% confidence interval [CI]: 1.004-1.156; P=0.039) and duration of ECMO support (OR: 1.006; 95% CI: 1.003-1.009; P=0.0001) were the independent risk factors for ECMO-related NI. Duration of ECMO support > 144 hours (OR: 2.460; 95% CI: 1.155-7.238; P<0.0001) and ECMO-related NI (OR: 3.726; 95% CI: 1.274-10.895; P=0.016) increased significantly the risk of in-hospital death.
Conclusion: Prolonged duration of ECMO support was an independent risk factor for NI. Surgical correcting latent causes of cardiopulmonary failure and shortening duration of ECMO whenever possible would reduce susceptibility to NI.
Keywords: Cross infection; Extracorporeal membrane oxygenation; Odds Ratio; Incidence; Risk Factors; Body mass index; Hospital mortality; Cardiac surgical procedures
Mitral Valve-In-Valve: Defining the Indication Limits by in vitro Hydrodynamic Tests in a Brazilian Transcatheter Prosthesis
Braz J Cardiovasc Surg. 2021;36(6):752-759
Introduction: Reoperations in cardiac surgery represent a clinical challenge, particularly because of the higher rate of perioperative morbidity and mortality. Mitral valve reoperation owing to bioprosthesis dysfunction, transcatheter treatment with a prosthesis implantation over the prosthesis has emerged as an alternative, especially for patients with a previous approach. In this study, we analyzed the hydrodynamic behavior of transcatheter prosthesis implantation in conventional mitral bioprostheses through hydrodynamic tests and produced a recommendation for the size of transcatheter valve most adequate for valve-in-valve procedure.
Methods: Mitral bioprostheses were attached to a flow duplicator and different combinations of transcatheter prostheses were implanted inside. The equipment simulates the hydrodynamic behavior of the valves submitted in vitro and determines transvalvular pressures and flow parameters.
Results: All tests could be performed. Better hydrodynamic performance occurred for transcatheter prostheses 1 mm smaller than bioprostheses, except for the 27-mm bioprostheses. Effective valve areas (cm²) and transvalvular gradients (mmHg) were, respectively: Bioprosthesis × Inovare: 27 × 28 mm: 1.65 and 5.95/29 × 28 mm and 31 × 30 mm: 2.15 and 3.6.
Conclusion: The mitral valve-in-valve implantation proved to be feasible in vitro. The use of 27-mm bioprostheses should be judicious, with preference for a 26-mm transcatheter valve. In the 29 and 31-mm bioprostheses, the implantation was very satisfactory, with good effective valve areas and transvalvular gradients, with preference for smaller transcatheter valves.
Keywords: Heart valve prosthesis implantation; Hydrodynamic; Mitral Valve; Reoperation; Hydrodynamics
Methods: Mitral bioprostheses were attached to a flow duplicator and different combinations of transcatheter prostheses were implanted inside. The equipment simulates the hydrodynamic behavior of the valves submitted in vitro and determines transvalvular pressures and flow parameters.
Results: All tests could be performed. Better hydrodynamic performance occurred for transcatheter prostheses 1 mm smaller than bioprostheses, except for the 27-mm bioprostheses. Effective valve areas (cm²) and transvalvular gradients (mmHg) were, respectively: Bioprosthesis × Inovare: 27 × 28 mm: 1.65 and 5.95/29 × 28 mm and 31 × 30 mm: 2.15 and 3.6.
Conclusion: The mitral valve-in-valve implantation proved to be feasible in vitro. The use of 27-mm bioprostheses should be judicious, with preference for a 26-mm transcatheter valve. In the 29 and 31-mm bioprostheses, the implantation was very satisfactory, with good effective valve areas and transvalvular gradients, with preference for smaller transcatheter valves.
Keywords: Heart valve prosthesis implantation; Hydrodynamic; Mitral Valve; Reoperation; Hydrodynamics
Delayed Chest Closure for Oversized Lung Allograft in Lung Transplantation: a Retrospective Analysis from Turkey
Braz J Cardiovasc Surg. 2021;36(6):760-768
Introduction: The aim of this study was to evaluate the delayed chest closure (DCC) results in patients who underwent lung transplantation.
