Volume 39 - Issue 4
EDITORIAL
COAPT Trial at 5 Years: Same Doubts Remain About the Efficacy of Transcatheter Edge-to-Edge in Functional Mitral Regurgitation
Braz J Cardiovasc Surg. 2024;39(4):e20230360
ORIGINAL ARTICLE
Assessment of EuroSCORE II and STS Score Performance and the Impact of Surgical Urgency in Isolated Coronary Artery Bypass Graft Surgery at a Referral Center in São Paulo, Brazil
Braz J Cardiovasc Surg. 2024;39(4):e20230282
Introduction: Risk prediction models, such as The Society of Thoracic Surgeons (STS) risk
score and the European System for Cardiac Operative Risk Evaluation II
(EuroSCORE II), are recommended for assessing operative mortality in
coronary artery bypass grafting (CABG). However, their performance is
questionable in Brazil.
Objective: To assess the performance of the STS score and EuroSCORE II in isolated CABG at a Brazilian reference center.
Methods: Observationaland prospective study including 438 patients undergoing isolated CABG from May 2022-May 2023 at the Instituto Dante Pazzanese de Cardiologia. Observed mortality was compared with predicted mortality (STS score and EuroSCORE II) by discrimination (area under the curve [AUC]) and calibration (observed/expected ratio [O/E]) in the total sample and subgroups of stable coronary artery disease (CAD) and acute coronary syndrome (ACS).
Results: Observed mortality was 4.3% (n=19) and estimated at 1.21% and 2.74% by STS and EuroSCORE II, respectively. STS (AUC=0.646; 95% confidence interva [CI] 0.760-0.532) and EuroSCORE II (AUC=0.697; 95% CI 0.802-0.593) presented poor discrimination. Calibration was absent for the North American mode (P<0.05) and reasonable for the European model (O/E=1.59, P=0.056). In the subgroups, EuroSCORE II had AUC of 0.616 (95% CI 0.752-0.480) and 0.826 (95% CI 0.991-0.661), while STS had AUC of 0.467 (95% CI 0.622-0.312) and 0.855 (95% CI 1.0-0.706) in ACS and CAD patients, respectively, demonstrating good score performance in stable patients.
Conclusion: The predictive models did not perform optimally in the total sample, but the EuroSCORE was superior, especially in elective stable patients, where accuracy was satisfactory.
Keywords: Heart Disease Risk Factors; Risk assessment; Myocardia Revascularization; Coronary disease
Objective: To assess the performance of the STS score and EuroSCORE II in isolated CABG at a Brazilian reference center.
Methods: Observationaland prospective study including 438 patients undergoing isolated CABG from May 2022-May 2023 at the Instituto Dante Pazzanese de Cardiologia. Observed mortality was compared with predicted mortality (STS score and EuroSCORE II) by discrimination (area under the curve [AUC]) and calibration (observed/expected ratio [O/E]) in the total sample and subgroups of stable coronary artery disease (CAD) and acute coronary syndrome (ACS).
Results: Observed mortality was 4.3% (n=19) and estimated at 1.21% and 2.74% by STS and EuroSCORE II, respectively. STS (AUC=0.646; 95% confidence interva [CI] 0.760-0.532) and EuroSCORE II (AUC=0.697; 95% CI 0.802-0.593) presented poor discrimination. Calibration was absent for the North American mode (P<0.05) and reasonable for the European model (O/E=1.59, P=0.056). In the subgroups, EuroSCORE II had AUC of 0.616 (95% CI 0.752-0.480) and 0.826 (95% CI 0.991-0.661), while STS had AUC of 0.467 (95% CI 0.622-0.312) and 0.855 (95% CI 1.0-0.706) in ACS and CAD patients, respectively, demonstrating good score performance in stable patients.
Conclusion: The predictive models did not perform optimally in the total sample, but the EuroSCORE was superior, especially in elective stable patients, where accuracy was satisfactory.
Keywords: Heart Disease Risk Factors; Risk assessment; Myocardia Revascularization; Coronary disease
Functional Physical Analysis and Quality of Life in the Preoperative and Early Postoperative Periods of Cardiac Surgery and 30 Days After Hospital Discharge
Braz J Cardiovasc Surg. 2024;39(4):e20220453
Introduction: The analysis of patients submitted to heart surgery at three assessment times has been insufficiently described in the literature.
Objective: To analyze chest expansion, maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), distance traveled on the six-minute walk test (6MWT), and quality of life in the preoperative period, fourth postoperative day (4th PO), and 30th day after hospital discharge (30th-day HD) in individuals submitted to elective heart surgery.
Methods: A descriptive, analytical, cross-sectional study was conducted with 15 individuals submitted to elective heart surgery between 2016 and 2020 who did not undergo any type of physiotherapeutic intervention in Phase II of cardiac rehabilitation. The outcome variables were difference in chest expansion (axillary, nipple, and xiphoid), MIP, MEP, distance on 6MWT, and quality of life. The assessment times were preoperative period, 4th PO, and 30th-day HD.
Results: Chest expansion diminished between the preoperative period and 4th PO, followed by an increase at 30th-day HD. MIP, MEP, and distance traveled on the 6MWT diminished between the preoperative period and 4th PO, with a return to preoperative values at 30th-day HD. General quality of life improved between the preoperative period and 4th PO and 30th-day HD. An improvement was found in the social domain between the preoperative period and the 30th-day HD.
