Volume 40 - Issue 5
Association Between Suicide Donors and Outcomes in Heart Transplantation: A Retrospective Cohort Study
Methods: A retrospective analysis was conducted on 97 adult heart transplant recipients at the Instituto do Coração of São Paulo between 2020 and 2021. Data on donor characteristics (age, sex, mechanism of brain death), recipient preoperative status (age, sex, cardiomyopathy etiology, body mass index, comorbidities, use of intra-aortic balloon pump, extracorporeal membrane oxygenation [ECMO]), intraoperative variables (ischemia time, cardiopulmonary bypass time, implantation time), and postoperative outcomes (use of ECMO, mortality) were analyzed.
Results: Of the 97 transplants analyzed, six were from suicide donors (6.2%). Recipients of hearts from suicide donors had a significantly higher need for ECMO (33.3% vs. 4.4%, P = 0.036), increased PGD (66.7% vs. 19.8%, P < 0.05), and higher 30-day mortality (50% vs. 3.3%, P < 0.05) compared to non-suicide donors. No significant intraoperative time differences were found between the groups.
Conclusion: This study is the first to identify a significant association between heart transplantation from suicide donors and adverse outcomes, including higher rates of PGD and early mortality. These findings suggest possible psychological and biological influences on organ quality and transplantation outcomes. Further research is needed to clarify these associations and inform donor selection criteria.
Keywords: Heart transplantation; Donors; Primary Graft Dysfunction; Organ preservation; Inflammatory Markers;
Is the Treatment of Coronary Artery Disease Following the Recommendations Set Out in the Proposed Guidelines and in the SYNTAX Study?
Introduction: Coronary artery disease (CAD) is the main cause of death among cardiovascular diseases. Current guidelines aim to guide clinical practice in choosing the best treatment, based on the best scientific evidence. The SYnergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) score uses anatomical and clinical factors, helping to assess the complexity of coronary lesions.
Objective: To verify whether the treatment used in CAD complied with the recommendations set out in the guidelines and in the SYNTAX study. Methods: Single-center, cross-sectional, observational, descriptive, and retrospective study, which analyzed medical records over a three-year period. Patients diagnosed with CAD who had obstructive disease in at least two vessels were selected. The exams were evaluated by a specialist who was unaware of the report and the treatment used for each patient. SYNTAX 1 and 2 scores were calculated, and the recommended treatment was compared to the established treatment.
Results: Two hundred and ten patients were distributed, according to SYNTAX Score 1, into the groups low (Group A), intermediate (Group B), and high risk (Group C). Of 155 patients in Groups B and C, 105 (67.7%) were treated with percutaneous coronary intervention (PCI), vs. 24 (15.5%) with CABG. When calculating the SYNTAX Score 2 of the 101 patients with recommended treatment for CABG, 71 (70.3%) received PCI, compared to 18 (17.8%) treated with CABG. All patients recommended for preferential treatment for PCI had the recommendation respected.
Conclusion: The treatment offered was not supported by current guidelines and recommendations. Expanding the sample size may determine the current situation of the treatment of CAD in Brazil.
Redox Signaling Biomarker and Transcription Factor Assessments Are Important to Evaluate Myocardial Protection Status Through Different Cardioplegias
Risk Factors Associated with Mortality After Pericardial Window in Hospitalized Patients — A Retrospective Analysis
Introduction: Chronic pericardial effusion is a common pericardial syndrome associated with multiple etiologies. Most studies report good outcomes and success rate after pericardial window, although mortality varies. This study aimed to identify risk predictors for mortality in addition to determining factors associated with in-hospital mortality over a 30-day period in patients who underwent surgical pericardial window.
Methods: We retrospectively reviewed case files from patients who underwent pericardial window for the treatment of pericardial effusion from 2007 to 2023.
