Volume 25 - Número 1
EDITORIAL
A time of renewal
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
Classification of journals in the QUALIS System of CAPES – changing the criteria is URGENT!
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
Cardiac surgery: complex individual and organizational factors and their interactions. Concepts and practices.
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
International Cooperation in Brazil: Children’s HeartLink
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
From the Australia's Great Barrier Reef to the Brazil's Arrecifes. Building Bridges of Reflection
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
SPECIAL ARTICLE
Concepts of basic physics that every cardiovascular surgeon should know. Part I - Mechanics of fluids
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
The professional activity that the cardiovascular surgeon performs is much more than a simple gesture to mechanically operate the patient's heart. There is in every act of intraoperative most notions of physiology and physics than we generally realize. This paper discusses, in the light of mathematics, on the dynamics of fluids, ie blood, focused on invasive measurements of blood pressure, the effect of vessel size on its internal resistance and the flow passing through it in conversion of various units of measurements of pressure and resistance, blood viscosity and its relationship to the vessel, hemodilution, differences in laminar and turbulent flow, velocity and blood pressure and wall tension after a stenosis and the origin of poststenotic aneurysm. This study is not to enable the reader to the knowledge of all physics, but to show it as a useful tool in explaining phenomena known in the routine of cardiovascular surgery
Keywords: Physics; Cardiovascular surgical procedures; Fluid mechanics; Hemodynamics
ORIGINAL ARTICLE
Assesment of the EuroSCORE as a predictor for mortality in valve cardiac surgery at the Heart Institute of Pernambuco
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
Objective: To assess the applicability of the European Rysk System in Cardiac Operations (EuroSCORE) in patients undergoing cardiac valve surgery at the Heart Institute of Pernambuco. Method: 840 patients operated on between 2001 and 2009, who medical records contained all the informations to calculate the EuroSCORE were included in the study. Hospital death was the end-point of the study. In order to assess the applicability of the EuroSCORE it was used the non parametric test of Mann-Whitney. The calibration of the model was measured by comparing the morbidity observed with that expected, using the Hosmer-Lemeshow Test of Goodness of Fit. The accuracy of the model was evaluated by the ROC curve (receiver operating characteristic curve). Results: The comparison of expected and observed mortality, by Hosmer-Lemershow test, showed good predictive capacity (P = 0.767) as well as when compared to each value of addictive EuroSCORE (P = 0,455). The area of ROC curve was 0.731 (IC 95%, 0.660 - 0.793) with P < 0.001. The global predicted mortality was practically identical to that observed (7.9%). The low-risk group (EuroSCORE 0-2) comprised 345 patients with a mortality of 3.19%. The medium-risk group (EuroSCORE 3-5) comprised 364 patients, with a mortality of 7.69% and the high-risk group (EuroSCORE > 6) included 131 patients, with a mortality of 20.6%. The regression logistic analyses allowed to identify the following risk-factors for death: age > 60 years, gender female, previous operation, active endocarditis, associated surgery of the thoracic aorta and extra-cardiac arteriopathy. Conclusion: The EuroSCORE, a simple and objective method, proved to be a satisfactory predictor of operative mortality and risk factors for death in patients submitted to valve cardiac operations in the Heart Institute of Pernambuco.