Conclusion: Heart surgery causes immediate physical deficit, but physical functioning can be recovered 30 days after hospital discharge, resulting in an improvement in quality of life one month after surgery.
Keywords: Thoracic Surgery; Respiratory Muscle Strength; Quality of Life; Cardiac Rehabilitation; Preoperative Period;
Objective: To analyze chest expansion, maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), distance traveled on the six-minute walk test (6MWT), and quality of life in the preoperative period, fourth postoperative day (4th PO), and 30th day after hospital discharge (30th-day HD) in individuals submitted to elective heart surgery.
Methods: A descriptive, analytical, cross-sectional study was conducted with 15 individuals submitted to elective heart surgery between 2016 and 2020 who did not undergo any type of physiotherapeutic intervention in Phase II of cardiac rehabilitation. The outcome variables were difference in chest expansion (axillary, nipple, and xiphoid), MIP, MEP, distance on 6MWT, and quality of life. The assessment times were preoperative period, 4th PO, and 30th-day HD.
Results: Chest expansion diminished between the preoperative period and 4th PO, followed by an increase at 30th-day HD. MIP, MEP, and distance traveled on the 6MWT diminished between the preoperative period and 4th PO, with a return to preoperative values at 30th-day HD. General quality of life improved between the preoperative period and 4th PO and 30th-day HD. An improvement was found in the social domain between the preoperative period and the 30th-day HD.
Conclusion: Heart surgery causes immediate physical deficit, but physical functioning can be recovered 30 days after hospital discharge, resulting in an improvement in quality of life one month after surgery.
Keywords: Thoracic Surgery; Respiratory Muscle Strength; Quality of Life; Cardiac Rehabilitation; Preoperative Period;
Atrial Fibrillation After Coronary Artery Bypass Grafting and Its Relationship with Hospital Complications in São Paulo State
Braz J Cardiovasc Surg. 2024;39(4):e20230270
Introduction: Atrial fibrillation is the main complication in the postoperative period of cardiovascular surgery. Its genesis is multifactorial, so its rapid identification to mitigate the associated risks is essential.
Objective: To evaluate the incidence of atrial fibrillation in patients undergoing coronary artery bypass grafting (CABG) and its relationship with other complications in our setting.
Methods: This is a multicenter, observational study involving patients undergoing isolated CABG between 2017 and 2019 with data from the Registro Paulista de Cirurgia Cardiovascular (or REPLICCAR II). Variables were prospectively collected in REDCap following the definitions given by version 2.73 of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Data were collected with prior authorization from the local ethics committee and analyses performed in R software.
Results: A total of 3,803 patients were included, of these 605 had postoperative atrial fibrillation (POAF). In order to adjust the groups, propensity score matching was used. Such analyses resulted in 605 patients in each group (without POAF vs. with POAF). Among patients with POAF, the mean age was 67.56 years, with a prevalence of males (73.6%, 445 patients). Patients belonging to the group with POAF had a mortality rate of 9.26% (P=0.007), longer ventilation time (P<0.001), pneumonia (P<0.001), and sepsis (P<0.001). In multiple analysis, acute renal dysfunction (P=0.032) and longer intensive care unit stay (P<0,001) were associated with the presence of POAF.
Conclusion: POAF in CABG is associated with longer intensive care unit and hospital stay, as well as renal dysfunction, pneumonia, and in-hospital mortality.
Keywords: Database; Coronary artery bypass; Atrial fibrillation; Mortality;
Objective: To evaluate the incidence of atrial fibrillation in patients undergoing coronary artery bypass grafting (CABG) and its relationship with other complications in our setting.
Methods: This is a multicenter, observational study involving patients undergoing isolated CABG between 2017 and 2019 with data from the Registro Paulista de Cirurgia Cardiovascular (or REPLICCAR II). Variables were prospectively collected in REDCap following the definitions given by version 2.73 of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Data were collected with prior authorization from the local ethics committee and analyses performed in R software.
Results: A total of 3,803 patients were included, of these 605 had postoperative atrial fibrillation (POAF). In order to adjust the groups, propensity score matching was used. Such analyses resulted in 605 patients in each group (without POAF vs. with POAF). Among patients with POAF, the mean age was 67.56 years, with a prevalence of males (73.6%, 445 patients). Patients belonging to the group with POAF had a mortality rate of 9.26% (P=0.007), longer ventilation time (P<0.001), pneumonia (P<0.001), and sepsis (P<0.001). In multiple analysis, acute renal dysfunction (P=0.032) and longer intensive care unit stay (P<0,001) were associated with the presence of POAF.
Conclusion: POAF in CABG is associated with longer intensive care unit and hospital stay, as well as renal dysfunction, pneumonia, and in-hospital mortality.
Keywords: Database; Coronary artery bypass; Atrial fibrillation; Mortality;
Evaluation of the Patients with Recurrent Angina After Coronary Artery Bypass Grafting
Braz J Cardiovasc Surg. 2024;39(4):e20230303
Introduction: In this study, we aimed to evaluate the most common causes of recurrent angina after coronary artery bypass grafting (CABG) and our treatment approaches applied in these patients.
Methods: We included all patients who underwent CABG, with or without percutaneous coronary intervention after CABG, at our hospital from September 2013 to December 2019. Patients were divided into two groups according to the time of onset of anginal pain after CABG. Forty-five patients (58.16 ± 8.78 years) had recurrent angina in the first postoperative year after CABG and were specified as group I (early recurrence). Group II (late recurrence) comprised 82 patients (58.05 ± 8.95 years) with angina after the first year of CABG.