Results: One hundred and two patients were included in our analysis, with an overall hospitalized mortality after pericardial window of 28% (n = 29). When assessing etiology, mortality was similar between all causes of effusion (P = 0.359). In echocardiography, there was a significantly lower left ventricular ejection fraction (P = 0.016) in patients who died after the surgical procedure. Similarly, the presence of cardiac cavity collapse before the procedure was significant for an increase in mortality (P ≤ 0.0001). Logistic and Cox regression analysis showed that cardiac cavity collapse, complications, and lung cancer were associated with increased postoperative mortality following pericardial window.
Conclusion: Although surgical pericardial window offers feasible treatment with good success rates, in-hospital mortality is elevated, particularly in patients with cardiac cavity collapse and complications.
Impact of Right Atrial Appendage Ligation vs. Repair on Serum Atrial Natriuretic Peptide, Brain Natriuretic Peptide, and Atrial Fibrillation following Coronary Artery Bypass Grafting
Objective: In this study, we aimed to compare the levels of serum atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) with ligation and primary repair of right atrial appendage after venous decannulation procedure in isolated coronary artery bypass grafting (CABG) and their relationship with postoperative atrial fibrillation (POAF).
Methods: In this prospective randomized study, 38 patients who underwent isolated CABG in Haydarpasa Training Hospital between March 2015 and November 2015 were included. Patients were divided into two groups whose atrial appendage were ligated (group A) or primary repaired (group B) after right atrial appendage decannulation. Both groups were evaluated in terms of perioperative serum ANP/BNP levels and POAF incidence. ANP/BNP levels were measured by taking blood samples through the central venous catheter on the preoperative day and postoperative days 1 and 3.
Results: While six POAF incidents were observed in group A, there were none in group B. There was no statistical difference between the groups (P > 0.05) in the evaluation of ANP/BNP levels. POAF rate in group A was statistically significantly higher than in group B (P < 0.05).
Conclusion: No significant difference in perioperative ANP/BNP levels was observed between the two groups. Also, no correlation between ANP/BNP levels and POAF were detected. Development of POAF significantly increased in group A. Therefore, we advocate that the prevalence of atrial fibrillation might be reduced in patients who had undergone right atrial repair with primary repair method.
Application Effects of Single-Lumen Endotracheal Tube Intubation for General Anesthesia in Totally Thoracoscopic Cardiac Surgery
Introduction: The rapid advancement of medical technology has enabled the application of single-lumen endotracheal tube (SLET) incubation anesthesia in thoracoscopic surgeries for thoracic diseases, demonstrating promising results. This study aims to explore the application of extracorporeal circulation (ECC) and combined intravenous-inhalation anesthesia (CIIA) with SLET intubation in totally thoracoscopic cardiac surgery (TTCS).
Methods: In this single-center, double-blind, randomized controlled trial, we assessed primary outcomes, including intraoperative metrics and postoperative conditions. Secondary outcomes included the number of patients achieving spontaneous resuscitation and those requiring extracorporeal defibrillation after opening the ascending aorta, alertness/sedation scores five minutes post-extubation, and incidence of postoperative complications.
Results: The observation group showed shorter durations in the anesthesia recovery room, intensive care unit retention, extubation, eye-opening time, and postoperative hospital stay compared to the control group (t = 5.913, 8.820, 7.792, 6.904, 11.140; all P < 0.001) and had higher proportion of patients with an alertness/sedation score of five (43/109, 39.45%) and rate of spontaneous resuscitation after opening the ascending aorta (97/109, 88.99%) compared to the control group ([8/109, 34%], [84/109, 77.06%]). In contrast, the rate of external electrical defibrillation (12/109, 11.01%) and the incidence of postoperative complications (2/109, 1.83%) were lower than in the control group ([25/109, 22.94%], [10/109, 9.17%]) (χ2 = 31.350, 5.501, 5.644; all P < 0.05).
Conclusion: Maintaining oxygen saturation in thoracoscopic surgery requires effective cooperation of anesthesia and ECC. The combined use of ECC and CIIA with SLET intubation in TTCS is a safe, effective approach that warrants broader clinical application.
New-Onset Atrial Fibrillation Following Isolated Coronary Artery Bypass Grafting: Is Pulmonary Hypertension a Risk Factor?