Keywords: Heart valves/surgery; Risk assessment; Clinical trial; Evaluation of results of therapeutic interventions
Postoperative mediastinitis in cardiovascular surgery. Analysis of 1038 consecutive surgeries
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
OBJECTIVE: To report the incidence of mediastinitis in cardiovascular surgery postoperation. METHODS: The records of all 1038 patients who underwent cardiovascular surgical procedures between May/2007 and June/2009 were reviewed. All operations were performed in Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE. RESULTS: The complication occurred within, on average, 13 days after operation, in total of 25 (2.4%), eight (32%) deaths occurred. Several risk factors mediastinitis were identified: 56% diabetes, 56% smokers, 20% obeses, 16% with chronic obstructive pulmonary disease and 8% of chronic renal failure. Mediastinitis were reported in 21 (84%) cases of patients submitted to coronary artery bypass grafting, being associated to major risk of infection development (IC 3.448.30, P=0.0001). High rates of complications were observed: respiratory insufficiency (44%), stroke (16%), cardiogenic shock (12%), acute renal failure (28%), pulmonary infection (36%), multiple organs failure (16%) and esternal deiscence (48%). Bacterial cultures of exudates were positive in 84% of patients; Staphylococcus aureus was the most responsible pathogen (28.8%). CONCLUSION: Mediastinitis stays a serious surgical complication and difficult management in cardiovascular surgery postoperation. The disease stays with low incidence, but still with high lethality. Coronary bypass was associated to major risk of infection development
Keywords: Infection; Mediastinitis; Cardiac surgical procedures
Hospital mortality in surgery for reconstruction outflow right ventricle with pulmonary homograft
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
BACKGROUND: Hospital mortality for surgical reconstruction of the outflow of the right ventricle with pulmonary homograft is variable. OBJECTIVES: To identify risk factors associated with hospital mortality and clinical profile of patients. METHODS: Children underwent reconstruction of the outflow tract of right ventricle with pulmonary homograft. Analyzed as risk factors for the clinical, surgical and morphological aspects of the prosthesis. RESULTS: Ninety-two patients operated on between 1998 and 2005 presented mainly pulmonary atresia with ventricular septal defect and tetralogy of Fallot. Forty patients were treated in the first month of life. He needed 38 surgeries to Blalock Taussig due to clinical severity. The median age at surgery for total correction was 22 months, ranging from 1 to 157 months. Size pulmonary homograft ranging from 12 to 26 mm and length of bypass was 132 ± 37 minutes. After surgery there were seventeen deaths (18% cases) on average 10.5 ± 7.5 days. The predominant cause was multiple organ failure. In the univariate analysis between the types of heart disease, they found in favor of age at surgery, size of homograft, pulmonary valve Z value, CPB time, maintaining the integrity of the homograft and pulmonary tree change. There was no statistical differencein hospital mortality between the variables and the type of heart disease. CONCLUSION: The congenital obstructive right requires surgical care in the first days of life. The total correction surgery has a risk rate of 18% but there was no association with any variable studied
Keywords: Heart defects, congenital; Cardiovascular surgical procedures; Transplantation, homologous; Mortality
Use of nefidipine and acute kidney injury incidence in postoperative of myocardial revascularization surgery with cardiopulmonary bypass
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
Objective: The objective of this work was to evaluate the influence of the use of nifedipine on the outcome of renal function in patients undergoing myocardial revascularization with extracorporeal circulation. Methods: The casuistics and variables related to extracorporeal circulation were studied. Serum creatinine levels were measured preoperatively, 24, 48 hours and on 7th day postoperatively. Renal failure was defined as an increase in 30% of serum creatinine levels at 24 or 48 hours postoperatively compared to those at baseline. Patients were assigned to four groups: G1 (patients who received nifedipine preoperatively); G2 (patients who received nifedipine postoperatively); G3 (patients who received nifedipine pre and postoperatively) and G4 (patients who did not receive nifedipine). Results: The mean serum creatinine levels postoperatively presented greater rise in G4 (G4>G1=G2=G3), and G4 also presented a higher percentage of patients with acute renal failure (G4>G1 and G4>G3, P<0.05; G1=G3 and G2=G4, P>0.05). Conclusion: The evaluation of serum creatinine values and incidence of acute kidney injury postoperatively suggest a possible nefro-potective effect of nifedipine in patients undergoing myocardial revascularization with extracorporeal circulation.
Keywords: Extracorporeal circulation; Acute renal Insufficiency; Myocardial revascularization
Comparison study of two different patient-controlled anesthesia regiments after cardiac surgery
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
Introduction: Acute and severe pain is frequent in patients who undergo cardiothoracic surgery. Patient controlled analgesia (PCA) can be used to manage postoperative pain. Objective: To compare analgesia of morphine PCA alone (without continous infusion) with morphine PCA plus a continuous infusion on postoperative period after cardiac surgery and to evaluate pain scores, morphine consumption, number of demand, patient satisfaction and side effects. Methods: Randomized trial was conducted to assess patients who underwent cardiac surgery receiving either morphine PCA alone or morphine PCA plus continous infusion. In the post operative period, PCA was started at extubation in both regiments according to randomization. Pain intensity, morphine consumption, number of demand, satisfaction and side effects were assessed at zero, six, twelve, eighteen, twenty four and thirty hours after patients' extubation. Results: The study enrolled 100 patients. 50 patients received morphine PCA alone, (Group A) and 50 patients received morphine PCA plus a background infusion, (Group B). Group B patients had less demand, consumed more morphine and were more satisfied regarding analgesia. No statistical differences were shown between groups related to pain intensity, and side effects. Conclusions: Pain control was effective and similar in both groups. Morphine PCA alone seems to be better for postoperative pain manage in cardiac surgery, due to its less morphine expense with the same effectiveness.