Results: The mean preoperative left ventricular ejection fraction was 53.22 ± 8.87% in group I, and 54.7 ± 8.58% in group II (P=0.38). No significant difference was registered between groups I and II regarding preoperative angiographic findings (P>0.05). Failed grafts were found in 27.7% (n=28/101) of the grafts in group I as compared to 26.8% (n=51/190) in group II (P>0.05). Twenty-four (53.3%) patients were treated medically in group I, compared with 54 (65.8%) patients in group II (P=0.098). There was a need for intervention in 46.6% (n=21) of group I patients, and in 34.1% (n=28) of group II patients.
Conclusion: Recurrent angina is a complaint that should not be neglected because most of the patients with recurrent angina are diagnosed with either native coronary or graft pathology in coronary angiography performed.
Keywords: Coronary artery bypass; Stroke Volume; Percutaneous Coronary Intervention; Vascular Graft Occlusion;
Methods: We included all patients who underwent CABG, with or without percutaneous coronary intervention after CABG, at our hospital from September 2013 to December 2019. Patients were divided into two groups according to the time of onset of anginal pain after CABG. Forty-five patients (58.16 ± 8.78 years) had recurrent angina in the first postoperative year after CABG and were specified as group I (early recurrence). Group II (late recurrence) comprised 82 patients (58.05 ± 8.95 years) with angina after the first year of CABG.
Results: The mean preoperative left ventricular ejection fraction was 53.22 ± 8.87% in group I, and 54.7 ± 8.58% in group II (P=0.38). No significant difference was registered between groups I and II regarding preoperative angiographic findings (P>0.05). Failed grafts were found in 27.7% (n=28/101) of the grafts in group I as compared to 26.8% (n=51/190) in group II (P>0.05). Twenty-four (53.3%) patients were treated medically in group I, compared with 54 (65.8%) patients in group II (P=0.098). There was a need for intervention in 46.6% (n=21) of group I patients, and in 34.1% (n=28) of group II patients.
Conclusion: Recurrent angina is a complaint that should not be neglected because most of the patients with recurrent angina are diagnosed with either native coronary or graft pathology in coronary angiography performed.
Keywords: Coronary artery bypass; Stroke Volume; Percutaneous Coronary Intervention; Vascular Graft Occlusion;
Minimally Invasive Coronary Artery Bypass Grafting in a Low-Risk Asian Cohort: A Propensity-Score Matched Study
Braz J Cardiovasc Surg. 2024;39(4):e20220421
Introduction: Minimally invasive coronary artery bypass grafting (MICS CABG) offers a new
paradigm in coronary revascularization. This study aims to compare the
outcomes of MICS CABG with those of conventional median sternotomy CABG (MS
CABG) within a growing minimally invasive cardiac surgical program in
Singapore.
Methods: Propensity matching produced 111 patient pairs who underwent MICS CABG or MS CABG between January 2009 and February 2020 at the National University Heart Centre, Singapore. Minimally invasive direct coronary artery bypass surgery patients were matched to single- or double-graft MS CABG patients (Group 1). Multivessel MICS CABG patients were matched to MS CABG patients with equal number of grafts (Group 2).
Results: Overall, MICS CABG patients experienced shorter postoperative length of stay (P<0.071). In Group 2, procedural duration (P<0.001) was longer among MICS CABG patients, but it did not translate to adverse postoperative events. Postoperative outcomes, including 30-day mortality, reopening for bleeding, new onset atrial fibrillation as well as neurological, pulmonary, renal, and infectious complications were comparable between MICS and MS CABG groups.
Conclusion: MICS CABG is a safe and effective approach for surgical revascularization of coronary artery disease and trends toward a reduction in hospital stay.
Keywords: Sternotomy; Coronary artery bypass; Propensity Matching; Atrial fibrillation; Universities
Methods: Propensity matching produced 111 patient pairs who underwent MICS CABG or MS CABG between January 2009 and February 2020 at the National University Heart Centre, Singapore. Minimally invasive direct coronary artery bypass surgery patients were matched to single- or double-graft MS CABG patients (Group 1). Multivessel MICS CABG patients were matched to MS CABG patients with equal number of grafts (Group 2).
Results: Overall, MICS CABG patients experienced shorter postoperative length of stay (P<0.071). In Group 2, procedural duration (P<0.001) was longer among MICS CABG patients, but it did not translate to adverse postoperative events. Postoperative outcomes, including 30-day mortality, reopening for bleeding, new onset atrial fibrillation as well as neurological, pulmonary, renal, and infectious complications were comparable between MICS and MS CABG groups.
Conclusion: MICS CABG is a safe and effective approach for surgical revascularization of coronary artery disease and trends toward a reduction in hospital stay.
Keywords: Sternotomy; Coronary artery bypass; Propensity Matching; Atrial fibrillation; Universities
Outcomes of Transcatheter Aortic Valve Implantation in Patients with and without Diabetes Mellitus
Braz J Cardiovasc Surg. 2024;39(4):e20230088
Introduction: Diabetes mellitus (DM) in patients undergoing cardiac transcatheter or
surgical interventions usually is correlated with poor outcomes.
