Volume 40 - Número 2
EDITORIAL
A Paradigm Shift in Managing Carotid Artery Disease Associated with Coronary Artery Bypass Grafting
Braz J Cardiovasc Surg 40;
e20250901
Publish in: 8/2/2025
ORIGINAL ARTICLE
One-stage Surgery for Intracardiac Leiomyomatosis
Braz J Cardiovasc Surg 40;
e20230291
Publish in: 8/2/2025
Introduction: Intracardiac leiomyomatosis is a rare, histologically benign, but biologically aggressive tumor developed from uterus. This study aimed to summarize our experience with one-stage surgery for intracardiac leiomyomatosis.
Methods: We retrospectively reviewed seven patients who underwent surgical treatment for intracardiac leiomyomatosis between May 2016 and November 2021.
Results: All seven patients were female, aged 35 to 57 years. All lesions in the veins and cardiac chambers were removed entirely. Four of the seven patients received tumor thrombectomy through an abdominal approach. The other three patients received median sternotomy and cardiopulmonary bypass. No perioperative deaths or serious complications occurred during the observation period. The mean operation time in the abdominal approach group was shorter than that in the cardiopulmonary bypass group (308.9 ± 93.2 minutes vs. 486.3 ± 108.6 minutes; P=0.031). Blood loss during surgery in the abdominal approach group was less than that in the cardiopulmonary bypass group (1625 ± 216 mL vs. 2500 ± 1080 mL; P=0.148). All seven patients were free from tumor recurrence or death during the follow-up.
Conclusion: For patients with intracardiac intravenous leiomyomatosis single-stage operation through an abdominal approach under the surveillance of intraoperative transesophageal echocardiography without the need for cardiopulmonary bypass for specified patients is feasible. Patients in the abdominal approach group can benefit from a shorter operation time and less blood loss. In our small series of varied presentations and tumor extent, we have been able to avoid two-stage surgery, because even short-term interval between the two operations may result in recurrence.
Keywords: Cardiopulmonary bypass; Chambers; Transesophageal Echocardiography; Leiomyomatosis; Sternotomy; Surveillance in Disasters; Thrombectomy;
Methods: We retrospectively reviewed seven patients who underwent surgical treatment for intracardiac leiomyomatosis between May 2016 and November 2021.
Results: All seven patients were female, aged 35 to 57 years. All lesions in the veins and cardiac chambers were removed entirely. Four of the seven patients received tumor thrombectomy through an abdominal approach. The other three patients received median sternotomy and cardiopulmonary bypass. No perioperative deaths or serious complications occurred during the observation period. The mean operation time in the abdominal approach group was shorter than that in the cardiopulmonary bypass group (308.9 ± 93.2 minutes vs. 486.3 ± 108.6 minutes; P=0.031). Blood loss during surgery in the abdominal approach group was less than that in the cardiopulmonary bypass group (1625 ± 216 mL vs. 2500 ± 1080 mL; P=0.148). All seven patients were free from tumor recurrence or death during the follow-up.
Conclusion: For patients with intracardiac intravenous leiomyomatosis single-stage operation through an abdominal approach under the surveillance of intraoperative transesophageal echocardiography without the need for cardiopulmonary bypass for specified patients is feasible. Patients in the abdominal approach group can benefit from a shorter operation time and less blood loss. In our small series of varied presentations and tumor extent, we have been able to avoid two-stage surgery, because even short-term interval between the two operations may result in recurrence.
Keywords: Cardiopulmonary bypass; Chambers; Transesophageal Echocardiography; Leiomyomatosis; Sternotomy; Surveillance in Disasters; Thrombectomy;
Ex vivo Coronary Angiography: Safety of Iopromide in Cold Preservation of Pig Hearts
Braz J Cardiovasc Surg 40;
e20240080
Publish in: 8/2/2025
Objective: To evaluate the effects of intracoronary iopromide (Ultravist®, Germany) administration on the recovery of cardiac pump function and cardiomyocytes metabolism during ex vivo cold preservation of pig hearts in the early posttransplant period.
Methods: Three-month-old mini pigs weighing 73 ± 2.8 kg were used as experimental models (n=12). Physiological parameters were obtained with the IntelliVue MP70 system (Philips, Netherlands). Blood samples were taken from the coronary sinus to evaluate myocardial ischemia markers - troponin I, creatine phosphokinase-MB, lactate dehydrogenase, and lactate - and apex biopsy was performed before and after the ischemia period according to the protocol. Myocardial samples were taken from the left ventricle and prepared according to the protocol either.
Results: Twelve orthotopic heart transplantations were performed during the study. Sample size was divided into two groups with six each. Cardiac output was 5.11 (4.99; 5.41) l/min and 5.77 (4.97; 6.62) l/min (P-0.0009) after 120 minutes of cardiac activity in both groups. Change of lactate dehydrogenase, creatine phosphokinase-MB, and troponin I levels in the coronary sinus blood were significantly higher in the early reperfusion period. However, there were no statistically significant differences between the groups (P>0.05). Myocardial oxygen consumption was considerably reduced during reperfusion but returned to baseline by 60 minutes of postischemia without significant differences between groups (P>0.05).