Keywords: Analgesia, Patient-Controlled; Cardiovascular surgical procedures; Postoperative care
Surgical biatrial ablation of atrial fibrillation: initial results
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
OBJECTIVE: To evaluate the results of intraoperative radiofrequency ablation with biatrial procedure in the treatment of chronic atrial fibrillation in patients with associated cardiac disease. METHODS: Between February 2008 and May 2009, 15 consecutive patients were underwent mitral valve procedure plus modified radiofrequency biatrial ablation of chronic atrial fibrillation. The mean age was 47.73 ± 9.85 years and 60% were male. The mean left atrial diameter was 55.06 ± 7.56 mm. RESULTS: There were no hospital mortality or complications related to radiofrequency ablation. The mean follow-up period was 7 ± 4 months. At the time of hospital discharge nine (60%) patients were in sinus rhythm. After a mean follow-up period 11 (73.3%) were in sinus rhythm. CONCLUSION: Intraoperative biatrial radiofrequency ablation is a safe and effective technique for the treatment of chronic atrial fibrillation, with satisfactory midterms outcomes in terms of conversion to sinus rhythm.
Keywords: Catheter ablation; Atrial fibrillation; Mitral valve; Cardiac surgical procedures
Systemic inflammation caused by chronic periodontitis in acute ischemic heart attack patients
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
OBJECTIVE: Infectious and inflammatory processes mediated by bacteria in distant sites have been described as a risk factor for acute ischemic heart disease (AIHD). METHODS: One hundred one patients with AIHD with and without chronic periodontitis (CP) were included in this study. Patients were admitted to the HC UNICAMP and stratified into three groups: in group 1, we selected patients with severe chronic periodontitis (31 men and 19 women, mean age 55.1 ± 11.29 years old); the group 2 with mild chronic periodontitis (40 men and 28 women, mean age 54.8 ± 10.37 years old) and group 3 represented by the toothless (43 men and 20 women, mean age 67.5 ± 8.55 years old). Blood samples were collected to measure the lipid profiles, hematological and blood glucose levels. In addition, biopsies of seventeen coronary arteries with atherosclerosis and an equal number of internal mammary arteries without atherosclerotic degeneration in group 1 were investigated. Statistical analysis by analysis of variance (ANOVA) and Scheffé test for multiple comparisons was performed. RESULTS: Triglyceride and LDL levels were elevated in group 1 than in group 2. HDL were reduced by 20% in group 1 and remained reduced by 8% in toothless. Blood glucose was higher in group 1. DNA of periodontal bacteria was detected in 58.8% of the coronary arteries. CONCLUSIONS: Patients with (AIHD) and severe chronic periodontitis may have altered lipid profile, as well as microorganisms associated with CP can permeate into coronary vessels.
Keywords: Periodontitis; DNA, bacterial; Atherosclerosis; Risk factors; Coronary disease
The effects of modified ultrafiltration on pulmonary function and transfusion requirements in patients underwent coronary artery bypass graft surgery
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
Objective: The inflammatory response after cardiac surgery increases vascular permeability leading to higher mortality and morbidity in the post operative time. The modified ultrafiltration (MUF) had shown benefits on respiratory, and hemodynamic in pediatric patients. This approach in adults is not well established yet. We hypothesize that modified ultrafiltration may improve respiratory, hemodynamic and coagulation function in adults after cardiac surgeries. Methods: A prospective randomized study was carried out with 37 patients who underwent coronary artery bypass graft surgery (CABG) were randomized either to MUF (n=20) at the end of bypass or to control (no MUF) (n=17). The anesthesia and ICU team were blinded for the group selection. The MUF were carried out for 15 minutes after the end of bypass. The patients data were taken at beginning of anesthesia, ending of bypass, ending MUF, 24 hours, and 48 hours after surgery. For clinical outcome the pulmonary, hemodynamic and coagulation function were evaluated. Results: We observed lower drain loss in the MUF group compared to control group after 48 hours (598 ± 123 ml vs. 848 ± 455 ml; P=0.04) and required less red blood cells units transfusion compared to control group (0.6 ± 0.6 units/patient vs.1.6 ± 1.1 units/patient; P=0.03). The MUF group showed lower airway resistance (9.3 ± 0.4 cmH2O.L-1s-1 vs. 12.1 ± 0.8 cmH2O.L-1s-1; P=0.04). There were no deaths in both groups. Conclusion: The MUF reduces post operatory bleeding and red blood cells units transfusion, but with no differences on clinical outcome were observed. The routinely MUF employment was not associated with hemodynamic instability.
