Volume 40 - Issue 6

Introduction: This study assessed the impact of a quality and safety (Q&S) improvement program on outcomes in pediatric and congenital heart surgery (PCHS) through an international non-governmental collaboration in a low-and-middle-income country (LMIC).
Methods: Surgical data from two distinct periods, PRE (January 2016 – December 2019) and POST (January 2020 – May 2024) Q&S implementation, were analyzed. Outcomes included 30-day mortality, urgency status, patient age, and procedure complexity using the Risk Adjustment for Congenital Heart Surgery (RACHS) 1 classification.
Results: A total of 4,297 surgeries were performed: 2,429 in the PRE and 1,868 in the POST era. Overall, 30-day mortality decreased significantly from 7.5% to 5.1% (P = 0.002), reaching 3.1% in 2024. Urgent surgeries increased from 28% to 44% (P < 0.0001), while mortality in elective and urgent cases dropped from 3.9% to 1.7% (P = 0.0007) and from 16.5% to 9.6% (P < 0.0001), respectively. A shift toward more neonatal and infant cases was observed, with significant reductions in mortality in both groups (P = 0.01). Case mix complexity also increased (RACHS categories 3–6), yet mortality declined across all RACHS strata.
Conclusion: The introduction of Q&S initiatives led to marked improvements in PCHS outcomes, even amid growing case complexity and acuity. These findings highlight the value of structured protocols and sustained Q&S efforts and underscore the transformative role of international partnerships in strengthening surgical care in LMICs.

Introduction: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a popular and severe complication after cardiac surgery. We aimed to set up a quick and accurate predictive model for rapid identification of CSA-AKI and to evaluate its predictive value.
Methods: In this retrospective study, we included a total of 120 patients who underwent heart surgery and divided them into 55 patients who developed kidney injury following heart surgery (CSA-AKI group) and 65 patients who did not experience kidney injury after the same surgical procedure (non-CSA-AKI group). The predictive capacity of various laboratory indicators for CSA-AKI were assessed, including tumor necrosis factor-α (TNF-α), interleukin 2, interleukin 6, and neutrophil gelatinase-associated lipocalin (NGAL). Additionally, receiver operating characteristic curve analysis was employed to evaluate the performance of the model in predicting CSA-AKI.
Results: After cardiac surgery, patients who developed CSA-AKI exhibited significantly higher levels of TNF-α, interleukin 2, interleukin 6, and NGAL compared to the control group. Receiver operating characteristic curve analysis revealed that TNF-α, interleukin 2, interleukin 6, and NGAL showed good diagnostic performance, with area under the curve values of 0.66, 0.78, 0.66, and 0.80, respectively. Further analysis demonstrated that the combination of TNF-α, interleukin 2, interleukin 6, and NGAL had the highest predictive value for acute kidney injury (area under the curve = 0.93).
Conclusion: TNF-α, interleukin 2, interleukin 6, and NGAL exhibited a promising predictive capability for CSA-AKI, while a combined diagnostic model was established to enhance the diagnostic value further.

Objective: We herein probed the effects of ozone autohemotherapy (O3-AHT) on inflammatory response and postoperative cognitive function in patients undergoing valve replacement with cardiopulmonary bypass (CPB).
Methods: Totally, 130 patients undergoing valve replacement with CPB were included in the study (O3-AHT) and control (banked blood transfusion) groups. Blood samples were taken for blood gas analysis, with arterial oxygen saturation, jugular venous oxygen saturation, partial pressure of arterial oxygen and jugular venous PO₂, hemoglobin, and cerebral oxygen extraction rate documented. Interleukin (IL)-6, tumor necrosis factor alpha (TNF-α), and IL-1β levels and serum S100β and neuron-specific enolase (NSE) concentrations were measured by enzyme-linked immunosorbent assay, followed by cognitive function assessment by Mini-Mental State Examination and Montreal Cognitive Assessment scales.
Results: The research group exhibited elevated thrombin time, activated partial thromboplastin time, and prothrombin time and decreased fibrinogen level immediately after surgery; it also presented reduced 24-hour postoperative serum IL-6, TNF-α, IL-1β, S100β, and NSE levels. Intraoperative cerebral oxygen metabolism was improved, and cognitive dysfunction was alleviated in the research group. The comparison of transfusion complication incidence between the two groups showed no significant difference.
Conclusion: The application of O3-AHT in patients undergoing valve replacement with CPB enhanced intraoperative brain oxygen metabolism and reduced postoperative 24-hour inflammatory response and cognitive dysfunction.