Methods: Sixty patients were evaluated retrospectively. Only bilateral lung transplantations and DCC for oversized lung allograft (OLA) were included in the study. Six patients who underwent single lung transplantation, four patients who underwent lobar transplantation, two patients who underwent retransplantation, and four patients who underwent DCC due to bleeding risk were excluded from the study. Forty-four patients were divided into groups as primary chest closure (PCC) (n=28) and DCC (n=16). Demographics, donor characteristics, and operative features and outcomes of the patients were compared.
Results: The mean age was 44.5 years. There was no significant difference between the demographics of the groups (P>0.05). The donor/recipient predicted total lung capacity ratio was significantly higher in the DCC group than in the PCC group (1.06 vs. 0.96, P=0.008). Extubation time (4.3 vs. 3.1 days, P=0.002) and intensive care unit length of stay (7.6 vs. 5.2 days, P=0.016) were significantly higher in the DCC group than in the PCC group. In the DCC group, postoperative wound infection was significantly higher than in the PCC group (18.6% vs. 0%, P=0.19). Median survival was 14 months in all patients and there was no significant difference in survival between the groups (16 vs. 13 months, P=0.300).
Conclusion: DCC is a safe and effective method for the management of OLA in lung transplantation.
Keywords: Surgical wound infection; Reoperation; Airway Extubation; Lung transplantation; Total lung capacity; Tissue donors; Thorax; Intensive care units; Allografts;
Methods: Sixty patients were evaluated retrospectively. Only bilateral lung transplantations and DCC for oversized lung allograft (OLA) were included in the study. Six patients who underwent single lung transplantation, four patients who underwent lobar transplantation, two patients who underwent retransplantation, and four patients who underwent DCC due to bleeding risk were excluded from the study. Forty-four patients were divided into groups as primary chest closure (PCC) (n=28) and DCC (n=16). Demographics, donor characteristics, and operative features and outcomes of the patients were compared.
Results: The mean age was 44.5 years. There was no significant difference between the demographics of the groups (P>0.05). The donor/recipient predicted total lung capacity ratio was significantly higher in the DCC group than in the PCC group (1.06 vs. 0.96, P=0.008). Extubation time (4.3 vs. 3.1 days, P=0.002) and intensive care unit length of stay (7.6 vs. 5.2 days, P=0.016) were significantly higher in the DCC group than in the PCC group. In the DCC group, postoperative wound infection was significantly higher than in the PCC group (18.6% vs. 0%, P=0.19). Median survival was 14 months in all patients and there was no significant difference in survival between the groups (16 vs. 13 months, P=0.300).
Conclusion: DCC is a safe and effective method for the management of OLA in lung transplantation.
Keywords: Surgical wound infection; Reoperation; Airway Extubation; Lung transplantation; Total lung capacity; Tissue donors; Thorax; Intensive care units; Allografts;
Evaluations of Antioxidant Enzyme Activities, Total Sialic Acid and Trace Element Levels in Coronary Artery Bypass Grafting Patients
Braz J Cardiovasc Surg. 2021;36(6):769-779
Introduction: In this study, patients before and after cardiac surgery with cardiopulmonary bypass (CPB) and control subjects were evaluated for erythrocyte glutathione peroxidase, catalase and superoxide dismutase enzyme activities, in addition to glutathione, malondialdehyde, serum total sialic acid, lipid-bound sialic acid, total antioxidant status, trace elements and mineral levels. The correlation of these variables with coronary artery disease (CAD) was also assessed.
Methods: A total of 30 CAD patients and 30 control subjects were included in the study. CAD patients were divided into three groups: before surgery (BS), first day after surgery (1st day AS) and seventh day after surgery (7th day AS).
Results: Malondialdehyde (MDA) and total sialic acid (TSA) levels were significantly higher in CAD (BS) than in the control group (P<0.05, P<0.05). In addition, GSH and TAS levels were significantly lower in the 1st day AS group than in the control group (P<0.001, P<0.01). Moreover, Co, Cu, Mg, Se, V and Zn levels were significantly lower in CAD (BS) group than in the control group (P<0.01, P<0.01, P<0.01, P<0.01, P<0.05, P<0.001).