Conclusion: We observed that intracoronary iopromide administration was safe during the ex vivo stage cold preservation phase of the study. Intracoronary iopromide administration did not affect cardiac pump function and cardiomyocytes metabolism in the early posttransplant period.
Keywords: Cardiac output; Cold Temperature; Coronary sinus; Creatine Kinase; Myocardial ischemia; Myocytes; Cardiac; Ischemia; L-Lactate Dehydrogenase; Lactic acid; Swine; Troponin I;
Methods: Three-month-old mini pigs weighing 73 ± 2.8 kg were used as experimental models (n=12). Physiological parameters were obtained with the IntelliVue MP70 system (Philips, Netherlands). Blood samples were taken from the coronary sinus to evaluate myocardial ischemia markers - troponin I, creatine phosphokinase-MB, lactate dehydrogenase, and lactate - and apex biopsy was performed before and after the ischemia period according to the protocol. Myocardial samples were taken from the left ventricle and prepared according to the protocol either.
Results: Twelve orthotopic heart transplantations were performed during the study. Sample size was divided into two groups with six each. Cardiac output was 5.11 (4.99; 5.41) l/min and 5.77 (4.97; 6.62) l/min (P-0.0009) after 120 minutes of cardiac activity in both groups. Change of lactate dehydrogenase, creatine phosphokinase-MB, and troponin I levels in the coronary sinus blood were significantly higher in the early reperfusion period. However, there were no statistically significant differences between the groups (P>0.05). Myocardial oxygen consumption was considerably reduced during reperfusion but returned to baseline by 60 minutes of postischemia without significant differences between groups (P>0.05).
Conclusion: We observed that intracoronary iopromide administration was safe during the ex vivo stage cold preservation phase of the study. Intracoronary iopromide administration did not affect cardiac pump function and cardiomyocytes metabolism in the early posttransplant period.
Keywords: Cardiac output; Cold Temperature; Coronary sinus; Creatine Kinase; Myocardial ischemia; Myocytes; Cardiac; Ischemia; L-Lactate Dehydrogenase; Lactic acid; Swine; Troponin I;
Frailty Assessment to Improve Risk Stratification in Elderly Patients Undergoing Elective Cardiac Surgery
Braz J Cardiovasc Surg 40;
e20230182
Publish in: 8/2/2025
Introduction: Frailty is a biological syndrome of the elderly characterized by decreased
physiological reserve and weakened response to stressors. Most cardiac
surgical risk models incorporate chronologic age as a risk parameter, but
not frailty. We aimed to identify the frailty assessment tool with the
highest prognostic value to predict postoperative adverse outcomes in
elderly patients undergoing cardiac surgery and to investigate whether
addition of a frailty parameter to cardiac surgical risk models would
increase predictive power.
Methods: This is a single-center, prospective, observational study. Consecutive adults, undergoing elective cardiac surgery between January and May 2020, were included. The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) and Society of Thoracic Surgeons risk scores were calculated. Fried Scale, Short Physical Performance Battery, Clinical Frailty Scale, and serum albumin were used for frailty assessment. Patients were followed-up for 30 days postoperatively or until discharge. Primary endpoint was a composite of mortality and major morbidity.
Results: One hundred sixty-four patients were included (34.76% women, median age 70 years [interquartile range, 67-74]. EuroSCORE II and albumin were the only tools significantly associated with the primary endpoint (P=0.045 and P=0.031, respectively). Model created by combination of EuroSCORE II and albumin was not associated with the primary outcome (P=0.571), however EuroSCORE II’s R-squared value increased from 0.07 to 0.144 after addition of albumin.
Conclusion: Addition of albumin measurement as a frailty marker to EuroSCORE II has the potential to improve EuroSCORE II’s ability to predict early postoperative mortality/morbidity in elderly patients undergoing cardiac surgery.
Keywords: Aged; Prognosis; Frailty; Serum Albumin; Patient Discharge, Cardiac Surgical Procedures; Risk Factors; Morbidity
Methods: This is a single-center, prospective, observational study. Consecutive adults, undergoing elective cardiac surgery between January and May 2020, were included. The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) and Society of Thoracic Surgeons risk scores were calculated. Fried Scale, Short Physical Performance Battery, Clinical Frailty Scale, and serum albumin were used for frailty assessment. Patients were followed-up for 30 days postoperatively or until discharge. Primary endpoint was a composite of mortality and major morbidity.