Introduction: This study aimed to clarify whether pulmonary hypertension is a risk factor for postoperative new-onset atrial fibrillation (NOAF) following isolated coronary artery bypass grafting (CABG).
Methods: Data of 4,782 patients were retrospectively examined from clinical database, and data of isolated CABG performed patients (n = 854) with preoperative echocardiography including pulmonary artery pressure (PAP) measurement were enrolled in study. While 115 patients had post-CABG NOAF (atrial fibrillation [AF] group), 739 did not have AF (non-AF group). Demographic, clinical, and treatment-related parameters were compared between groups, and independent clinical predictors of NOAF were identified by multivariate analysis.
Results: Patients of AF group were significantly older and had higher European System for Cardiac Operative Risk Evaluation (EuroSCORE) points, significantly elevated mean systolic PAP, and more pulmonary hypertension. Multivariate regression analysis revealed that mean systolic PAP (odds ratio [OR]: 1.027, 95% confidence interval [CI]: 1.006 - 1.048) and pulmonary hypertension (≥ 30 mmHg; OR: 1.659, 95% CI: 1.093 - 2.518) were independent risk factors for post-CABG NOAF. Chronic obstructive pulmonary disease (COPD) (OR: 2.033, 95% CI: 1.265 - 3.268) and mean duration of ventilation support (OR: 1.059, 95% CI: 1.017 - 1.104) were additionally determined as risk factors for post-CABG NOAF.
Conclusion: This study identified patients' age, high EuroSCORE points, presence of COPD, prolonged ventilation support, and increased PAP as predictors of post-CABG NOAF. Understanding the risk factors will provide better guidance in preventing this complication and its potential consequences. Prospective randomized controlled trials are required to further validate these findings and provide more robust evidence.
Long-Term Safety and Performance of a National Pericardium Organic Valvular Bioprosthesis in the Brazilian Public Health System: Retrospective Analysis Up To 26 Years of Follow-up
Objective: To evaluate the long-term performance of a bovine pericardium valve prosthesis in individuals who required valve replacement in the Brazilian public health system.
Methods: Medical records of patients having mitral or aortic valve replacement with bovine pericardium valve prostheses between 1978 and 1994 at a Brazilian hospital were reviewed in this retrospective study. Safety was assessed through the complications and serious adverse events rates in the early and long terms. Successful valve replacement was defined by absence of complications and serious adverse events up to 30 days after surgery.
Results: A total of 439 surgeries were performed in 382 patients with a mean age of 46.45 ± 13.93 years. Mean follow-up time was 6.26 years (up to 26.13 years). Rheumatic etiology was present in 83.5% of the cases. Mitral valve replacement was the most performed surgery. Five complications in five patients were recorded up to 30 days after surgery, and the rate of serious adverse events for the same period was 10.3%. Successful valve replacement rate was 90.7%. Postoperative complications were reported during the follow-up period in 29.6% of the procedures, being calcification the most common with 17.3%.
Conclusions: Despite the young age of the patients, safety outcomes were in accordance with what is reported in the literature for bioprostheses, with acceptable complication, serious adverse events, and freedom from reintervention rates.
Early- to Mid-Term Results of Aortic Valve Neocuspidization for Rheumatic Aortic Valve Disease
Introduction: Recently, there has been a widespread use of aortic valve neocuspidization, but there is limited data regarding rheumatic heart disease. In this study, we reviewed our experience.
Methods: A total of 33 patients (22 men, 66.7%) with rheumatic aortic valve disease (mean age 39.36 ± 10.65 years) underwent aortic valve replacement between June 2019 and October 2023.
