Volume 39 - Issue 5
EDITORIAL
Patient Blood Management in Cardiovascular Surgery
Braz J Cardiovasc Surg. 2024;39(5):e20240994
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(5):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
Comparison of the Effect of Pump Flow Type (Pulsatile or Non-Pulsatile) on Postoperative Neurocognitive Functions in Coronary Artery Surgery
Braz J Cardiovasc Surg. 2024;39(5):e20230345
Introduction: The effect of pump flow type on perfusion in coronary surgery using
cardiopulmonary bypass (CPB) is discussed. We aimed to evaluate the effect
of pump flow type on cognitive functions with neurocognitive function
tests.
Methods: One hundred patients who underwent isolated coronary artery bypass surgery between November 2020 and July 2021 were divided into two equa groups. Groups were formed according to pump flow type pulsatile (Group 1) and non-pulsatile (Group 2). Clock drawing test (CDT) and standardized mini mental test (SMMT) were performed on the patients in both groups in the preoperative period, on the 1st preoperative day, and on the day before discharge. Neurocognitive effects were compared with all follow-up parameters.
Results: There was no difference between the groups in terms of demographic data and in terms of neurocognitive tests performed before the operation. SMMT on postoperative day 1 (Group I: 27.64 ± 1.05; Group II: 24.44 ± 1.64; P=0.001) and CDT (Group I: 5.4 ± 0.54; Group II: 4 .66 ± 0.52; P=0.001), and SMMT on the day before discharge (Group I: 27.92 ± 1.16; Group II: 24.66 ± 1.22; P=0.001) and CDT (Group I: 5 It was calculated as .66 ± 0.48; Group II: 5.44 ± 0.5; P=0.001). The duration of intensive care and hospitalization were higher in the non-pulsatile group.
Conclusion: We think that the type of pump flow used in coronary artery bypass surgery using CPB is effective in terms of neurocognitive functions and that pulsatile flow makes positive contributions to this issue.
Keywords: Cardiopulonary Bypass; Patient discharge; Pulsative Flow; Coronary artery bypass; Cognition; Mental Status and Dementia Test; Intelligence Tests; Critical Care
Methods: One hundred patients who underwent isolated coronary artery bypass surgery between November 2020 and July 2021 were divided into two equa groups. Groups were formed according to pump flow type pulsatile (Group 1) and non-pulsatile (Group 2). Clock drawing test (CDT) and standardized mini mental test (SMMT) were performed on the patients in both groups in the preoperative period, on the 1st preoperative day, and on the day before discharge. Neurocognitive effects were compared with all follow-up parameters.
Results: There was no difference between the groups in terms of demographic data and in terms of neurocognitive tests performed before the operation. SMMT on postoperative day 1 (Group I: 27.64 ± 1.05; Group II: 24.44 ± 1.64; P=0.001) and CDT (Group I: 5.4 ± 0.54; Group II: 4 .66 ± 0.52; P=0.001), and SMMT on the day before discharge (Group I: 27.92 ± 1.16; Group II: 24.66 ± 1.22; P=0.001) and CDT (Group I: 5 It was calculated as .66 ± 0.48; Group II: 5.44 ± 0.5; P=0.001). The duration of intensive care and hospitalization were higher in the non-pulsatile group.
Conclusion: We think that the type of pump flow used in coronary artery bypass surgery using CPB is effective in terms of neurocognitive functions and that pulsatile flow makes positive contributions to this issue.
Keywords: Cardiopulonary Bypass; Patient discharge; Pulsative Flow; Coronary artery bypass; Cognition; Mental Status and Dementia Test; Intelligence Tests; Critical Care
Survival Analysis in Adult Heart Transplantation: Experience from a Brazilian Single Center
Braz J Cardiovasc Surg. 2024;39(5):e20230394
Introduction: Heart transplantation is the gold standard for advanced heart failure
treatment. This study examines the survival rates and risk factors for early
mortality in adult heart transplant recipients at a Brazilian center.