Results: One hundred sixty-four patients were included (34.76% women, median age 70 years [interquartile range, 67-74]. EuroSCORE II and albumin were the only tools significantly associated with the primary endpoint (P=0.045 and P=0.031, respectively). Model created by combination of EuroSCORE II and albumin was not associated with the primary outcome (P=0.571), however EuroSCORE II’s R-squared value increased from 0.07 to 0.144 after addition of albumin.
Conclusion: Addition of albumin measurement as a frailty marker to EuroSCORE II has the potential to improve EuroSCORE II’s ability to predict early postoperative mortality/morbidity in elderly patients undergoing cardiac surgery.
Keywords: Aged; Prognosis; Frailty; Serum Albumin; Patient Discharge, Cardiac Surgical Procedures; Risk Factors; Morbidity
Use of Antegrade Coronary Oxygen Persufflation as a Strategy for Donor Heart Preservation
Braz J Cardiovasc Surg 40;
e20230469
Publish in: 8/2/2025
Objective: To assess the technical feasibility and functional, metabolic, and structural myocardial
integrity of the donor heart after four hours of direct coronary oxygen persufflation
(COP).
Methods: This research was carried out on three-month-old minipig siblings weighing 23-36 kg. Cardiac arrest was achieved by administrating two liters of Bretschneider’s cardioplegic solution (histidine-tryptophan-ketoglutarate [HTK]) (Custodiol®, Germany) into the aortic root. Orthotopic heart transplantation was performed after three hours of cardiac arrest.
Results: A statistically significant decrease in cardiac output was observed in both groups (from 3.36 ± 0.36 l/min and 3.72 ± 0.52 l/min in the HTK group and modified HTK + COP to 2.35 ± 0.52 l/min and 2.15 ± 0.34 l/min, respectively) (Р<0.05). Differences between both groups were insignificant (P>0.05). Cardiac output was 2.99 ± 0.45 l/min and 2.48 ± 0.58 l/min (Р>0.05) in both groups after 120 min of cardiac recovery. Lactate dehydrogenase, creatine phosphokinase-MB, and troponin I changes in coronary sinus blood were significantly higher in the early reperfusion period. Statistical insignificance was observed between both groups (P>0.05). Myocardial oxygen consumption was 8.2 [7.35; 9.35] ml-О2/min/100 g and 7.7 [6.75; 10.12] ml-О2/min/100g in both groups (P>0.05). Histological examinations demonstrate no significant myocardial ischemic injury in the persufflation group.
Conclusion: The study demonstrated technical feasibility and safety of direct coronary persufflation for four hours during ex vivo donor heart conditioning. However, no significant advantages of direct COP were observed over the standard cold preservation protocol.
Keywords: Oxygen Consumption; Organ preservation; Cardioplegic solutions; Heart transplantation; Feasibility Studies; Siblings; Tissue donors; Heart Arrest; Cardiac output; Reperfusion
Methods: This research was carried out on three-month-old minipig siblings weighing 23-36 kg. Cardiac arrest was achieved by administrating two liters of Bretschneider’s cardioplegic solution (histidine-tryptophan-ketoglutarate [HTK]) (Custodiol®, Germany) into the aortic root. Orthotopic heart transplantation was performed after three hours of cardiac arrest.
Results: A statistically significant decrease in cardiac output was observed in both groups (from 3.36 ± 0.36 l/min and 3.72 ± 0.52 l/min in the HTK group and modified HTK + COP to 2.35 ± 0.52 l/min and 2.15 ± 0.34 l/min, respectively) (Р<0.05). Differences between both groups were insignificant (P>0.05). Cardiac output was 2.99 ± 0.45 l/min and 2.48 ± 0.58 l/min (Р>0.05) in both groups after 120 min of cardiac recovery. Lactate dehydrogenase, creatine phosphokinase-MB, and troponin I changes in coronary sinus blood were significantly higher in the early reperfusion period. Statistical insignificance was observed between both groups (P>0.05). Myocardial oxygen consumption was 8.2 [7.35; 9.35] ml-О2/min/100 g and 7.7 [6.75; 10.12] ml-О2/min/100g in both groups (P>0.05). Histological examinations demonstrate no significant myocardial ischemic injury in the persufflation group.
Conclusion: The study demonstrated technical feasibility and safety of direct coronary persufflation for four hours during ex vivo donor heart conditioning. However, no significant advantages of direct COP were observed over the standard cold preservation protocol.
Keywords: Oxygen Consumption; Organ preservation; Cardioplegic solutions; Heart transplantation; Feasibility Studies; Siblings; Tissue donors; Heart Arrest; Cardiac output; Reperfusion
The Effect of Prognostic Nutritional Index in Predicting Clinical Outcomes in Valve Replacement Patients
Braz J Cardiovasc Surg 40;
e20230503
Publish in: 8/2/2025
Introduction: Cardiopulmonary bypass is known to be a cause of systemic inflammatory
response. The systemic inflammatory response affects albumin and lymphocyte
levels and is associated with the development of complications. Serum
albumin and lymphocyte concentrations have been used to create
inflammation-based risk scores, which predict prognosis in different patient
groups. One of these risk scores is called the Prognostic Nutritional Index
(PNI). In this study, our objective was to examine how changes in PNI
values, measured at different times before and after surgery, impact
clinical outcomes and hospital mortality.