Transcatheter aortic valve implantation (TAVI) has been developed as a
therapy choice for inoperable, high-, or intermediate-risk surgical patients
with severe aortic stenosis (AS).
Objective: To evaluate the impact of DM and hemoglobin A1c (HbA1c) on outcomes and survival after TAVI.
Methods: Five hundred and fifty-two symptomatic severe AS patients who underwent TAVI, of whom 164 (29.7%) had DM, were included in this retrospective study. Follow-up was performed after 30 days, six months, and annually.
Results: The device success and risks of procedural-related complications were similar between patients with and without DM, except for acute kidney injury, which was more frequent in the DM group (2.4% vs. 0%, P=0.021). In-hospital and first-year mortality were similar between the groups (4.9% vs. 3.6%, P=0.490 and 15.0% vs. 11.2%, P=0.282, respectively). There was a statistical difference between HbA1c ≥ 6.5 and HbA1c ≤ 6.49 groups in total mortality (34.4% vs. 15.8%, P<0.001, respectively). The only independent predictors were Society of Thoracic Surgeons score (hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.09-1.51; P=0.003) and HbA1c level ≥ 6.5 (HR 10.78, 95% CI 2.58-21.50; P=0.003) in multivariable logistic regression analysis.
Conclusion: In this study, we conclude that DM was not correlated with an increased mortality risk or complication rates after TAVI. Also, it was shown that mortality was higher in patients with HbA1c ≥ 6.5, and it was an independent predictor for long-term mortality.
Keywords: Transcatheter Aortic Valve Replacement; Glycated Hemoglobin; Aortic valve stenosis; Acute kidney injury
Objective: To evaluate the impact of DM and hemoglobin A1c (HbA1c) on outcomes and survival after TAVI.
Methods: Five hundred and fifty-two symptomatic severe AS patients who underwent TAVI, of whom 164 (29.7%) had DM, were included in this retrospective study. Follow-up was performed after 30 days, six months, and annually.
Results: The device success and risks of procedural-related complications were similar between patients with and without DM, except for acute kidney injury, which was more frequent in the DM group (2.4% vs. 0%, P=0.021). In-hospital and first-year mortality were similar between the groups (4.9% vs. 3.6%, P=0.490 and 15.0% vs. 11.2%, P=0.282, respectively). There was a statistical difference between HbA1c ≥ 6.5 and HbA1c ≤ 6.49 groups in total mortality (34.4% vs. 15.8%, P<0.001, respectively). The only independent predictors were Society of Thoracic Surgeons score (hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.09-1.51; P=0.003) and HbA1c level ≥ 6.5 (HR 10.78, 95% CI 2.58-21.50; P=0.003) in multivariable logistic regression analysis.
Conclusion: In this study, we conclude that DM was not correlated with an increased mortality risk or complication rates after TAVI. Also, it was shown that mortality was higher in patients with HbA1c ≥ 6.5, and it was an independent predictor for long-term mortality.
Keywords: Transcatheter Aortic Valve Replacement; Glycated Hemoglobin; Aortic valve stenosis; Acute kidney injury
Lymphocyte Levels and Morbidity and Mortality in Cardiovascular Surgery With Cardiopulmonary Bypass
Braz J Cardiovasc Surg. 2024;39(4):e20230136
Introduction: A year ago, in a sample of 113 patients, our research group found that a high
number of lymphocytes in the immediate postoperative period was correlated
to a poor prognosis in cardiovascular surgeries. This study is an expansion
of the initial study in order to confirm this finding.
Methods: We analyzed the data of 338 consecutive patients submitted to cardiovascular surgeries with cardiopulmonary bypass performed at Hospital Universitário Ciências Médicas (Belo Horizonte/Brazil) from 2015 to 2017. We analyzed 39 variables with the outcomes death, hospital stay, and intensive care unit stay.
Results: The value of lymphocytes in the immediate postoperative period > 2175.0/mm³ was an indicator of poor prognosis in this sample (P<0.001). The variables female sex, age, high level of European System for Cardiac Operative Risk Evaluation II, increased stay in the intensive care unit and in the ward, elevation of creatinine in the preoperative period and at intensive care unit discharge, elevation of the percentage of immediate postoperative period segmented neutrophils, high immediate postoperative period neutrophil/lymphocyte ratio, fasting hyperglycemia, preoperative critical condition, reintubation, mild or transient acute renal failure, surgical infection, cardiopulmonary bypass, and aortic cross-clamping and mechanical ventilation durations also had an impact on the mortality outcome.
Conclusion: The value of lymphocytes in the immediate postoperative period > 2175.0/mm3 was an indicator of poor prognosis in cardiovascular surgery with cardiopulmonary bypass.
Keywords: Cardiovascular surgical procedures; Lymphocyte Count; Indicators of Morbidity and Mortality
Methods: We analyzed the data of 338 consecutive patients submitted to cardiovascular surgeries with cardiopulmonary bypass performed at Hospital Universitário Ciências Médicas (Belo Horizonte/Brazil) from 2015 to 2017. We analyzed 39 variables with the outcomes death, hospital stay, and intensive care unit stay.