Methods: This retrospective cohort study involved 255 adult heart transplant patients from a single center in Brazil. Data were collected from medical records and databases including three defined periods (2012-2015, 2016-2019, and 2020-2022). Statistical analysis employed Kaplan-Meier survival curves, Cox proportional hazards analysis for 30-day mortality risk factors, and Log-rank tests.
Results: The recipients were mostly male (74.9%), and the mean age was 46.6 years. Main causes of heart failure were idiopathic dilated cardiomyopathy (33.9%), Chagas cardiomyopathy (18%), and ischemic cardiomyopathy (14.3%). The study revealed an overall survival of 68.1% at one year, 58% at five years, and 40.8% at 10 years after heart transplantation. Survivalimproved significantly over time, combining the most recent periods (2016 to 2022) it was 73.2% in the first year and 63% in five years. The main risk factors for 30-day mortality were longer time on cardiopulmonary bypass, the initial period of transplants (2012 to 2015), older age of the donor, and nutritional status of the donor (overweight or obese). The main causes of death within 30 days post-transplant were infection and primary graft dysfunction.
Conclusion: The survival analysis by period demonstrated that the increased surgical volume, coupled with the team’s experience and modifications to the immunosuppression protocol, contributed to the improved early and mid-term outcomes.
Keywords: Survival rate; Chagas cardiomyopathy; Overweight; Dilated cardiomyopathy; Cardiopulmonar Bypass; Caude of Death; Heart transplantation; Risk Factors
Methods: This retrospective cohort study involved 255 adult heart transplant patients from a single center in Brazil. Data were collected from medical records and databases including three defined periods (2012-2015, 2016-2019, and 2020-2022). Statistical analysis employed Kaplan-Meier survival curves, Cox proportional hazards analysis for 30-day mortality risk factors, and Log-rank tests.
Results: The recipients were mostly male (74.9%), and the mean age was 46.6 years. Main causes of heart failure were idiopathic dilated cardiomyopathy (33.9%), Chagas cardiomyopathy (18%), and ischemic cardiomyopathy (14.3%). The study revealed an overall survival of 68.1% at one year, 58% at five years, and 40.8% at 10 years after heart transplantation. Survivalimproved significantly over time, combining the most recent periods (2016 to 2022) it was 73.2% in the first year and 63% in five years. The main risk factors for 30-day mortality were longer time on cardiopulmonary bypass, the initial period of transplants (2012 to 2015), older age of the donor, and nutritional status of the donor (overweight or obese). The main causes of death within 30 days post-transplant were infection and primary graft dysfunction.
Conclusion: The survival analysis by period demonstrated that the increased surgical volume, coupled with the team’s experience and modifications to the immunosuppression protocol, contributed to the improved early and mid-term outcomes.
Keywords: Survival rate; Chagas cardiomyopathy; Overweight; Dilated cardiomyopathy; Cardiopulmonar Bypass; Caude of Death; Heart transplantation; Risk Factors
Intercostal Lung Hernias Presenting After Minimally Invasive Cardiac Surgery
Braz J Cardiovasc Surg. 2024;39(5):e20230403
Introduction: With the introduction of minimally invasive cardiac surgery, more commonly
cases of lung herniation are starting to appear. Acquired lung hernias are
classified as postoperative, traumatic, pathologic, and spontaneous. Up to
83% of lung hernias are intercostal. Herein, we describe patients presenting
with intercostal lung hernias following minimally invasive cardiac surgery
at a single center in Medellín, Colombia.
Methods: We conducted a retrospective search of all patients presenting with intercostal lung hernias secondary to minimally invasive cardiac surgery at our clinic in Medellín since the beginning of our program, from 2010 to 2022. Mini-sternotomies were excluded from our study. We reviewed the incision type and other possible factors leading to intercostal lung hernia development. We also describe the approach taken for these patients.