Methods: One hundred and sixty-four patients were retrospectively scanned and included in the study. Patients were divided into aortic valve replacement (AVR) and mitral valve replacement (MVR) groups. The patient's preoperative and postoperative PNI values were examined. Duration of cross-clamping, cardiopulmonary bypass time, length of hospital and intensive care unit stay, postoperative mortality, atrial fibrillation, and acute kidney injury (AKI) development were evaluated.
Results: Preoperative and second PNI values were lower in the patients that developed AKI and non-survivors. The PNI cutoff value was ≤ 28.01 in non-survivors (P=0.001). In the MVR group, the decrease in PNI value over time was statistically significant (P<0.001). There was a negative correlation between preoperative PNI value and length of stay in intensive care unit, cross-clamping, and cardiopulmonary bypass duration (P<0.05, P<0.01).
Conclusion: A correlation was determined between the PNI value and development of postoperative AKI and mortality. PNI value, an easy method to use, can be used in the follow-up of these patients.
Keywords: Atrial fibrillation; Nutritional Assessment; Hospital mortality; Cardiopulmonary bypass; Aortic valve; Constriction; Inflammation; Intensive care units
Methods: One hundred and sixty-four patients were retrospectively scanned and included in the study. Patients were divided into aortic valve replacement (AVR) and mitral valve replacement (MVR) groups. The patient's preoperative and postoperative PNI values were examined. Duration of cross-clamping, cardiopulmonary bypass time, length of hospital and intensive care unit stay, postoperative mortality, atrial fibrillation, and acute kidney injury (AKI) development were evaluated.
Results: Preoperative and second PNI values were lower in the patients that developed AKI and non-survivors. The PNI cutoff value was ≤ 28.01 in non-survivors (P=0.001). In the MVR group, the decrease in PNI value over time was statistically significant (P<0.001). There was a negative correlation between preoperative PNI value and length of stay in intensive care unit, cross-clamping, and cardiopulmonary bypass duration (P<0.05, P<0.01).
Conclusion: A correlation was determined between the PNI value and development of postoperative AKI and mortality. PNI value, an easy method to use, can be used in the follow-up of these patients.
Keywords: Atrial fibrillation; Nutritional Assessment; Hospital mortality; Cardiopulmonary bypass; Aortic valve; Constriction; Inflammation; Intensive care units
Penetrating Cardiac Injury: A 20-Year Retrospective Analysis at a High-Complexity University Center
Braz J Cardiovasc Surg 40;
e20240049
Publish in: 8/2/2025
Introduction: Penetrating cardiac injury, though infrequent, is associated with substantial
mortality. In 2005, our research team conducted a comprehensive
retrospective analysis of penetrating cardiac injuries managed at our
facility from 1990 to 2003. Now, two decades later, we conducted the present
study on penetrating cardiac injuries attended in our hospital over the last
20 years.
Methods: This is a retrospective analysis of medical records and trauma database data, with a focus on survivors of penetrating cardiac trauma, excluding those deceased upon arrival.
Results: Out of 1,093 cases, 25 had penetrating cardiac injuries with an overall mortality rate of 36%. Hemorrhage was the leading cause of death, and survival was correlated with higher systolic blood pressure upon admission and the level of consciousness.
Conclusion: The study highlights the need for rapid intervention and emphasizes the importance of managing bleeding and supporting hemodynamics. It also points to areas for improvement in emergency care and the benefits of interdisciplinary collaboration.
Keywords: Blood Pressure; Cause of Death; Consciousness; Emergency Medical Services; Hemodynamics; Hemorrhage; Hospitals; Medical Records; Mortality
Methods: This is a retrospective analysis of medical records and trauma database data, with a focus on survivors of penetrating cardiac trauma, excluding those deceased upon arrival.
Results: Out of 1,093 cases, 25 had penetrating cardiac injuries with an overall mortality rate of 36%. Hemorrhage was the leading cause of death, and survival was correlated with higher systolic blood pressure upon admission and the level of consciousness.
Conclusion: The study highlights the need for rapid intervention and emphasizes the importance of managing bleeding and supporting hemodynamics. It also points to areas for improvement in emergency care and the benefits of interdisciplinary collaboration.