Results: The value of lymphocytes in the immediate postoperative period > 2175.0/mm³ was an indicator of poor prognosis in this sample (P<0.001). The variables female sex, age, high level of European System for Cardiac Operative Risk Evaluation II, increased stay in the intensive care unit and in the ward, elevation of creatinine in the preoperative period and at intensive care unit discharge, elevation of the percentage of immediate postoperative period segmented neutrophils, high immediate postoperative period neutrophil/lymphocyte ratio, fasting hyperglycemia, preoperative critical condition, reintubation, mild or transient acute renal failure, surgical infection, cardiopulmonary bypass, and aortic cross-clamping and mechanical ventilation durations also had an impact on the mortality outcome.
Conclusion: The value of lymphocytes in the immediate postoperative period > 2175.0/mm3 was an indicator of poor prognosis in cardiovascular surgery with cardiopulmonary bypass.
Keywords: Cardiovascular surgical procedures; Lymphocyte Count; Indicators of Morbidity and Mortality
Sutureless Aortic Valve Replacement vs. Transcatheter Aortic Valve Implantation in Patients with Small Aortic Annulus: Clinical and Hemodynamic Outcomes from a Multi-Institutional Study
Braz J Cardiovasc Surg. 2024;39(4):e20230155
Objective: This study aimed to compare hemodynamic performances and clinical outcomes of
patients with small aortic annulus (SAA) who underwent aortic valve
replacement by means of sutureless aortic valve replacement (SUAVR) or
transcatheter aortic valve implantation (TAVI).
Methods: From 2015 to 2020, 622 consecutive patients with SAA underwent either SUAVR or TAVI. Through a 1:1 propensity score matching analysis, two homogeneous groups of 146 patients were formed. Primary endpoint: all cause-death at 36 months. Secondary endpoints: incidence of moderate to severe patient-prosthesis mismatch (PPM) and incidence of major adverse cardiovascular and cerebrovascular events (MACCEs)
Results: All-cause death at three years was higher in the TAVI group (SUAVR 12.2% vs. TAVI 21.0%, P=0.058). Perioperatively, comparable hemodynamic performances were recorded in terms of indexed effective orifice area (SUAVR 1.12 ± 0.23 cm2/m2vs. TAVI 1.17 ± 0.28 cm2/m2, P=0.265), mean transvalvular gradients (SUAVR 12.9 ± 5.3 mmHg vs. TAVI 12.2 ± 6.2 mmHg, P=0.332), and moderate-to-severe PPM (SUAVR 4.1% vs. TAVI 8.9%, P=0.096). TAVI group showed a higher cumulative incidence of MACCEs at 36 months (SUAVR 18.1% vs. TAVI 32.6%, P<0.001). Pacemaker implantation (PMI) and perivalvular leak ≥ 2 were significantly higher in TAVI group and identified as independent predictors of mortality (PMI: hazard ratio [HR] 3.05, 95% confidence interval [CI] 1.34-6.94, P=0.008; PPM: HR 2.72, 95% CI 1.25-5.94, P=0.012).
Conclusion: In patients with SAA, SUAVR and TAVI showed comparable hemodynamic performances. Moreover, all-cause death and incidence of MACCEs at follow-up were significantly higher in TAVI group.
Keywords: Transcatheter Aortic Valve Replacement; Aorta Valve; Hemodynamics; Prostheses and implants; Propensity Scores
Methods: From 2015 to 2020, 622 consecutive patients with SAA underwent either SUAVR or TAVI. Through a 1:1 propensity score matching analysis, two homogeneous groups of 146 patients were formed. Primary endpoint: all cause-death at 36 months. Secondary endpoints: incidence of moderate to severe patient-prosthesis mismatch (PPM) and incidence of major adverse cardiovascular and cerebrovascular events (MACCEs)
Results: All-cause death at three years was higher in the TAVI group (SUAVR 12.2% vs. TAVI 21.0%, P=0.058). Perioperatively, comparable hemodynamic performances were recorded in terms of indexed effective orifice area (SUAVR 1.12 ± 0.23 cm2/m2vs. TAVI 1.17 ± 0.28 cm2/m2, P=0.265), mean transvalvular gradients (SUAVR 12.9 ± 5.3 mmHg vs. TAVI 12.2 ± 6.2 mmHg, P=0.332), and moderate-to-severe PPM (SUAVR 4.1% vs. TAVI 8.9%, P=0.096). TAVI group showed a higher cumulative incidence of MACCEs at 36 months (SUAVR 18.1% vs. TAVI 32.6%, P<0.001). Pacemaker implantation (PMI) and perivalvular leak ≥ 2 were significantly higher in TAVI group and identified as independent predictors of mortality (PMI: hazard ratio [HR] 3.05, 95% confidence interval [CI] 1.34-6.94, P=0.008; PPM: HR 2.72, 95% CI 1.25-5.94, P=0.012).
Conclusion: In patients with SAA, SUAVR and TAVI showed comparable hemodynamic performances. Moreover, all-cause death and incidence of MACCEs at follow-up were significantly higher in TAVI group.
Keywords: Transcatheter Aortic Valve Replacement; Aorta Valve; Hemodynamics; Prostheses and implants; Propensity Scores
Global Perfusion Practice Survey: Readiness of On-Call and Emergency Operation Rooms
Braz J Cardiovasc Surg. 2024;39(4):e20230236
Introduction: Perfusion safety in cardiac surgery is vital, and this survey explores
perfusion practices, perspectives, and challenges related to it.
Specifically, it examines the readiness of on-call and emergency operation
rooms for perfusion-related procedures during urgent situations. The aim is
to identify gaps and enhance perfusion safety protocols, ultimately
improving patient care.