Results: The most common pathology was severe stenosis (14 patients, 42.4%), with bicuspid morphology in 11 patients (33.3%). The mean cardiopulmonary bypass and aortic cross-clamping times were 151 ± 24.26 and 127 ± 21.05 minutes, respectively. There was no perioperative mortality. One patient who developed significant aortic regurgitation underwent valve replacement prior to discharge. The pre-discharge average peak/mean gradients were 12 ± 3.7/6 ± 2 mmHg, respectively. Follow-up was complete (mean: 31.54 ± 12.94 months). There were two late mortalities (6%), one due to endocarditis and another due to coronavirus disease. One patient (3%) needed a permanent pacemaker one year later. Overall survival at one, two, and four years were 97%, 97%, and 94% respectively, and freedom from reoperation was consistent at 97%. The peak/mean gradients remained low at one and three years (12 ± 2.7 mmHg/4.8 ± 1.7 mmHg and 10.14 ± 4.02/4.4 ± 2.3 mmHg, respectively). Overall four-year freedom from at least moderate regurgitation was 97%.
Conclusion: Our data shows promising results for this procedure in rheumatic pathology. The hemodynamic data is satisfactory and the early- to mid-term results are encouraging; however, long-term data is needed to determine durability.
Association of Aortic Cross-Clamping Time with Systemic Immune Inflammation and Systemic Inflammatory Response Indexes in Isolated Coronary Bypass Surgery
Introduction: Prolonged aortic cross-clamping may intensify systemic inflammation after cardiac surgery. This study aimed to evaluate the effect of cross-clamp duration on systemic inflammatory response index (SIRI) and systemic immune inflammation index (SIII) in isolated coronary artery bypass grafting (CABG).
Method: This retrospective study included 155 patients who underwent first-time isolated CABG between January 2021 and June 2024. Patients were divided into two groups based on median cross-clamping time: Group I (≤ 64 minutes, n = 83) and Group II (> 64 minutes, n = 72). Demographic, hematologic, and biochemical data were collected. SIII was calculated as platelet × neutrophil/lymphocyte; SIRI as neutrophil × monocyte/lymphocyte.
Results: The mean aortic cross-clamping time of Group I was 53 minutes (interquartile range 44 - 60 minutes) and of Group II it was 78 minutes (interquartile range 71 - 87 minutes) (P < 0.001). An increase in systemic immune inflammation index and systemic inflammatory response index values was observed in both groups at the 24th postoperative hour. Postoperative systemic immune inflammation index and systemic inflammatory response index levels were significantly higher in Group II (P < 0.05). There was a weak but significant positive correlation between aortic cross-clamping time and postoperative systemic inflammation response index (r = 0.220; P = 0.006).
Conclusion: Prolonged aortic cross-clamping time is associated with an increased postoperative inflammatory response. These indices may serve as biomarkers for evaluating systemic inflammation following coronary artery bypass grafting.
Personalized External Aortic Root Support (PEARS) in the Treatment of Marfan Syndrome and Bicuspid Aortic Valve Aneurysms: First Case Series in the American Continent
Introduction: Conventional surgical approaches for aortic root aneurysms, including valved grafts and valve-sparing techniques, present inherent limitations such as the requirement for anticoagulation and the potential for late reoperation. Personalized External Aortic Root Support (PEARS), utilizing the ExoVasc® implant, represents a novel approach that aims to overcome these limitations.
Methods: This report presents the initial clinical experience with the ExoVasc® PEARS implant in the Americas, encompassing 10 patients (six males, age range 30 - 52 years, mean age 37.8 years) diagnosed with aortic root aneurysms. Indications for PEARS included Marfan syndrome (eight patients, including one reoperation), bicuspid aortic valve (two patients, including one with anomalous coronary artery), and associated valvular dysfunction. Cardiopulmonary bypass was utilized in four cases.
Results: No major adverse postoperative events were observed. Postoperative recovery was generally uneventful, with minor complications, including pericarditis and atrial fibrillation, successfully managed with medical therapy. Aortic dimensions remained stable at 30-day and one-year follow-ups.
Conclusion: This initial experience demonstrates the feasibility, safety, and efficacy of the PEARS technique for the treatment of aortic root aneurysms. Potential advantages over traditional approaches include the possibility for off-pump procedures, reduced risk of aortic valve dysfunction, shorter hospital stays, and elimination of the need for long-term anticoagulation therapy. Further investigation is warranted to evaluate the long-term durability and clinical outcomes of this innovative approach.