Keywords: Blood Pressure; Cause of Death; Consciousness; Emergency Medical Services; Hemodynamics; Hemorrhage; Hospitals; Medical Records; Mortality
Fontan Surgical Planning: Numerical Simulations Reveal Efficient Geometries Predicting Post-Surgical Outcomes
Braz J Cardiovasc Surg 40;
e20240217
Publish in: 8/2/2025
Introduction: Computational fluid dynamics has the potential to assist cardiovascular surgeons in making more accurate decisions, allowing the prediction of post-surgical outcomes, provided that pre-surgical conditions are well established. However, the application of current techniques, which are based on volume methods, is still limited to a few specialized centers. Lack of knowledge, coupled with the need for advanced computational resources, can serve as obstacles to implementation. Objective: This study aimed to develop a replicable surgical planning procedure for a simplified and clinically feasible total cavopulmonary geometry.
Methods: The finite volume method was used to simulate different configurations of cavopulmonary anastomosis under continuous and pulsatile flow and thus gain a better understanding of blood behavior, energy efficiency, and shear stress in the studied regions.
Results: Two geometries were found to be efficient in distributing blood flow in a physiological manner, with adequate shear stress and energy loss. In addition to the correct placement of the anastomosis, the results underscored the need for attention regarding potential stenoses in pulmonary arteries to obtain adequate geometries.
Conclusion: The developed method proved to be effective for early visualization of post-surgical results, particularly in complex clinical cases. Furthermore, the method contributes to a comprehensive understanding of hemodynamics in the studied area, improving the accuracy of cardiovascular surgical planning.
Keywords: Hydrodynamics; Pulsative Flow; Pulonary Artery; Pathologic Constriction; Surgical Anastomosis; Right Heart Bypass; Surgeons
Methods: The finite volume method was used to simulate different configurations of cavopulmonary anastomosis under continuous and pulsatile flow and thus gain a better understanding of blood behavior, energy efficiency, and shear stress in the studied regions.
Results: Two geometries were found to be efficient in distributing blood flow in a physiological manner, with adequate shear stress and energy loss. In addition to the correct placement of the anastomosis, the results underscored the need for attention regarding potential stenoses in pulmonary arteries to obtain adequate geometries.
Conclusion: The developed method proved to be effective for early visualization of post-surgical results, particularly in complex clinical cases. Furthermore, the method contributes to a comprehensive understanding of hemodynamics in the studied area, improving the accuracy of cardiovascular surgical planning.
Keywords: Hydrodynamics; Pulsative Flow; Pulonary Artery; Pathologic Constriction; Surgical Anastomosis; Right Heart Bypass; Surgeons
Cardiopulmonary Bypass and Cross-Clamping Times in Aortic Valve Replacement Surgery by Ministernotomy with Sutureless Prosthesis Implantation Compared to Conventional Prosthesis: A Cross-Sectional Study
Braz J Cardiovasc Surg 40;
e20240290
Publish in: 8/2/2025
Introduction: Valve replacement is one of the effective treatments for aortic valve
disease. This study aims to compare cardiopulmonary bypass and ischemia
times in aortic valve replacement surgeries using stented biological and
sutureless prostheses (PERCEVAL®) through a minimally invasive
ministernotomy approach. Methods: This single-center
cross-sectional study, conducted from February 2015 to February 2021,
assessed clinical and epidemiological characteristics in aortic valve
replacement patients. It analyzed factors including hospital stay, early
outcomes, valve etiology, intraoperative diagnosis, systolic gradients, left
ventricular ejection fraction, and left ventricular mass. Two groups were
studied: 12 patients with PERCEVAL® prostheses and 81 with
conventional bioprostheses.
Results: This study included 93 patients (age: 59 ± 16 years), 61.3% were male, and 80.2% had hypertension; dyslipidemias were present in 34.1% and 25.3% were diabetic. Cardiopulmonary bypass and cross-clamping times were 61 minutes and 41 minutes in the conventional bioprostheses group and 59.5 minutes and 39.5 minutes in the PERCEVAL® group (P=0.143 and P=0.058, respectively). Intensive care unit and overall hospital stays were statistically comparable between both groups (P=0.662 and P=0.599, respectively). All participants survived the 30-day postoperative period, with minimal complications, no significant differences in echocardiographic parameters were observed, yet higher values for certain cardiac function indicators were noted in the conventional bioprostheses group.
Conclusion: The groups with conventional bioprostheses and sutureless prostheses (PERCEVAL®) didn't display significant differences in the analyzed variables for ministernotomy aortic valve replacement surgery. They exhibited similar results in terms of hospital stay duration, 30-day outcomes, and cardiac function values.
Keywords: Aortic valve; Bioprosthesis; Cardiopulmonary bypass; Constriction; Left Ventricular Function; Aortic Valve Disease; Ischemia
Results: This study included 93 patients (age: 59 ± 16 years), 61.3% were male, and 80.2% had hypertension; dyslipidemias were present in 34.1% and 25.3% were diabetic. Cardiopulmonary bypass and cross-clamping times were 61 minutes and 41 minutes in the conventional bioprostheses group and 59.5 minutes and 39.5 minutes in the PERCEVAL® group (P=0.143 and P=0.058, respectively). Intensive care unit and overall hospital stays were statistically comparable between both groups (P=0.662 and P=0.599, respectively). All participants survived the 30-day postoperative period, with minimal complications, no significant differences in echocardiographic parameters were observed, yet higher values for certain cardiac function indicators were noted in the conventional bioprostheses group.