Conclusions: It was concluded that the levels of LDL-C, total cholesterol, triglycerides and CRP significantly associated with parameters, as well as Cu, Ca and SOD activity, should be measured together to monitor CAD. It is also considered that measuring TSA and MDA might be an appropriate choice for biomarkers of CAD.
Keywords: Coronary Artery Disease; Trace Elements; Glutathione Peroxidase; Superoxide Dismutase; Catalase; Total Sialic Acid; Malondialdehyde
Methods: A total of 30 CAD patients and 30 control subjects were included in the study. CAD patients were divided into three groups: before surgery (BS), first day after surgery (1st day AS) and seventh day after surgery (7th day AS).
Results: Malondialdehyde (MDA) and total sialic acid (TSA) levels were significantly higher in CAD (BS) than in the control group (P<0.05, P<0.05). In addition, GSH and TAS levels were significantly lower in the 1st day AS group than in the control group (P<0.001, P<0.01). Moreover, Co, Cu, Mg, Se, V and Zn levels were significantly lower in CAD (BS) group than in the control group (P<0.01, P<0.01, P<0.01, P<0.01, P<0.05, P<0.001).
Conclusions: It was concluded that the levels of LDL-C, total cholesterol, triglycerides and CRP significantly associated with parameters, as well as Cu, Ca and SOD activity, should be measured together to monitor CAD. It is also considered that measuring TSA and MDA might be an appropriate choice for biomarkers of CAD.
Keywords: Coronary Artery Disease; Trace Elements; Glutathione Peroxidase; Superoxide Dismutase; Catalase; Total Sialic Acid; Malondialdehyde
Predictive Factors of Prolonged Ventilation Following Cardiac Surgery with Cardiopulmonary Bypass
Braz J Cardiovasc Surg. 2021;36(6):780-787
Introduction: In this trial, we initially aimed to investigate the major predictive factors for prolonged mechanical ventilation (PMV) following cardiac surgery with cardiopulmonary bypass (CPB) in our center and, secondarily, we tried to find out the effects of the independent factors on mortality.
Methods: Between July 2017 and August 2018, 207 patients who underwent cardiac surgery with CPB were retrospectively investigated. The patients were randomly divided into two subgroups according to the duration of ventilator dependence (group 1 <24 hours, n=164, 79%; group 2 >24 hours, n=43, 21%).
Results: 207 patients (mean age 59.47±10.56) who underwent cardiac surgery with CPB were enrolled in this study (n=145, 70% of male patients; n=62, 30% of female patients). Amid these patients, 43 (n=43, 20.77%) had prolonged intubation time. After multivariate logistic regression analysis among preoperative factors, female gender (OR=2.321, P=0.028), leukocytosis (OR=1.233, P=0.006), perioperative lactate level (OR=1.224, P=0.027), CPB time (OR=1.012, P=0.012) and postoperative revision for bleeding (OR=23.125, P=0.040) were significantly detected. The effect of predictive factors on mortality after cardiac surgery was determined and found that PMV did not affect hospital mortality (OR=1.979, P=0.420).
Conclusion: In our report, we revealed, differently from previous studies, that intraoperative lactate levels which manifest organ perfusion and oxygenation were included and were significantly different in the early extubation group compared to the PMV group. Female gender, preoperative leukocytosis, intraoperative CPB time, lactate levels and postoperative revision for bleeding were the independent predictive factors for PMV. Moreover, PMV did not affect the early-term mortality during hospital stay.
Keywords: Cardiopulmonary bypass; Respiration; Artificial; Perfusion; Intubation; Intratracheal; Airway Extubation; Hemorrhage
Methods: Between July 2017 and August 2018, 207 patients who underwent cardiac surgery with CPB were retrospectively investigated. The patients were randomly divided into two subgroups according to the duration of ventilator dependence (group 1 <24 hours, n=164, 79%; group 2 >24 hours, n=43, 21%).
Results: 207 patients (mean age 59.47±10.56) who underwent cardiac surgery with CPB were enrolled in this study (n=145, 70% of male patients; n=62, 30% of female patients). Amid these patients, 43 (n=43, 20.77%) had prolonged intubation time. After multivariate logistic regression analysis among preoperative factors, female gender (OR=2.321, P=0.028), leukocytosis (OR=1.233, P=0.006), perioperative lactate level (OR=1.224, P=0.027), CPB time (OR=1.012, P=0.012) and postoperative revision for bleeding (OR=23.125, P=0.040) were significantly detected. The effect of predictive factors on mortality after cardiac surgery was determined and found that PMV did not affect hospital mortality (OR=1.979, P=0.420).