Results: From 2010 up until 2022, 803 adult patients underwent minimally invasive cardiac surgeries through a mini-thoracotomy. At the time of data retrieval, nine patients presented with intercostal lung hernias at the previous incision site. Five hernias (55%) were from right 2nd intercostal parasternal mini-thoracotomies for aortic valve surgeries. Four hernias (45%) were from right 4th intercostal lateral mini-thoracotomies for mitral valve surgeries. Our preferred repair technique is a video-assisted thoracoscopic mesh approach.
Conclusion: Minimally invasive cardiac surgical approaches are becoming more routine. Proper wound closure is critical in preventing lung hernias. Additionally, timely diagnosis and opportune hernia surgery using video-assisted thoracoscopic mesh repair can prevent further complications.
Keywords: Hernia; Thoracotomy; Sternotomy; Mitral Valve; Video-Assisted Thoracic Surgery; Surgical Mesh; Cardiac surgical procedures; Lung
Methods: We conducted a retrospective search of all patients presenting with intercostal lung hernias secondary to minimally invasive cardiac surgery at our clinic in Medellín since the beginning of our program, from 2010 to 2022. Mini-sternotomies were excluded from our study. We reviewed the incision type and other possible factors leading to intercostal lung hernia development. We also describe the approach taken for these patients.
Results: From 2010 up until 2022, 803 adult patients underwent minimally invasive cardiac surgeries through a mini-thoracotomy. At the time of data retrieval, nine patients presented with intercostal lung hernias at the previous incision site. Five hernias (55%) were from right 2nd intercostal parasternal mini-thoracotomies for aortic valve surgeries. Four hernias (45%) were from right 4th intercostal lateral mini-thoracotomies for mitral valve surgeries. Our preferred repair technique is a video-assisted thoracoscopic mesh approach.
Conclusion: Minimally invasive cardiac surgical approaches are becoming more routine. Proper wound closure is critical in preventing lung hernias. Additionally, timely diagnosis and opportune hernia surgery using video-assisted thoracoscopic mesh repair can prevent further complications.
Keywords: Hernia; Thoracotomy; Sternotomy; Mitral Valve; Video-Assisted Thoracic Surgery; Surgical Mesh; Cardiac surgical procedures; Lung
Construction and Surgical Training of Coronary Anastomosis on a Low-Cost Portable Simulator: Experience in a Peruvian Multicenter Study
Braz J Cardiovasc Surg. 2024;39(5):e20230479
Introduction: The operating room is no longer the ideal place for early surgica training of
cardiothoracic surgery residents, forcing the search for simulation-based
learning options. The study’s aim was the construction and surgicaltraining
of coronary anastomosis in a portable, low-cost, homemade simulator.
Methods: This is an observational, analytical, and multicenter study. The simulator was built with common materials and was evaluated with the Objective Structured Assessment ofTechnical Skills (or OSATS) Modified. All junior and senior residents from nine national cardiothoracic surgery centers were considered for 90 days. Operative skill acquisition and time in the creation of side-to-side (S-T-S), end-to-side (E-T-S), and end-to-end (E-T-E) coronary anastomoses were evaluated. All sessions were recorded and evaluated by a single senior cardiothoracic surgeon during two time periods.
Results: One hundred and forty residents were assessed in 270 sessions. In junior residents, a significant improvement in final scores was identified in S-T-S (use of Castroviejo needle holder, needle angles, and needle transfer) (P<0.05). In seniors, a significant improvement was identified in S-T-S (graft orientation, appropriate spacing, use of forceps, angles, and needle transfer) anastomoses (P<0.05). A significant improvement in the final anastomosis time of senior residents over junior residents was identified in S-T-S (8.11 vs. 11.22 minutes), E-T-S (7.93 vs. 10.10 minutes), and E-T-E (6.56 vs. 9.68 minutes) (P=0.039).
Conclusion: Our portable and low-cost coronary anastomosis simulator is effective in improving operative skills in cardiothoracic surgery residents; therefore, skills acquired through simulation-based training transfer have a positive impact on the surgical environment.