Conclusion: The groups with conventional bioprostheses and sutureless prostheses (PERCEVAL®) didn't display significant differences in the analyzed variables for ministernotomy aortic valve replacement surgery. They exhibited similar results in terms of hospital stay duration, 30-day outcomes, and cardiac function values.
Keywords: Aortic valve; Bioprosthesis; Cardiopulmonary bypass; Constriction; Left Ventricular Function; Aortic Valve Disease; Ischemia
Comparative Study on the Outcomes of Right Ventricular Outflow Tract Stenting vs. Modified Blalock-Taussig Shunt in Patients with Tetralogy of Fallot: A Prospective Randomized Trial
Braz J Cardiovasc Surg 40;
e20230478
Publish in: 8/2/2025
Objective: To evaluate pulmonary vascular development and outcomes of complete
correction following palliative treatment in infants with critical tetralogy
of Fallot.
Methods: This prospective, randomized, two-center study included infants with tetralogy of Fallot who underwent surgery between June 2018 and 2022. The patients were divided into two groups - those who underwent stenting of the right ventricular outflow tract (stent group, n=21) and those who underwent modified Blalock-Taussig shunt placement (shunt group, n=21).
Results: In the stent group, a significantly greater increase in Nakata index was observed, with mean values rising from 104.2 to 208.6 mm2/m2, compared to an increase from 107.3 to 169.4 mm2/m2 in the shunt group (P<0.01). According to the mixed model analysis, the rate of growth of the right pulmonary artery in the stent group was 2.05*10-2 z score/day, which was 3.01 times greater than that in the shunt group (P<0.01). The rate of growth of the left pulmonary artery in the stent group was 2.3*10-2 z score/day, which was 1.47 times greater than that in the shunt group (P<0.01). In one patient (4.8%), after 76 days following the stenting of the RVOT, a severe infectious process with sepsis occurred, leading to a fatal outcome. Complete correction in the stent group involved transannular patch repair of the right ventricular outflow tract to the pulmonary artery in 12 patients (60%), while the same procedure was performed in 15 patients (71.4%) in the shunt group (P=0.52).
Conclusion: Stenting of the right ventricular outflow tract provides hemodynamic stabilization and symmetric growth of the pulmonary vascular bed compared to the formation of a modified Blalock-Taussig shunt.
Keywords: Tetralogy of Fallot; Pulmonary artery; Blalock-Taussig Procedure; Stents; Sepsis
Methods: This prospective, randomized, two-center study included infants with tetralogy of Fallot who underwent surgery between June 2018 and 2022. The patients were divided into two groups - those who underwent stenting of the right ventricular outflow tract (stent group, n=21) and those who underwent modified Blalock-Taussig shunt placement (shunt group, n=21).
Results: In the stent group, a significantly greater increase in Nakata index was observed, with mean values rising from 104.2 to 208.6 mm2/m2, compared to an increase from 107.3 to 169.4 mm2/m2 in the shunt group (P<0.01). According to the mixed model analysis, the rate of growth of the right pulmonary artery in the stent group was 2.05*10-2 z score/day, which was 3.01 times greater than that in the shunt group (P<0.01). The rate of growth of the left pulmonary artery in the stent group was 2.3*10-2 z score/day, which was 1.47 times greater than that in the shunt group (P<0.01). In one patient (4.8%), after 76 days following the stenting of the RVOT, a severe infectious process with sepsis occurred, leading to a fatal outcome. Complete correction in the stent group involved transannular patch repair of the right ventricular outflow tract to the pulmonary artery in 12 patients (60%), while the same procedure was performed in 15 patients (71.4%) in the shunt group (P=0.52).
Conclusion: Stenting of the right ventricular outflow tract provides hemodynamic stabilization and symmetric growth of the pulmonary vascular bed compared to the formation of a modified Blalock-Taussig shunt.
Keywords: Tetralogy of Fallot; Pulmonary artery; Blalock-Taussig Procedure; Stents; Sepsis
Predictors of Postoperative Hospital-Acquired Infection and Mortality Following Cardiac Surgery in a Low-Income Country: A Retrospective Cohort Study
Braz J Cardiovasc Surg 40;
e20240111
Publish in: 8/2/2025
Introduction: Recognizing the risk factors for postoperative hospital-acquired infection
and mortality is crucial for better outcomes. We aimed to determine the risk
predictors for postoperative hospital-acquired infection and death following
cardiac surgery.
Methods: This is a retrospective cohort study that included 880 consecutive adult patients who underwent cardiac surgery between 2015 and 2021. Multivariable logistic regression was performed to assess the predictors of postoperative hospital-acquired infection and mortality.