Keywords: Ultrafiltration; Coronary artery bypass; Myocardial revascularization; Hemorrhage
Aortic root reconstruction through valve-sparing operation: critical analysis of 11 years of follow-up
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
Introduction: The composite mechanical valve conduit replacement is the standardized operation for aneurysms of the aortic root. The objective of this study is to evaluate the long-term surgical results of aortic valve-preserving procedures to the root reconstruction. Methods: From 1996 to 2008, 54 consecutive patients underwent two different techniques of valve-sparing aortic root operation (40 Yacoub operations and 14 David operations). Mean age was 48 ± 14 years (range 17 to 74). 36 patients (66.7%) were male and 16 (29.6%) experienced Marfan's syndrome. The mean Euroscore was 4 ± 1.25. The mean follow up time was 4.1 years (from 49 days to 10.9 years). Clinical and echocardiographic parameters were analysed. T-Student paired test, the McNemar Non Parametric test and the Kaplan-Meyer Outcome Curves have been used. Results: The hospital mortality was 5.6% and the average hospitalization time was 9±4 days. One non related late death (2%) was reported. The actuarial survival and freedom from reoperation were respectively 94.4% and 96% within 11 years of follow-up. There were benefits in reduction of functional class (P=0.002; 78% CF I), in reduction of aortic regurgitation (P<0.001; 78% with or without discrete reflux), in reduction of systolic and diastolic diameters, end-sytolic and end-diastolic volumes of left ventricle (respectively P=0.004; P<0.0001; P=0.036 and P<0.001). Two (3.9%) patients required aortic valve replacement due to severe aortic regurgitation during this same period. No thromboembolic, endocarditis or bleeding events were reported during the follow-up. Conclusion: The valve-sparing operation for aortic root aneurysms is an effective alternative to the use of a mechanical valve conduit replacement.
Keywords: Aortic aneurysm, thoracic/surgery; Aortic valve; Aorta/surgery
Effect of leisure-time physical activity on the prognosis of coronary artery bypass graft surgery
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
Objective: The objective of this study was to evaluate the effect of leisure-time physical activity (LTPA) in the early outcome of coronary artery bypass graft surgery (CABG). Methods: This prospective cohort study analyzed 202 patients submitted to CABG. The patients were assigned to two groups, active or sedentary, according to the practice of LTPA in the preoperative period. The independent variable LTPA practiced by the patients in the previous year of the surgery was evaluated. The occurrence of the major adverse cardiac events as death, acute myocardial infarction, reoperation and the hospital stay after surgery were planned to be evaluated. Results: The mean age of patients was 62 ± 10 years, and 134 (66%) were men. Sixty-six (33%) patients practiced LTPA and were classified as active, and 136 (67%) were sedentary. The active group showed 78% less probability (OR= 0.22; CI 95%: 0.09-0.51) to suffer a MACE P<0.001 and a reduction of 33% in length of hospital stay as compared for sedentary patients (HR= 0.67; IC 95%: 0.49 - 0.93). P= 0.018. Conclusion: LTPA is an important predictor of major adverse cardiac events and hospital stay.
Keywords: Exercise; Myocardial revascularization; Cardiovascular surgical procedures
Impact of coronary artery bypass graft surgery in smoking cessation
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
Background: Tobacco use is an important modifiable risk factor for cardiovascular disease. Few studies have investigated the frequency of smoking cessation among patients submitted to heart surgery. Objective: To determine the frequency of smoking cessation in patients submitted to coronary artery bypass graft surgery. Methods: In this cohort study, 203 consecutive patients, aged above 18, submitted to coronary artery bypass graft surgery in the period from January 2006 to March 2007, were interviewed in relation to the use of cigarettes in the pre- and postoperative period. Smokers were stratified according to the levels of nicotine dependence with the use of Fagerström Nicotine Dependence Test. They were followed as outpatients during 60 and 90 days for the occurrence of smoking. Results: The mean age of the group was 62 ± 10 years, and 134 (66%) were male. Before surgery, 146 (71.9%) patients were smokers. A significant number of patients stopped smoking in the postoperative period: 136 (93.15%) and 137 (93.84%) on days 60 and 90, respectively, remained not smoking after surgery. Conclusion: Coronary artery bypass graft surgery is an important determinant of smoking cessation.