Conclusion: In our report, we revealed, differently from previous studies, that intraoperative lactate levels which manifest organ perfusion and oxygenation were included and were significantly different in the early extubation group compared to the PMV group. Female gender, preoperative leukocytosis, intraoperative CPB time, lactate levels and postoperative revision for bleeding were the independent predictive factors for PMV. Moreover, PMV did not affect the early-term mortality during hospital stay.
Keywords: Cardiopulmonary bypass; Respiration; Artificial; Perfusion; Intubation; Intratracheal; Airway Extubation; Hemorrhage
Risk Score Elaboration for Stroke in Cardiac Surgery
Braz J Cardiovasc Surg. 2021;36(6):788-795
Introduction: Stroke is a complication that causes considerable morbidity and mortality during the heart surgery postoperative period (incidence: 1.3 to 5%; mortality: 13 to 41%). Models for assessing the risk of stroke after heart surgery have been proposed, but most of them do not evaluate postoperative morbidity. The aim of this study was to develop a risk score for postoperative stroke in patients who undergo heart surgery with cardiopulmonary bypass.
Methods: A cohort study was conducted with data from 4,862 patients who underwent surgery from 1996 to 2016. Logistic regression was used to assess relationships between risk factors and stroke. Data from 3,258 patients were used to construct the model. The model’s performance was then validated using data from the remainder of the patients (n=1,604). The model’s accuracy was tested using the area under the receiver operating characteristic (ROC) curve.
Results: The prevalence of stroke during the postoperative period was 3% (n=149); 59% of the patients who exhibited this outcome were male, 51% were aged ≥ 66 years, and 31.5% of the patients died. The variables that remained as independent predictors of the outcome after multivariate analysis were advanced age, urgent/emergency surgery, peripheral arterial occlusive disease, history of cerebrovascular disease, and cardiopulmonary bypass time ≥ 110 minutes. The area under the ROC curve was 0.71 (95% confidence interval 0.66 - 0.75).
Conclusion: We were able to develop a risk score for stroke after heart surgery. This score classifies patients as low, medium, high, or very high risk of a surgery-related stroke.
Keywords: Stroke; Risk Factors; Cardiac surgical procedures; Postoperative period; Arterial Occlusive Diseases
Methods: A cohort study was conducted with data from 4,862 patients who underwent surgery from 1996 to 2016. Logistic regression was used to assess relationships between risk factors and stroke. Data from 3,258 patients were used to construct the model. The model’s performance was then validated using data from the remainder of the patients (n=1,604). The model’s accuracy was tested using the area under the receiver operating characteristic (ROC) curve.
Results: The prevalence of stroke during the postoperative period was 3% (n=149); 59% of the patients who exhibited this outcome were male, 51% were aged ≥ 66 years, and 31.5% of the patients died. The variables that remained as independent predictors of the outcome after multivariate analysis were advanced age, urgent/emergency surgery, peripheral arterial occlusive disease, history of cerebrovascular disease, and cardiopulmonary bypass time ≥ 110 minutes. The area under the ROC curve was 0.71 (95% confidence interval 0.66 - 0.75).
Conclusion: We were able to develop a risk score for stroke after heart surgery. This score classifies patients as low, medium, high, or very high risk of a surgery-related stroke.
Keywords: Stroke; Risk Factors; Cardiac surgical procedures; Postoperative period; Arterial Occlusive Diseases
Glasgow Prognostic Score as a Marker of Mortality after TAVI
Braz J Cardiovasc Surg. 2021;36(6):796-801
Introduction: The Glasgow prognostic score (GPS) reflects host systemic inflammatory response and has been reported to be significant as a prognostic indicator in cancer-bearing patients. The aim of this study was to evaluate the predictive value of GPS in outcomes of patients with severe aortic stenosis who were treated with transcatheter aortic valve implantation (TAVI).