Results: Patients who developed postoperative hospital-acquired infection had higher values on European System for Cardiac Operative Risk Evaluation score (4.01% vs. 2.51%; P=0.001), as well as longer hospital preoperative stay (9.44 vs. 8.28 days; P=0.049) and hospital length of stay (28.41 vs. 16.16 days; P<0.001). After multivariable analysis, predictors of postoperative hospital-acquired infection were longer hospital preoperative stay (odds ratio 1.024; 95% confidence interval 1.005-1.044; P=0.009), higher body mass index (odds ratio 1.043; 95% confidence interval 1.008-1.079; P=0.015), and longer extracorporeal circulation time (odds ratio 1.007; 95% confidence interval 1.003-1.012; P<0.001). Both longer extracorporeal circulations time and postoperative hospital-acquired infection were significantly associated with higher mortality before hospital discharge (odds ratio 1.012; 95% confidence interval 1.006-1.019; P<0.001; and odds ratio 2.418; 95% confidence interval 1.385-4.233; P=0.001, respectively).
Conclusion: Extended preoperative hospitalization, body mass index, and extracorporeal circulation time are correlated with heightened postoperative hospital-acquired infection rates. Moreover, longer extracorporeal circulation time and postoperative hospital-acquired infection incidence emerged as significant predictors of mortality following cardiac surgery.
Keywords: Cardiac surgical procedures; Hospitalization Infection; Mortality
Methods: This is a retrospective cohort study that included 880 consecutive adult patients who underwent cardiac surgery between 2015 and 2021. Multivariable logistic regression was performed to assess the predictors of postoperative hospital-acquired infection and mortality.
Results: Patients who developed postoperative hospital-acquired infection had higher values on European System for Cardiac Operative Risk Evaluation score (4.01% vs. 2.51%; P=0.001), as well as longer hospital preoperative stay (9.44 vs. 8.28 days; P=0.049) and hospital length of stay (28.41 vs. 16.16 days; P<0.001). After multivariable analysis, predictors of postoperative hospital-acquired infection were longer hospital preoperative stay (odds ratio 1.024; 95% confidence interval 1.005-1.044; P=0.009), higher body mass index (odds ratio 1.043; 95% confidence interval 1.008-1.079; P=0.015), and longer extracorporeal circulation time (odds ratio 1.007; 95% confidence interval 1.003-1.012; P<0.001). Both longer extracorporeal circulations time and postoperative hospital-acquired infection were significantly associated with higher mortality before hospital discharge (odds ratio 1.012; 95% confidence interval 1.006-1.019; P<0.001; and odds ratio 2.418; 95% confidence interval 1.385-4.233; P=0.001, respectively).
Conclusion: Extended preoperative hospitalization, body mass index, and extracorporeal circulation time are correlated with heightened postoperative hospital-acquired infection rates. Moreover, longer extracorporeal circulation time and postoperative hospital-acquired infection incidence emerged as significant predictors of mortality following cardiac surgery.
Keywords: Cardiac surgical procedures; Hospitalization Infection; Mortality
REVIEW ARTICLE
Rheumatic Mitral Valve Surgery: Repair or Replacement?
Braz J Cardiovasc Surg 40;
e20230294
Publish in: 8/2/2025
Introduction: Rheumatic heart disease remains a public health problem, especially in developing countries. The mitral valve (MV) is the main affected cardiac structure, requiring intervention in many cases. The discussion of which is the best option - repair or replacement - is still a controversy.
Objective: To compare the survival of patients with rheumatic MV submitted to replacement or repair.
Methods: We systematically reviewed the English literature through PubMed®, Literatura Latino-Americana e do Caribe em Ciências da Saúde (or LILACS), Scientific Electronic Library Online (or SciELO), and Google Scholar between January 2021 and February 2022, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (or PRISMA) methodology. Articles with a sample of at least 30 patients who underwent MV replacement or repair were included.
Results: Six studies including 2874 patients were analyzed. Most of the patients were female (2001; 69.6%) with a ratio of 2.3:1. The ages ranged from 11 to 66 years. The mean follow-up varied from six to 106 months. In the MV repair group, mortality was 2.5% (62 of 2473) and reoperation was 3.7% (93 of 2473), while in the MV replacement group, mortality was 8.2% (106 of 1291), and 3.6% (54 of 1475) of the patients required reoperation. The patient's survival was similar (85% for repair and 87% for replacement). The main complications post-MV repair or replacement were stroke (1.8%; 2.5%) and endocarditis (0.5%; 1.3%).
Conclusion: The MV repair had lower mortality and fewer complications compared to MV replacement. Reoperation rate and survival are similar.
Keywords: Rheumatic heart disease; Reoperation; Mitral Valve; Treatment outcome; Review;
Objective: To compare the survival of patients with rheumatic MV submitted to replacement or repair.