Keywords: Operating Rooms; Surgeons; Clinical Competence; Internship and Residency; Curriculum; Thoracic Surgery
Methods: This is an observational, analytical, and multicenter study. The simulator was built with common materials and was evaluated with the Objective Structured Assessment ofTechnical Skills (or OSATS) Modified. All junior and senior residents from nine national cardiothoracic surgery centers were considered for 90 days. Operative skill acquisition and time in the creation of side-to-side (S-T-S), end-to-side (E-T-S), and end-to-end (E-T-E) coronary anastomoses were evaluated. All sessions were recorded and evaluated by a single senior cardiothoracic surgeon during two time periods.
Results: One hundred and forty residents were assessed in 270 sessions. In junior residents, a significant improvement in final scores was identified in S-T-S (use of Castroviejo needle holder, needle angles, and needle transfer) (P<0.05). In seniors, a significant improvement was identified in S-T-S (graft orientation, appropriate spacing, use of forceps, angles, and needle transfer) anastomoses (P<0.05). A significant improvement in the final anastomosis time of senior residents over junior residents was identified in S-T-S (8.11 vs. 11.22 minutes), E-T-S (7.93 vs. 10.10 minutes), and E-T-E (6.56 vs. 9.68 minutes) (P=0.039).
Conclusion: Our portable and low-cost coronary anastomosis simulator is effective in improving operative skills in cardiothoracic surgery residents; therefore, skills acquired through simulation-based training transfer have a positive impact on the surgical environment.
Keywords: Operating Rooms; Surgeons; Clinical Competence; Internship and Residency; Curriculum; Thoracic Surgery
Early Mortality in Cardiac Surgery - Is Lactate Significant?
Braz J Cardiovasc Surg. 2024;39(5):e20230245
Introduction: Serum lactate is a consequence of tissue hypoperfusion and has been used
routinely for patient management following cardiac surgery. This study aims
to determine the association of lactate with early mortality and
postoperative morbidity.
Methods: This is a prospective cohort study carried out in the Department of Cardiovascular and Thoracic Surgery, King George’s Medical University (India), from January 2020 to December 2022. A total of 270 patients were included in this study. Serum lactate levels were measured preoperatively, intraoperatively on-pump, coming off-pump, and at six, 12, 24, and 48 hours postoperatively.
Results: Early mortality was noted in 17 cases (6.3%). While both lactate and lactate clearance correlated with duration of mechanical ventilation, vasopressor duration, and intensive care unit and hospital stay, correlation with early mortality was noted only with lactate at 24 hours. Logistic regression analysis demonstrated that lactate levels at preoperative period (adjusted odds ratio [OR] 4.76 [1.67-13.59], P=0.004) and at 24 hours after bypass (OR 1.21 [1.00-1.47], P=0.046) and vasopressor duration (OR 1.11 [1.04-1.19], P=0.002) are independent predictors of mortality. Receiver operating characteristic curve analysis showed that arterial lactate on-pump, off-pump, and at six, 12, and 24 hours after surgery had significant area under the curve for predicting mortality.
Conclusion: Arterial lactate and lactate clearance show good correlation with duration of mechanical ventilation, vasopressor support, and intensive care unit and hospital stay and can serve as a good indicator to guide therapeutic decisions in postoperative period. However, it fails to be a sensitive predictor of mortality.
Keywords: Cardiac surgical procedures; Latic Acid; Mortality; Intensive care units; Postoperative period; Length Stay;
Methods: This is a prospective cohort study carried out in the Department of Cardiovascular and Thoracic Surgery, King George’s Medical University (India), from January 2020 to December 2022. A total of 270 patients were included in this study. Serum lactate levels were measured preoperatively, intraoperatively on-pump, coming off-pump, and at six, 12, 24, and 48 hours postoperatively.