Introduction: Mechanical circulatory support (MCS) devices have evolved significantly over the past decades and play a vital role in managing end-stage heart failure, especially as a bridge to heart transplantation. From the pioneering heart-lung machines to third-generation ventricular assist devices (VADs), MCS technology has advanced to provide more durable, efficient, and safer options for both short- and long-term support. This review outlines the historical development of mechanical assist devices, the types of available supports – ranging from intra-aortic balloon pumps and extracorporeal membrane oxygenation to implantable devices like HeartMate 3 – and their clinical indications and complications. Special attention is given to right ventricular dysfunction, thromboembolic and hemorrhagic complications, and infections, which remain major challenges in the management of patients with MCS devices.
In Brazil, despite the growing evidence supporting MCS in critically ill patients, access remains limited due to financial and systemic constraints. The review explores the current landscape of device availability in the country, national guidelines, cost-effectiveness data, and the impact of recent changes in transplant allocation criteria that prioritize patients receiving mechanical support. Notably, the approval of long-term VADs for destination therapy in the public health system in 2024 marks a significant milestone.
This review offers a comprehensive perspective on MCS utilization, highlighting both global advances and Brazil-specific challenges. By identifying gaps in access and proposing future directions, it advocates for expanded use of these life-saving technologies to improve survival and quality of life in advanced heart failure patients.

Three-dimensional (3D) printing is an innovative technology with increasing and emerging potential in cardiothoracic surgery. This technology has significantly impacted translational research, education, and clinical practice. In high-income countries, 3D printing has vastly broadened the understanding of the cardiovascular system and helped in surgical planning by facilitating the nuanced creation of patient-specific cardiac models with exact precision to allow the development of personalized devices and surgical tools to facilitate improved patient outcomes. However, in low-income countries, such as those in Africa, there is limited access to 3D printing technology. The growing burden of complex cardiovascular diseases in Africa warrants the need for this technology to improve the standard of care for cardiac surgical patients. This review discusses the fundamentals of 3D printing, its relevance to current disease burdens in the context of the African population, its current state and future prospects in African cardiac care, its unmet needs, challenges, and how to implement it in the continent.

In this article, the authors present the indication for surgical ablation of atrial fibrillation and of left atrial appendage occlusion. They also present technical aspects of Cox-Maze IV operation and of left atrial appendage clip occlusion. They discuss the result of those techniques and what the guidelines recommend for their use.

We present a case of left atrial thrombus mimicking myxoma after orthotopic heart transplantation. Multimodality imaging established the diagnosis of atrial myxoma, and the patient was treated accordingly, but the definite diagnosis after surgical excision and histology showed left atrial thrombus. This report demonstrates the limitations of multimodality diagnosis in tumors with features highly suggestive of an atrial myxoma.

We report the case of a surgical treatment after transcatheter edge-to-edge mitral valve repair failure in a 79-year-old patient who had undergone cardiac surgery 30 years earlier. The transcatheter procedure of mitral valve got complicated by single leaflet device attachment leading to recurrent severe regurgitation. Despite the extremely high surgical risk and a porcelain aorta, we deemed the patient operable thanks to his performant physical and cognitive status. He underwent mitral valve replacement with a bioprosthesis in deep hypothermic circulatory arrest and retrograde cerebral perfusion. The postoperative course was regular, and he is in good functional class at one-year follow-up.

Implanting sutureless aortic valves enables a reduction in surgical times and related complications. Nonetheless, their application has been limited in cases involving aortic aneurysms due to anchor system concerns. We present a case of aortic valve replacement using a Perceval^TM sutureless aortic valve in a patient with stage IV chronic kidney disease, an ascending aortic aneurysm, and a porcelain aorta. The procedure was performed concomitantly with coronary artery bypass grafting involving two grafts, as well as ascending aorta and hemiarch replacement. This case underscores the critical importance of time efficiency, technical modifications for valve implantation, and strategic surgical planning to mitigate potential intraoperative and postoperative complications.

Cardiopulmonary bypass (CPB) in children presents challenges related to blood volume and surface area of the circuit. Conventional ultrafiltration (CUF) is used to minimize complications, but modified ultrafiltration (MUF) can optimize clinical outcomes. We propose a modification to the CPB circuit, incorporating three luer connectors and a 12 Fr extension tube, allowing for simple and safe MUF implementation. Since 2014, this technique has been applied to approximately 3,500 children weighing < 20 kg, proving to be effective and low-cost. The new configuration does not require additional pumps, facilitates volume replacement, and maintains blood temperature, thereby improving procedural safety. Results indicate that this circuit modification for MUF offers safe and efficient management strategy for pediatric patients, with low risk of complications and potential easy implementation in various cardiovascular surgery centers.