Efficacy and Safety Profile of Low-Dose Tranexamic Acid Regimen in Cardiac Surgery: A Meta-Analysis
Introduction: Various dosing regimens of tranexamic acid have been reported to exhibit varying efficacy and safety profiles. Herein, we conducted a meta-analysis to evaluate the efficacy and safety of low-dose regimens in open-heart surgery.
Methods: Three databases were systematically searched for randomized trials examining the bleeding reduction effect of tranexamic acid in open-heart surgery. The pooled data of the low-dose group was then compared with the control, high-dose, and epsilon aminocaproic acid groups. The boundary between the low- and high-dose groups was a bolus of 30 mg/kg followed by 16 mg/kg/hour.
Results: The meta-analysis included 81 studies. The low-dose tranexamic acid regimen was associated with a decreased incidence of reoperation (risk ratio: 0.52; 95% confidence interval: 0.39–0.69; high quality of evidence), perioperative myocardial infarction (risk ratio: 0.64; 95% confidence interval: 0.43–0.95; high quality of evidence), the amount of postoperative bleeding in 24 hours, and the need for transfusion of packed red cells compared to control, without increasing the rates of mortality, venous thromboembolism, or stroke. Compared with the high-dose group, the low-dose group had a lower incidence of seizures and stroke. The low-dose of tranexamic acid group also showed significantly reduced postoperative bleeding; however, the cost of an increased risk of seizure events was higher in the low-dose group than in the epsilon aminocaproic acid group.
Conclusion: Low-dose tranexamic acid effectively reduced bleeding, the risk of reoperation, and myocardial infarction without increasing the risk of adverse events.
Study Design Update of the Off-pump versus On-pump Coronary Artery Bypass Grafting in Frail Patients: FRAGILE Trial
The Off-pump versus On-pump Coronary Artery Bypass Grafting in Frail Patients (FRAGILE Trial) is a multicenter, randomized controlled trial comparing off-pump and on-pump coronary artery bypass grafting in frail or pre-frail patients undergoing coronary artery bypass grafting. This manuscript presents an update to the FRAGILE Trial study design, detailing protocol modifications made in response to the time gap between the study’s conception and its actual implementation. These changes were implemented early in the trial and were formally approved by the Ethics Committee, ensuring the scientific and ethical integrity of the study and reinforcing its relevance to address a gap in a vulnerable patient population.
Keywords: Coronary Artery Bypass Grafts; CABG; Frailty Syndrome; Outcomes; Coronary Artery DiseaseResearch and Development of Ventricular Assist Devices: Experiences from the Instituto Dante Pazzanese de Cardiologia
Ventricular assist devices have been widely accepted as an alternative treatment for advanced heart failure, while heart transplantation is a limited procedure because of the shortage of donors. In face of a scarce availability of these devices, many centers around the world have developed their own technologies. We describe historical and general features of the main ventricular assist devices developed at the Instituto Dante Pazzanese de Cardiologia. The auxiliary total artificial heart is an electromechanical pulsatile blood pump with left and right chambers, being originally designed to work as a heterotopic artificial heart. The spiral pump is a disposable device and currently available for clinical use in cardiopulmonary bypass. It works through a combination of centrifugal and axial pumping principles coming from a conically shaped impeller. The implantable centrifugal blood pump was conceived for long-term circulatory assistance with a unique impeller design concept producing a mixed flow. The apico-aortic blood pump consists of a miniaturized centrifugal pump originally conceived for bridge to transplantation strategy. The temporary circulatory support device is a new centrifugal blood pump for temporary ventricular assistance developed with the purpose of bridge-to-decision or recovery strategies. Additionally, the hybrid cardiovascular simulator was developed as a tool to test blood pumps as they minimize the need for animal experiments. Brazil represents an important reference with a few academic groups with a considerable output in ventricular assist devices research and development. Notable devices produced at Instituto Dante Pazzanese de Cardiologia have demonstrated excellent results for clinical application.