Results: Early mortality was noted in 17 cases (6.3%). While both lactate and lactate clearance correlated with duration of mechanical ventilation, vasopressor duration, and intensive care unit and hospital stay, correlation with early mortality was noted only with lactate at 24 hours. Logistic regression analysis demonstrated that lactate levels at preoperative period (adjusted odds ratio [OR] 4.76 [1.67-13.59], P=0.004) and at 24 hours after bypass (OR 1.21 [1.00-1.47], P=0.046) and vasopressor duration (OR 1.11 [1.04-1.19], P=0.002) are independent predictors of mortality. Receiver operating characteristic curve analysis showed that arterial lactate on-pump, off-pump, and at six, 12, and 24 hours after surgery had significant area under the curve for predicting mortality.
Conclusion: Arterial lactate and lactate clearance show good correlation with duration of mechanical ventilation, vasopressor support, and intensive care unit and hospital stay and can serve as a good indicator to guide therapeutic decisions in postoperative period. However, it fails to be a sensitive predictor of mortality.
Keywords: Cardiac surgical procedures; Latic Acid; Mortality; Intensive care units; Postoperative period; Length Stay;
Role of Preservation Solution in Human Aneurysmatic Aorta Harvest and Transport: A Comparative Analysis of Different Solutions for Tissue Injury Protection
Braz J Cardiovasc Surg. 2024;39(5):e20230434
Introduction: Human aortic tissues in vitro are tools to clarify the pathophysiological
mechanisms of the cardiovascular system, cell culture, and transplants.
Therefore, this study aims to analyze and compare the preservation of human
aneurysmatic aortic tissues in three different solutions.
Methods: Six human abdominal aortic aneurysms were obtained from patients after surgical ablation. The aorta samples were incubated in different solutions - 0.9% normal physiological saline solution, Ringer’s lactate solution, and histidine-tryptophan-ketoglutarate solution (Custodiol®). Segments were collected at 0, 6, 24, and 48 hours. Creatine kinase and nitrate/nitrite were quantified for each incubation time. The tissue’s alpha-smooth muscle actin was analyzed by immunofluorescence.
Results: There was a significant increase in creatine kinase formation in the normal saline group at 0 and 48 hours and in the Ringer’s lactate group at 0 and 48 hours (P=0.018 and P=0.028). The lower levels of creatine kinase and nitrate/nitrite and the aortic tissues’ morphological integrity show that histidine-tryptophan-ketoglutarate has better tissue protection. These data suggest that histidine-tryptophan-ketoglutarate induces a protective effect on smooth muscle cells, with less tissue depletion in the aortic aneurysm.
Conclusion: This study compared three preservation solutions with the potential for human abdominal aortic aneurysm tissue preservation. The histidine-tryptophan-ketoglutarate solution reduced tissue injury and improved tissue preservation in human abdominal aortic aneurysm tissue samples.
Keywords: Saline Solution; Tissue preservation; Cell culture techniques; Smooth Muscle Myocytes; Abdominal Aortic Aneurysm; Histidine; Nitrates; Nitrites;
Methods: Six human abdominal aortic aneurysms were obtained from patients after surgical ablation. The aorta samples were incubated in different solutions - 0.9% normal physiological saline solution, Ringer’s lactate solution, and histidine-tryptophan-ketoglutarate solution (Custodiol®). Segments were collected at 0, 6, 24, and 48 hours. Creatine kinase and nitrate/nitrite were quantified for each incubation time. The tissue’s alpha-smooth muscle actin was analyzed by immunofluorescence.
Results: There was a significant increase in creatine kinase formation in the normal saline group at 0 and 48 hours and in the Ringer’s lactate group at 0 and 48 hours (P=0.018 and P=0.028). The lower levels of creatine kinase and nitrate/nitrite and the aortic tissues’ morphological integrity show that histidine-tryptophan-ketoglutarate has better tissue protection. These data suggest that histidine-tryptophan-ketoglutarate induces a protective effect on smooth muscle cells, with less tissue depletion in the aortic aneurysm.