Methods: This was a preliminary survey conducted as an initial exploration before committing to a comprehensive study. The sample size was primarily determined based on a one-month time frame. The survey collected data from 236 healthcare professionals, including cardiac surgeons, perfusionists, and anesthetists, using an online platform. Ethical considerations ensured participant anonymity and voluntary participation. The survey comprised multiple-choice and open-ended questions to gather quantitative and qualitative data.
Results: The survey found that 53% preferred a dry circuit ready for emergencies, 19.9% preferred primed circuits, and 19.1% chose not to have a ready pump at all. Various reasons influenced these choices, including caseload variations, response times, historical practices, surgeon preferences, and backup perfusionist availability. Infection risk, concerns about error, and team dynamics were additional factors affecting circuit readiness.
Conclusion: This survey sheds light on current perfusion practices and challenges, emphasizing the importance of standardized protocols in regards to readiness of on-call and emergency operation rooms. It provides valuable insights for advancing perfusion safety and patient care while contributing to the existing literature on the subject.
Keywords: Emergencies; Reaction Time; Sample Size; Perfusion; Cardiac surgical procedures; Anesthetists; Patient Care; Delivery of Health Care
Methods: This was a preliminary survey conducted as an initial exploration before committing to a comprehensive study. The sample size was primarily determined based on a one-month time frame. The survey collected data from 236 healthcare professionals, including cardiac surgeons, perfusionists, and anesthetists, using an online platform. Ethical considerations ensured participant anonymity and voluntary participation. The survey comprised multiple-choice and open-ended questions to gather quantitative and qualitative data.
Results: The survey found that 53% preferred a dry circuit ready for emergencies, 19.9% preferred primed circuits, and 19.1% chose not to have a ready pump at all. Various reasons influenced these choices, including caseload variations, response times, historical practices, surgeon preferences, and backup perfusionist availability. Infection risk, concerns about error, and team dynamics were additional factors affecting circuit readiness.
Conclusion: This survey sheds light on current perfusion practices and challenges, emphasizing the importance of standardized protocols in regards to readiness of on-call and emergency operation rooms. It provides valuable insights for advancing perfusion safety and patient care while contributing to the existing literature on the subject.
Keywords: Emergencies; Reaction Time; Sample Size; Perfusion; Cardiac surgical procedures; Anesthetists; Patient Care; Delivery of Health Care
Ascending Aortic Progression After Isolated Aortic Valve Replacement Among Patients with Bicuspid and Tricuspid Aortic Valves
Braz J Cardiovasc Surg. 2024;39(4):e20230438
Objectives: The aims of the present study were to compare the long-term outcomes for
ascending aortic dilatation and adverse aortic events after isolated aortic
valve replacement between patients with bicuspid aortic valve (BAV) and
tricuspid aortic valve ( TAV).
Methods: This retrospective study included 310 patients who had undergone isolated aortic valve replacement with an ascending aorta diameter ≤ 45 mm between January 2010 and September 2021. The patients were divided into BAV group (n=90) and TAV group (n=220). The differences in the dilation rate of the ascending aorta and long-term outcomes were analyzed.
Results: Overall survival was 89 ± 4% in the BAV group vs. 75 ± 6% in the TAV group at 10 years postoperatively (P=0.007), yet this difference disappeared after adjusting exclusively for age (P=0.343). The mean annual growth rate of the ascending aorta was similar between the two groups during follow-up (0.5 ± 0.6 mm/year vs. 0.4 ± 0.5 mm/year; P=0.498). Ten-year freedom from adverse aortic events was 98.1% in the BAV group vs. 95.0% in the TAV group (P=0.636). Multivariable analysis revealed preoperative ascending aorta diameter to be a significant predictor of adverse aortic events (hazard ratio: 1.76; 95% confidence interval: 1.33 to 2.38; P<0.001).
Conclusion: Our study revealed that the long-term survival and the risks of adverse aortic events between BAV and TAV patients were similar after isolated aortic valve replacement. BAV was not a risk factor of adverse aortic events.
Keywords: Aortic Valve Replacement; Bicuspid Aortic Valve; Tricuspid Aortic Valve; Ascending Aorta; Clinical Outcome
Methods: This retrospective study included 310 patients who had undergone isolated aortic valve replacement with an ascending aorta diameter ≤ 45 mm between January 2010 and September 2021. The patients were divided into BAV group (n=90) and TAV group (n=220). The differences in the dilation rate of the ascending aorta and long-term outcomes were analyzed.
Results: Overall survival was 89 ± 4% in the BAV group vs. 75 ± 6% in the TAV group at 10 years postoperatively (P=0.007), yet this difference disappeared after adjusting exclusively for age (P=0.343). The mean annual growth rate of the ascending aorta was similar between the two groups during follow-up (0.5 ± 0.6 mm/year vs. 0.4 ± 0.5 mm/year; P=0.498). Ten-year freedom from adverse aortic events was 98.1% in the BAV group vs. 95.0% in the TAV group (P=0.636). Multivariable analysis revealed preoperative ascending aorta diameter to be a significant predictor of adverse aortic events (hazard ratio: 1.76; 95% confidence interval: 1.33 to 2.38; P<0.001).
Conclusion: Our study revealed that the long-term survival and the risks of adverse aortic events between BAV and TAV patients were similar after isolated aortic valve replacement. BAV was not a risk factor of adverse aortic events.