Methods: The study population consisted of 79 patients who underwent TAVI due to severe aortic stenosis between January 2018 and March 2019 in our clinic. Echocardiographic and laboratory data were recorded before the procedure and GPS was scored as 0, 1, or 2, based on serum albumin and C-reactive protein levels. European System for Cardiac Operative Risk Evaluation II scoring system was used for risk stratification. The primary endpoints of the study were postoperative in-hospital mortality, hospitalization due to cardiac causes, or mortality within a year.
Results: The 79 patients were classified into two groups according to outcomes. Fifteen patients (19%) reached the primary endpoints at one year of follow-up. Compared to the patients who did not reach the endpoints, these 15 patients were not different in terms of age, preoperative mean gradient, and ejection fraction (P>0.05 for all). GPS was the only laboratory parameter with statistically significant difference between the groups (P=0.008) and multivariate analysis showed that GPS was independent predictor of primary endpoints (P=0.012, odds ratio 4.51, 95% confidence interval 1.39-14.60).
Conclusion: GPS is an easy, noninvasive laboratory test which may be used as a predictive biomarker for outcomes in patients undergoing TAVI.
Keywords: Transcatheter Aortic Valve Replacement; Aortic valve stenosis; C-reactive protein; Hospital mortality; Prognosis; Serum Albumin
Methods: The study population consisted of 79 patients who underwent TAVI due to severe aortic stenosis between January 2018 and March 2019 in our clinic. Echocardiographic and laboratory data were recorded before the procedure and GPS was scored as 0, 1, or 2, based on serum albumin and C-reactive protein levels. European System for Cardiac Operative Risk Evaluation II scoring system was used for risk stratification. The primary endpoints of the study were postoperative in-hospital mortality, hospitalization due to cardiac causes, or mortality within a year.
Results: The 79 patients were classified into two groups according to outcomes. Fifteen patients (19%) reached the primary endpoints at one year of follow-up. Compared to the patients who did not reach the endpoints, these 15 patients were not different in terms of age, preoperative mean gradient, and ejection fraction (P>0.05 for all). GPS was the only laboratory parameter with statistically significant difference between the groups (P=0.008) and multivariate analysis showed that GPS was independent predictor of primary endpoints (P=0.012, odds ratio 4.51, 95% confidence interval 1.39-14.60).
Conclusion: GPS is an easy, noninvasive laboratory test which may be used as a predictive biomarker for outcomes in patients undergoing TAVI.
Keywords: Transcatheter Aortic Valve Replacement; Aortic valve stenosis; C-reactive protein; Hospital mortality; Prognosis; Serum Albumin
Is Vasoactive-Inotropic Score a Predictor for Mortality and Morbidity in Patients Undergoing Coronary Artery Bypass Surgery?
Braz J Cardiovasc Surg. 2021;36(6):802-806
Introduction: We aimed to investigate whether vasoactive-inotropic score (VIS) is a predictor for early postoperative morbidity and mortality.
Methods: This study was planned as a prospective cohort study, between Nov 20 2018 and May 15 2019, including a total of 290 patients aged 20 years or older who underwent elective on-pump coronary artery bypass grafting (CABG). Patients’ demographic data, aortic cross-clamp and cardiopulmonary bypass times, European System for Cardiac Operative Risk Evaluation (EuroSCORE) score, cardiac ejection fraction (EF), VIS, intubation duration, and intensive care unit length of stay were recorded. Postoperative mortality and morbidity were recorded. Hourly doses of inotropes for VIS were recorded for each patient, and VIS was calculated.
Results: Among the cases, 222 (77%) were male and 68 (23%) were female. The mean age of our patients was 62.5 years (37-86). Combined morbidity and mortality rates of our patients were 23.8%. An optimal cutoff point for VIS of 5.5 could predict combined morbidity and mortality with 90% sensitivity and 88% specificity. Low EF, prolonged operation time, high EuroSCORE, and high VIS are independent factors in the early postoperative period for the development of combined morbidity and mortality in patients who underwent elective CABG.
Conclusion: VIS is the most critical and EuroSCORE is the second most important scoring systems. They independently predict combined morbidity and mortality in undergoing elective coronary artery bypass surgery.