Conclusion: This study compared three preservation solutions with the potential for human abdominal aortic aneurysm tissue preservation. The histidine-tryptophan-ketoglutarate solution reduced tissue injury and improved tissue preservation in human abdominal aortic aneurysm tissue samples.
Keywords: Saline Solution; Tissue preservation; Cell culture techniques; Smooth Muscle Myocytes; Abdominal Aortic Aneurysm; Histidine; Nitrates; Nitrites;
REVIEW ARTICLE
The Advent of Artificial Intelligence into Cardiac Surgery: A Systematic Review of Our Understanding
Braz J Cardiovasc Surg. 2024;39(5):e20230308
Patient Blood Management Program Implementation: Comprehensive Recommendations and Practical Strategies
Braz J Cardiovasc Surg. 2024;39(5):e20240205
Introduction: Blood transfusion is one of the most common medical practices worldwide.
However, current scientific literature has shown that the immunomodulatory
effects of blood transfusion are associated with an increased likelihood of
infection, prolonged hospitalization, and morbimortality. Also, it means
high costs for healthcare systems.
Methods: In this context, acknowledging that blood transfusions are essentially heterologous cell transplantations, the use of therapeutic options has gained strength and is collectively known as the patient blood management (PBM) program. PBM is an approach based on three main pillars: (1) treating anemias and coagulopathies in an optimized manner, especially in the preoperative period; (2) optimizing perioperative hemostasis and the use of blood recovery systems to avoid the loss of the patient's blood; (3) anemia tolerance, with improved oxygen delivery and reduced oxygen demand, particularly in the postoperative period.
Results: Current scientific evidence supports the effectiveness of PBM by reducing the need for blood transfusions, decreasing associated complications, and promoting more efficient and safer blood management. Thus, PBM not only improves clinical outcomes for patients but also contributes to the economic sustainability of healthcare systems.
Conclusion: The aim of this review was to summarize PBM strategies in a comprehensive, evidence-based approach through a systematic and structured model for PBM implementation in tertiary hospitals. The recommendations proposed herein are from researchers and experts of a high-complexity university hospital in the network of the Sistema Único de Saúde, presenting itself as a strategy that can be followed as a guideline for PBM implementation in other settings.
Keywords: Blood transfusion; Guideline; Health Strategies; Hospitalization; Costs and cost analysis; Research Personnel; Tertiary Care Centers; Public Health
Methods: In this context, acknowledging that blood transfusions are essentially heterologous cell transplantations, the use of therapeutic options has gained strength and is collectively known as the patient blood management (PBM) program. PBM is an approach based on three main pillars: (1) treating anemias and coagulopathies in an optimized manner, especially in the preoperative period; (2) optimizing perioperative hemostasis and the use of blood recovery systems to avoid the loss of the patient's blood; (3) anemia tolerance, with improved oxygen delivery and reduced oxygen demand, particularly in the postoperative period.
Results: Current scientific evidence supports the effectiveness of PBM by reducing the need for blood transfusions, decreasing associated complications, and promoting more efficient and safer blood management. Thus, PBM not only improves clinical outcomes for patients but also contributes to the economic sustainability of healthcare systems.
Conclusion: The aim of this review was to summarize PBM strategies in a comprehensive, evidence-based approach through a systematic and structured model for PBM implementation in tertiary hospitals. The recommendations proposed herein are from researchers and experts of a high-complexity university hospital in the network of the Sistema Único de Saúde, presenting itself as a strategy that can be followed as a guideline for PBM implementation in other settings.
Keywords: Blood transfusion; Guideline; Health Strategies; Hospitalization; Costs and cost analysis; Research Personnel; Tertiary Care Centers; Public Health
BRIEF COMMUNICATION
Navigating the Challenges in Setting Up a Sustainable Open-Heart Surgery Unit in a Resource-Constrained Environment in Northern Nigeria: Model and Strategies
Braz J Cardiovasc Surg. 2024;39(5):e20230107
Introduction: Cardiac surgery requiring cardiopulmonary bypass had been unavailable in
Northern Nigeria and the federal capital territory of Nigeria regularly.