Keywords: Aortic Valve Replacement; Bicuspid Aortic Valve; Tricuspid Aortic Valve; Ascending Aorta; Clinical Outcome
Risk Model for Laryngeal Complications Prediction in Chinese Patients After Coronary Artery Bypass Grafting
Braz J Cardiovasc Surg. 2024;39(4):e20230424
Introduction: The aim of this study was to identify perioperative risk factors of laryngeal
symptoms and to develop an implementable risk prediction model for Chinese
hospitalized patients undergoing coronary artery bypass grafting (CABG).
Methods: A total of 1476 Chinese CABG patients admitted to Wuhan Asian Heart Hospital from January 2020 to June 2022 were included and then divided into a modeling cohort and a verification cohort. Univariate analysis was used to identify laryngeal symptoms risk factors, and multivariate logistic regression was applied to construct a prediction model for laryngeal symptoms after CABG. Discrimination and calibration of this model were validated based on the area under the receiver operating characteristic (ROC) curve and the Hosmer-Lemeshow (H-L) test, respectively.
Results: The incidence of laryngeal symptoms in patients who underwent CABG was 6.48%. Four independent risk factors were included in the model, and the established aryngeal complications risk calculation formula was Logit (P) = −4.525 + 0.824 × female + 2.09 × body mass index < 18.5 Kg/m2 + 0.793 × transesophageal echocardiogram + 1.218 × intensive care unit intubation time. For laryngeal symptoms, the area under the ROC curve was 0.769 in the derivation cohort (95% confidence interval [CI]: 0.698-0.840) and 0.811 in the validation cohort (95% CI: 0.742-0.879). According to the H-L test, the P-values in the modeling group and the verification group were 0.659 and 0.838, respectively.
Conclusion: The prediction model developed in this study can be used to identify high-risk patients for laryngealsymptoms undergoing CABG, and help clinicians implement the follow-up treatment.
Keywords: Coronary artery bypass; Laryngeal Complications; Risk Factors; Deglutition Disorders; Larynx
Methods: A total of 1476 Chinese CABG patients admitted to Wuhan Asian Heart Hospital from January 2020 to June 2022 were included and then divided into a modeling cohort and a verification cohort. Univariate analysis was used to identify laryngeal symptoms risk factors, and multivariate logistic regression was applied to construct a prediction model for laryngeal symptoms after CABG. Discrimination and calibration of this model were validated based on the area under the receiver operating characteristic (ROC) curve and the Hosmer-Lemeshow (H-L) test, respectively.
Results: The incidence of laryngeal symptoms in patients who underwent CABG was 6.48%. Four independent risk factors were included in the model, and the established aryngeal complications risk calculation formula was Logit (P) = −4.525 + 0.824 × female + 2.09 × body mass index < 18.5 Kg/m2 + 0.793 × transesophageal echocardiogram + 1.218 × intensive care unit intubation time. For laryngeal symptoms, the area under the ROC curve was 0.769 in the derivation cohort (95% confidence interval [CI]: 0.698-0.840) and 0.811 in the validation cohort (95% CI: 0.742-0.879). According to the H-L test, the P-values in the modeling group and the verification group were 0.659 and 0.838, respectively.
Conclusion: The prediction model developed in this study can be used to identify high-risk patients for laryngealsymptoms undergoing CABG, and help clinicians implement the follow-up treatment.
Keywords: Coronary artery bypass; Laryngeal Complications; Risk Factors; Deglutition Disorders; Larynx
REVIEW ARTICLE
Comparison of the Effects of Full Median Sternotomy vs. Mini-Incision on Postoperative Pain in Cardiac
Braz J Cardiovasc Surg. 2024;39(4):e20230154
Introduction: It is not yet clear whether cardiac surgery by mini-incision (minimally invasive cardiac surgery [MICS]) is overall less painful than the conventional approach by full sternotomy (FS). A meta-analysis is necessary to investigate polled results on this topic.
Methods: PubMed®/MEDLINE, Cochrane CENTRAL, Latin American and Caribbean Health Sciences Literature (or LILACS), and Scientific Electronic Library Online (or SciELO) were searched for all clinical trials, reported until 2022, comparing FS with MICS in coronary artery bypass grafting (CABG), mitral valve surgery (MVS), and aortic valve replacement (AVR), and postoperative pain outcome was analyzed. Main summary measures were the method of standardized mean differences (SMD) with a 95% confidence interval (CI) and P-values (considered statistically significant when < 0.05).
Results: In AVR, the general estimate of postoperative pain effect favored MICS (SMD 0.87 [95% CI 0.04 to 1.71], P=0.04). However, in the sensitivity analysis, there was no difference between the groups (SMD 0.70 [95% CI -0.69 to 2.09], P=0.32). For MVS, it was not possible to perform a meta-analysis with the included studies, because they had different methodologies. In CABG, the general estimate of the effect of postoperative pain did not favor any of the approaches (SMD -0.40 [95% CI -1.07 to 0.26], P=0.23), which was confirmed by sensitivity analysis (SMD -0.02 [95% CI -0.71 to 0.67], P=0.95).
Conclusion: MICS was not globally less painful than the FS approach. It seems that postoperative pain is more related to the degree of tissue retraction than to the size of the incision.