Keywords: Engineering; Heart-assist devices; Cardiopulmonary bypass; Animal experimentation; Heart failure; Heart transplantation; Artificial Heart;Therapeutic Considerations of Post-Myocardial Infarction Ventricular Septal Defect in the Elderly - An Educational Presentation
Post-myocardial infarction ventricular septal defect is an infrequent complication associated with low survival rates in the absence of surgical management. An 80-year-old woman presents to the emergency department with an inferior wall ST-segment elevation myocardial infarction with complete occlusion of the right coronary artery and a rupture of the interventricular septum with rapid deterioration to cardiogenic shock. Advanced age, female sex, and cardiogenic shock are associated with high mortality. The use of intra-aortic balloon pump improves hemodynamic status, allowing stabilization in the preoperative period.
Keywords: Heart Septal Defects. Ventricular. Myocardial infarction. Cardiogenic shock. Hospital Emergency Service. Preoperative Period.Triple Arterial Minimally Invasive Direct Coronary Artery Bypass Grafting: Step-By-Step Technique Report
Minimally invasive direct coronary artery bypass grafting (MIDCAB) has considerable benefits over the conventional coronary artery bypass grafting procedure. This case report presents the MIDCAB procedure in a multivessel coronary disease using triple arterial grafts and four arterial anastomoses. The initial anastomosis was made between the left intrathoracic mammary artery (LIMA) and the radial artery (RA), as an end-to-side "T" graft. Next, the RIMA was used to left anterior descending anastomosis. The first obtuse marginal (OM1) branch was grafted to allow LIMA-OM1 side-to-side anastomosis. Then, with the diagonal branch (Dg) opened, the formation of a "jumping" anastomosis was made using LIMA-OM1-Dg. The posterior descending artery (PDA) was used to create a LIMA-RA-PDA.
Keywords: Coronary artery bypass; Coronary Artery Disease; Surgical Anastomosis; Mammary arteries; Radial arteryRenal Transplant Patient After Type A Aortic Dissection and Renal Malperfusion
Acute type A aortic dissection (AAD) is a life-threatening emergency with high mortality. Preoperative organ malperfusion significantly worsens surgical outcomes. Isolated renal malperfusion is common in acute type A aortic dissection, increasing the risk of postoperative renal ischemia and early mortality. This case involves a young patient with renal malperfusion due to left renal artery closure by an intimal flap and true lumen compression of the abdominal aorta affecting both renal arteries. Endovascular intervention was not feasible. The patient later underwent a successful kidney transplant and has been followed up for years without complications.
Keywords: Renal Artery;Mortality;Aortic Dissection;IschemiaCase of a Middle-Aged Woman with Sick Sinus Syndrome and Cor Triatriatum Dexter
This case study involves a 51-year-old woman with a complex cardiovascular condition, namely cor triatriatum dexter, accompanied by sick sinus syndrome. She presented with bradycardia, dizziness, and amaurosis, and was admitted to the emergency department due to right limb numbness. Diagnostic examinations, including computed tomography and cardiac color ultrasound screening, revealed the presence of cor triatriatum dexter with an enlarged left atrium and ventricle. Additional abnormalities, such as absent inferior vena cava and polysplenia syndrome, were also detected. Based on the findings, a double-chamber pacemaker surgery was recommended, supported by cardiac and thoracic-abdominal computed tomography angiography and three-dimensional vascular reconstruction.
Keywords: Cor Triatriatum;Sick Sinus Syndrome;Bradycardia;Heterotaxy Syndrome;Inferior Vena Cava;Heart AtriaMethod of Implantation of the Bentall-De Bono Conduit into the Infra-annular Position — Description of the Technology
At this moment, many modifications of the Bentall-De Bono procedure have been introduced. The authors of most of the existing modifications aim to solve the problems of bleeding from the proximal anastomosis and the reimplantation of coronary arteries into the conduit. Both problems are among the most important reasons for unsatisfactory results of the Bentall-De Bono procedure. The new technique of proximal anastomosis formation presented in this work aims to solve the problems of bleeding from the zone of proximal anastomosis and reimplantation of low-positioned coronary artery orifices.
Keywords: Aneurysm;Ascending Aorta;Coronary Vessels;Replantation