Methods: We systematically reviewed the English literature through PubMed®, Literatura Latino-Americana e do Caribe em Ciências da Saúde (or LILACS), Scientific Electronic Library Online (or SciELO), and Google Scholar between January 2021 and February 2022, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (or PRISMA) methodology. Articles with a sample of at least 30 patients who underwent MV replacement or repair were included.
Results: Six studies including 2874 patients were analyzed. Most of the patients were female (2001; 69.6%) with a ratio of 2.3:1. The ages ranged from 11 to 66 years. The mean follow-up varied from six to 106 months. In the MV repair group, mortality was 2.5% (62 of 2473) and reoperation was 3.7% (93 of 2473), while in the MV replacement group, mortality was 8.2% (106 of 1291), and 3.6% (54 of 1475) of the patients required reoperation. The patient's survival was similar (85% for repair and 87% for replacement). The main complications post-MV repair or replacement were stroke (1.8%; 2.5%) and endocarditis (0.5%; 1.3%).
Conclusion: The MV repair had lower mortality and fewer complications compared to MV replacement. Reoperation rate and survival are similar.
Keywords: Rheumatic heart disease; Reoperation; Mitral Valve; Treatment outcome; Review;
HOW I DO IT
Concomitant Box Lesion Ablation for Atrial Fibrillation with a Standard Non-Irrigated Bipolar Radiofrequency Clamp: Simplified Approach Without Left Atriotomy
Braz J Cardiovasc Surg 40;
e20230432
Publish in: 8/2/2025
In this paper, the authors describe a simplified technique for concomitant left atrial posterior box isolation for atrial fibrillation using a standard nonirrigated bipolar radiofrequency clamp without opening the left atrium.
Keywords: Atrial Fibrillation; Surgical Ablation; Posterior Box Isolation
CASE REPORT
Occurrence of Acute Aortic Dissection Twice During the Same Pregnancy
Braz J Cardiovasc Surg 40;
e20230401
Publish in: 8/2/2025
Pregnancy-related aortic dissection is an uncommon and serious condition since it poses a risk to the lives of both the mother and the fetus. Here, we describe a pregnant woman who suffered from aortic dissection twice during the same pregnancy and whose fetus was safely delivered following aortic root replacement and thoracic aortic stent-graft implantation.
Keywords: Thoracic Aortic; Aortic Dissection; Pregnancy; Marfan syndrome; Stens; Transplants
Dacron® Graft Kinking Following Ascending Aorta Replacement Is Not Only a Cosmetic Issue
Braz J Cardiovasc Surg 40;
e20220468
Publish in: 8/2/2025
A 58-year-old man, who has undergone ascending aorta replacement, started to complain of pain in the lower limbs, shortness of breath, and progressive fatigue a few months after surgery. Transthoracic and transesophageal Doppler echocardiographies revealed a diseased bicuspid aortic valve and a subocclusive mass in the ascending aorta. Thoracic computed tomography angiography confirmed the presence of a subocclusive mass, pseudoaneurysm formation, and a distorted shape of the Dacron® graft. The patient underwent urgent surgery to remove the mass, which appeared to be a thrombus, and aortic valve and ascending aorta replacement. Kinking of vascular graft has been reported including surgical techniques to correct the excessive length to avoid gradients and guarantee laminar flow. When kinking is severe, high gradients and hemolysis can be detected. However, thrombus formation in the ascending aorta segment is less likely, due to the high blood velocity flow. Therefore, several concurrent causes should be considered. In this case, the most probable explanation for thrombus formation was kinking of a too long Dacron® graft, combined with extrinsic compression effect of the graft by the pseudoaneurysm at the anastomosis site and anomalous flow directed from the diseased bicuspid aortic valve. Various grades of Dacron® graft kinking might occur following ascending aorta replacement and undiagnosed at follow-up especially if resulting in mild symptoms, thus, careful visual and echocardiography evaluation should be done at the end of surgery. Finally, distorted Dacron® graft might trigger thrombus formation when inflammation and coagulation processes are set off during bacteria or viral infection.
Keywords: Aortic valve; Bicuspid Aortic Valve Disease; Polyethylene Terephthalates; Hemolysis; Surgical Anastomosis, Bacteria, Fatigue; Inflammation
LETTER TO THE EDITOR
Post-Infarction Left Ventricular Aneurysm Repair
Braz J Cardiovasc Surg 40;
e20230449
Publish in: 8/2/2025
Trends, Implications, and Outcomes in the Changing Landscape of Cardiac Surgery: Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis and Concomitant Coronary Artery Disease
Braz J Cardiovasc Surg 40;
e20240050
Publish in: 8/2/2025
Post-Cardiotomy Blood Parameters as a Prognostic Marker in Acute Aortic Dissection Surgery
Braz J Cardiovasc Surg 40;
e20240087
Publish in: 8/2/2025
ERRATUM