Keywords: Cardiac surgical procedures; Coronary artery bypass; Postoperative pain; Aortic valve; Mitral Valve;
Methods: PubMed®/MEDLINE, Cochrane CENTRAL, Latin American and Caribbean Health Sciences Literature (or LILACS), and Scientific Electronic Library Online (or SciELO) were searched for all clinical trials, reported until 2022, comparing FS with MICS in coronary artery bypass grafting (CABG), mitral valve surgery (MVS), and aortic valve replacement (AVR), and postoperative pain outcome was analyzed. Main summary measures were the method of standardized mean differences (SMD) with a 95% confidence interval (CI) and P-values (considered statistically significant when < 0.05).
Results: In AVR, the general estimate of postoperative pain effect favored MICS (SMD 0.87 [95% CI 0.04 to 1.71], P=0.04). However, in the sensitivity analysis, there was no difference between the groups (SMD 0.70 [95% CI -0.69 to 2.09], P=0.32). For MVS, it was not possible to perform a meta-analysis with the included studies, because they had different methodologies. In CABG, the general estimate of the effect of postoperative pain did not favor any of the approaches (SMD -0.40 [95% CI -1.07 to 0.26], P=0.23), which was confirmed by sensitivity analysis (SMD -0.02 [95% CI -0.71 to 0.67], P=0.95).
Conclusion: MICS was not globally less painful than the FS approach. It seems that postoperative pain is more related to the degree of tissue retraction than to the size of the incision.
Keywords: Cardiac surgical procedures; Coronary artery bypass; Postoperative pain; Aortic valve; Mitral Valve;
SPECIAL ARTICLE
Challenges of Congenital Heart Surgery in Brazil: It is Time to Designate Pediatric Congenital Heart Surgery Subspecialty
Braz J Cardiovasc Surg. 2024;39(4):e20240138
Congenital heart disease (CHD) affects eight to ten out of every 1,000 births,
resulting in approximately 23,057 new cases in Brazil in 2022. About one in four
children with CHD requires surgery or other procedures in the first year of life,
and it is expected that approximately 81% of these children with CHD will survive
until at least 35 years of age. Professionals choosing to specialize in CHD surgery
face numerous challenges, not only related to mastering surgical techniques
and the complexity of the diseases but also to the lack of recognition by medical
societies as a separate subspecialty. Furthermore, families face difficulties
when access to services capable of providing treatment for these children.
To address these challenges, it is essential to have specialized hospitals,
qualified professionals, updated technologies, sustainable industry,
appropriate financing, quality assessment systems, and knowledge generation. The path to excellence involves specialization across all involved parties.
As we reflect on the importance of Pediatric Cardiovascular Surgery and
Congenital Heart Diseases establishing themselves as a subspecialty of
Cardiovascular Surgery, it is essential to look beyond our borders to countries
like the United States of America and United Kingdom, where this evolution
is already a reality. This autonomy has led to significant advancements in
research, education, and patient care outcomes, establishing a care model.
By following this path in Brazil, we not only align our practice with the highest
international standards but also demonstrate our maturity and the ability to meet the
specific needs of patients with CHD and those with acquired childhood heart disease.
Keywords: Congenital Heart Defects; Certification; Training; Education; Patient Care; Medical Societies;
BRIEF COMMUNICATION
Computer-Assisted Transcatheter Mitral Valve Implantation for Valve-in-Valve Procedures
Braz J Cardiovasc Surg. 2024;39(4):e20230237
Transcatheter mitral valve-in-valve is an alternative to high-risk reoperation on a failing bioprosthesis. It entails specific challenges such as left ventricular outflow tract obstruction. We propose a patient-specific augmented imaging based on preoperative planning to assist the procedure.
Valve-in-valve simulation was performed to represent the optimal level of implantation and the neo-left ventricular outflow tract. These data were combined with intraoperative images through a real-time 3D/2D registration tool. All data were collected retrospectively on one case (pre and per-procedure imaging). We present for the first time an intraoperative guidance tool in transcatheter mitral valve-in-valve procedure.
Keywords: Mitral Valve Disease; Bioprosthesis; Reoperation; Left Ventricular Outflow Obstruction;
CASE REPORT
Resection of Mycotic Iliac Artery Aneurysm with Extra-Anatomic Bypass: An Alternative to Aneurysmorrhaphy in Difficult Situations
Braz J Cardiovasc Surg. 2024;39(4):e20230350
LETTER TO THE EDITOR
Artificial Intelligence, Academic Publishing, Scientific Writing, Peer Review, and Ethics
Braz J Cardiovasc Surg. 2024;39(4):e20230377
CLINICAL-SURGICAL CORRELATION
Infant Barlow’s Disease in Association with Atrial Septal Defect
Braz J Cardiovasc Surg. 2024;39(4):e20230278
Clinical data: Female, seven years old, referred to our service complaining about
congestive heart failure symptoms due to mitral valve regurgitation and atrial
septal defect. Technical description: Echocardiographic findings compatible with
Barlow’s disease and atrial septal defect, ostium secundum type. Operation: She was
submitted to mitral valvuloplasty with chordal shortening and prosthetic posterior ring (Gregori-Braile®) along with patch atrioseptoplasty. Comments: Mitral valve
regurgitation is a rare congenital heart disease and Barlow’s disease is probably rarer.
Mitral valve repair is the treatment of choice.
Keywords: Mitral valve insufficiency; Mitral Valve Annuloplasty; Congenital Heart Defect; Atrial Septal Defect; Thoracic Surgery;