Keywords: Length of stay; Cardiopulmonary bypass; Stroke Volume; Coronary artery bypass; Heart-lung machine; Morbidity; Intensive Care Units;
Methods: This study was planned as a prospective cohort study, between Nov 20 2018 and May 15 2019, including a total of 290 patients aged 20 years or older who underwent elective on-pump coronary artery bypass grafting (CABG). Patients’ demographic data, aortic cross-clamp and cardiopulmonary bypass times, European System for Cardiac Operative Risk Evaluation (EuroSCORE) score, cardiac ejection fraction (EF), VIS, intubation duration, and intensive care unit length of stay were recorded. Postoperative mortality and morbidity were recorded. Hourly doses of inotropes for VIS were recorded for each patient, and VIS was calculated.
Results: Among the cases, 222 (77%) were male and 68 (23%) were female. The mean age of our patients was 62.5 years (37-86). Combined morbidity and mortality rates of our patients were 23.8%. An optimal cutoff point for VIS of 5.5 could predict combined morbidity and mortality with 90% sensitivity and 88% specificity. Low EF, prolonged operation time, high EuroSCORE, and high VIS are independent factors in the early postoperative period for the development of combined morbidity and mortality in patients who underwent elective CABG.
Conclusion: VIS is the most critical and EuroSCORE is the second most important scoring systems. They independently predict combined morbidity and mortality in undergoing elective coronary artery bypass surgery.
Keywords: Length of stay; Cardiopulmonary bypass; Stroke Volume; Coronary artery bypass; Heart-lung machine; Morbidity; Intensive Care Units;
REVIEW ARTICLE
Syndrome of Ventricular Septal Defect and Aortic Regurgitation — A 22-Year Review of its Management
Braz J Cardiovasc Surg. 2021;36(6):807-816
Introduction: The presence of aortic regurgitation (AR) in the setting of ventricular septal defect (VSD) has always been a management challenge.
Methods: This is a retrospective study looking at patients who underwent VSD closure with or without aortic valve intervention between January 1st, 1992 and December 31st, 2014 at the Institute Jantung Negara. This study looked at all cases of VSD and AR, where AR was classified as mild, moderate, and severe, the intervention done in each of this grade, and the durability of that intervention. The interventions were classified as no intervention (NI), aortic valve repair (AVr), and aortic valve replacement (AVR).
Results: A total of 261 patients were recruited into this study. Based on the various grades of AR, 105 patients had intervention to their aortic valve during VSD closure. The rest 156 had NI. All patients were followed up for a mean time of 13.9±3.5 years. Overall freedom from reoperation at 15 years was 82.6% for AVr. Various factors were investigated to decide on intervening on the aortic valve during VSD closure. Among those that were statistically significant were the grade of AR, size of VSD, age at intervention, and number of cusp prolapse.
Conclusion: We can conclude from our study that all moderate and severe AR with small VSD in older patients with more than one cusp prolapse will need intervention to their aortic valve during the closure of VSD.
Keywords: Aortic valve insufficiency; Reoperation; Heart septal defects, ventricular; Heart valve prosthesis; Cardiac surgical procedures; Prolapse
Methods: This is a retrospective study looking at patients who underwent VSD closure with or without aortic valve intervention between January 1st, 1992 and December 31st, 2014 at the Institute Jantung Negara. This study looked at all cases of VSD and AR, where AR was classified as mild, moderate, and severe, the intervention done in each of this grade, and the durability of that intervention. The interventions were classified as no intervention (NI), aortic valve repair (AVr), and aortic valve replacement (AVR).
Results: A total of 261 patients were recruited into this study. Based on the various grades of AR, 105 patients had intervention to their aortic valve during VSD closure. The rest 156 had NI. All patients were followed up for a mean time of 13.9±3.5 years. Overall freedom from reoperation at 15 years was 82.6% for AVr. Various factors were investigated to decide on intervening on the aortic valve during VSD closure. Among those that were statistically significant were the grade of AR, size of VSD, age at intervention, and number of cusp prolapse.
Conclusion: We can conclude from our study that all moderate and severe AR with small VSD in older patients with more than one cusp prolapse will need intervention to their aortic valve during the closure of VSD.