Several attempts in the past at setting up this service in a self-sustaining
manner in Northern Nigeria had failed. This paper is a contrasting response
to an earlier publication that emphasized the less-than-desirable role
played by international cardiac surgery missions in the evolution of a
sustainable open-heart surgery program in Nigeria.
Methods: The cardiothoracic unit of Federal Medical Centre, Abuja, was established on March 1, 2021, but could not conduct safe open-heart surgery. The model and strategies employed in commencing open-heart surgeries, including the choice of personnel training within the country and focused collaboration with foreign missions, are discussed. We also report the first seven patients to undergo cardiac surgery under cardiopulmonary bypass in our government-run hospital as well as the transition from foreign missions to local team operations.
Results: Seven patients were operated on within the first six months of setting up with high levels of skill transfer and local team participation, culminating in one of the operations entirely carried out by the local team of personnel. All outcomes were good at an average of one-year follow-up.
Conclusion: In resource-constrained government-run hospitals, a functional, safe cardiac surgery unit can be set up by implementing well-planned strategies to mitigate encountered peculiar challenges. Furthermore, with properly harnessed foreign missions, a prior-trained local team of personnel can achieve independence and become a self-sustaining cardiac surgery unit within the shortest possible time.
Keywords: Cardiopulmonary bypass; Nigeria; Cardiac surgical procedures; Government; Strategies; Self-Sustainable
Methods: The cardiothoracic unit of Federal Medical Centre, Abuja, was established on March 1, 2021, but could not conduct safe open-heart surgery. The model and strategies employed in commencing open-heart surgeries, including the choice of personnel training within the country and focused collaboration with foreign missions, are discussed. We also report the first seven patients to undergo cardiac surgery under cardiopulmonary bypass in our government-run hospital as well as the transition from foreign missions to local team operations.
Results: Seven patients were operated on within the first six months of setting up with high levels of skill transfer and local team participation, culminating in one of the operations entirely carried out by the local team of personnel. All outcomes were good at an average of one-year follow-up.
Conclusion: In resource-constrained government-run hospitals, a functional, safe cardiac surgery unit can be set up by implementing well-planned strategies to mitigate encountered peculiar challenges. Furthermore, with properly harnessed foreign missions, a prior-trained local team of personnel can achieve independence and become a self-sustaining cardiac surgery unit within the shortest possible time.
Keywords: Cardiopulmonary bypass; Nigeria; Cardiac surgical procedures; Government; Strategies; Self-Sustainable
CASE REPORT
Type A Aortic Dissection Following Heart Transplantation
Braz J Cardiovasc Surg. 2024;39(5):e20230252
Ponytail Left Anterior Descending Artery: A Case Report
Braz J Cardiovasc Surg. 2024;39(5):e20230260
MULTIMEDIA
Left Anterior Minithoracotomy for Pulmonary Valve Replacement in Adults
Braz J Cardiovasc Surg. 2024;39(5):e20230324
Surgical interventions on the pulmonary valve in adults have been increasing over the years, as patients with congenital heart diseases are experiencing extended lifespans. Reoperations involving multiple sternotomies exhibit elevated morbidity and mortality rates. With nearly two decades of experience in minimally invasive video-assisted mitral valve surgery, we have chosen the left anterior minithoracotomy approach for addressing the pulmonary valve and right ventricular outflow tract in adult patients. The technique demonstrates safety based on initial outcomes, minimizing potential complications from multiple cardiac reapproaches. Our series of five patients demonstrated an absence of postoperative complications or mortality.
Keywords: Pulmonary valve; Mitral Valve; Reoperation; Sternotomy; Longevity; Congenital Heart Defects; Postoperative complications
LETTER TO THE EDITOR
Artificial Intelligence in the Hands of Perfusionists: Revolutionizing Cardiopulmonary Bypass
Braz J Cardiovasc Surg. 2024;39(5):e20240005