Keywords: Aortic valve insufficiency; Reoperation; Heart septal defects, ventricular; Heart valve prosthesis; Cardiac surgical procedures; Prolapse
HOW I DO IT
Endovascular Treatment of Coarctation of the Aorta with a Self-Expanding Endoprosthesis: How I Do It Using the Braile Dominus® Coarctation Aorta Device
Braz J Cardiovasc Surg. 2021;36(6):817-821
The coarctation of the aorta is a relatively highly prevalent congenital heart disease and may be diagnosed as an underline cause of hypertension in adolescents and adults. The gold standard treatment for coarctation of the aorta in these patients is being replaced - from open surgery to endovascular therapy. Some prostheses have been developed to treat the coarctation with less acute and chronic complications. The Dominus® Coarctation Aorta (Braile Biomédica) is the first self-expandable prosthesis created specifically to treat coarctation of the aorta, reducing possible acute complications, like aortic rupture or aortic dissection. Here, we discuss the step-by-step method for using this prosthesis.
Keywords: Aortic coarctation; Computed Tomography Angiography; Aortic rupture; Coarctation; Endovascular procedures; Prosthesis and implants
BRIEF COMMUNICATION
Teams, Rapid Recovery Protocols and Technology to Resume Cardiac Surgery in the COVID-19 Era
Braz J Cardiovasc Surg. 2021;36(6):822-824
The coronavirus disease 2019 (COVID-19) pandemic brings numerous challenges to the health ecosystem, including the safe resumption of elective cardiac surgery. In the pre-pandemic period, rapid recovery protocols demonstrated, through strategies focused on the multidisciplinary approach, reduction of hospital length of stay, infection rates and, consequently, costs. Even with several studies proving the benefits of these protocols, their acceptance and implementation have been slow. It is believed that the resumption of surgeries in the current context requires the use of rapid recovery protocols combined with the use of a mobile application promoting greater engagement between patients, caregivers and care teams.
Keywords: Cardiovascular surgical procedures; Quality Improvement; Technology; Patient Safety; Coronavirus Infections
EDUCATIONAL FORUM
Multivessel Woven Coronary Artery Disease
Braz J Cardiovasc Surg. 2021;36(6):825-828
Woven coronary disease is a rare pathology with unknown etiology. Although initially considered benign, recent publications report myocardial ischemia caused by the affected vessel. Since most patients are asymptomatic, long-term follow-up to understand its behavior is mandatory. We report a multivessel woven disease case with documented ischemia that was submitted to coronary artery bypass grafting and remained asymptomatic for two years of follow-up.
Keywords: Coronary Artery Disease; Woven Coronary Disease; Coronary Anomaly; Coronary Artery Bypass Grafts
CASE REPORT
Endovascular Repair of Primary Thoracic Aortic Mural Thrombus Following Upper Limb Embolization
Braz J Cardiovasc Surg. 2021;36(6):829-833
We report the case of a 41-year-old female who presented with left upper limb embolization due to primary thoracic aortic mural thrombus; this latter represented an uncommon condition with difficult diagnosis and a high rate of life-threatening complications. Upper extremities embolization is extremely rare because it usually occurs in the lower limbs. Management strategy is still controversial, and no clear guidelines indicate superiority of either conservative or invasive treatment approach to date. Our report illustrates how endovascular exclusion of thoracic aortic mural thrombus has the advantage to be a low-risk procedure that represents a definitive therapy.
Keywords: Thrombosis; Aorta; Thoracic; Computed Tomography; Thromboembolism; Upper Extremity; Lower ExtremityA Gauze-Pad Wrapping of the Heart Can Save a Patient’s Life
Braz J Cardiovasc Surg. 2021;36(6):834-835
We describe one case of iatrogenic rupture of the left ventricle after mitral valve replacement and myectomy of the outflow tract. The cause and site of the rupture could not be identified, neither from the internal nor from the external examination. After unsuccessful use of hemostatic patches in the surface of the ruptured area, wrapping of the ventricles with a surgical gauze pad controlled the hemorrhage, hence saving the patient’s life.
Keywords: Heart ventricles; Rupture; Mitral Valve; Hemorrhage; Iatrogenic Diseases; Hemostatics
LETTER TO THE EDITOR
Prevention of Cerebral Lesion in Asymptomatic Carotid and Vertebral Artery Stenosis in Urgent Cardiac Surgery
Braz J Cardiovasc Surg. 2021;36(6):836-836