Keywords: Myocardial revascularization; Risk factors; Smoking
Assessment of aprotinin in the reduction of inflammatory systemic response in children undergoing surgery with cardiopulmonary bypass
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
Objective: To evaluate if the hemostatic high-dose aprotinin seems to reduce the inflammatory process after extracorporeal circulation (ECC) in children.
Methods: A prospective randomized study was conducted on children aged 30 days to 4 years submitted to correction of acyanogenic congenital heart disease with ECC and divided into two groups: Control (n=9) and Aprotinin (n=10). In the Aprotinin Group the drug was administered before and during ECC and the systemic inflammatory response and hemostatic and multiorgan dysfunctions were analyzed on the basis of clinical and biochemical markers. Differences were considered to be significant when P<0.05. Results: The groups were similar regarding demographic and intraoperative variables, except for a greater hemodilution in the Aprotinin Group. The drug had no benefit regarding time of mechanical pulmonary ventilation, permanence in the postoperative ICU and length of hospitalization, or regarding the use of inotropic drugs and renal function. The partial arterial oxygen pressure/inspired oxygen fraction ratio (PaO2/FiO2) was significantly reduced 24 h after surgery in the Control Group. Blood loss was similar for both groups. Significant leukopenia was observed in the Aprotinin Group during ECC, followed by leukocytosis. Tumor necrosis factor alpha (TNF- á), interleukins (IL)-6, IL-8, IL-10, IL-6/IL-10 ratio did not differ significantly between groups. The postoperative IL-6/IL-10 fraction increased significantly in the Control Group. There were no complications with the use of aprotinin. Conclusion: In this series, hemostatic high-dose aprotinin did not minimize the clinical manifestations or serum markers of the inflammatory systemic response.
Keywords: Cardiovascular surgical procedures; Extracorporeal membrane oxygenation; Capillary leak syndrome; Aprotinin; Systemic inflammatory response syndrome
HOW TO DO IT
New technique: aortic and pulmonary translocation with preservation of pulmonary valve
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
We applied successfully, a new surgical technique, in two children with transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction, that utilized aortic translocation with the aortic valve and the coronary arteries to the left ventricle, after correction of left outflow tract obstruction and correction of the ventricular septal defect, associated to pulmonary root translocation to the right ventricle, conserving integrally the pulmonary valve.
Keywords: Transposition of great vessels/surgery; Congenital heart defects/surgery; Heart septal defects, ventricular; Pulmonary valve stenosis
BRIEF COMMUNICATION
Early extubation of children in the operating room after cardiac surgery
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
INTRODUCTION: Early extubation is related to short lenth of hospitalization and less complications. OBJECTIVE: Data analisys from children extubated atsurgical room after cardiac surgery with ECC. METHODS: Retrospective data analisys. Results: From March 2006 to January 2008, 15 children submitted to heart surgery were extubated at surgery room. Age in months was 4 to 216 (76.1 months). ECC time: 30 to 95 min (51.4 min), anoxia: 14 to 67 min (35.2 min). One patient had respiratory acidosis. CONCLUSION: Early extubation in seleted patients is possible.
Keywords: Extracorporeal circulation/methods; Anesthesia; Heart defects, congenital
CASE REPORT
Video-thoracoscopy closure of coronary artery fistula: case report
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
The coronary artery fistulas (FAC) are rare and often found occasionally. The conventional treatment can be made by surgical closure with median thoracotomy or with embolization by catheterization. We describe an innovative technique to ligature of FAC, on a full endoscopy. Women, 45 years with symptomatic fistula between coronary artery anterior descending and trunk artery pulmonary, which took thoracoscopy left, pericardiotomy and ligation of fistula with metal clip without thoracotomy. There were no complications, stayed 24 hours in the ICU and was in hospital 4 days. The technique was effective, allows easy accessibility surgical and quick post-operative recovery.
Keywords: Arterio-arterial fistula, surgery; Pulmonary artery, pathology; Coronary vessel anomalies, surgery; Video-assisted surgery
Endovascular approach for persistent ductus arteriosus closure in adult patient
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
The treatment for closure of persistent ductus arteriosus (PDA) in adults still controversial. The endovascular approach has been shown as an effective alternative to surgical treatment. We report a case of 45 years old pacient submitted to endovascular approach for PDA closure.
Keywords: Ductus arteriosus; Ductus arteriosus, patent; Heart Defects, congenital
Surgical repair of congenital diaphragmatic eventration in a septugerian lady
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
Congenital diaphragmatic eventration in an elderly is a rare anomaly. We describe a case of congenital diaphragmatic eventration causing respiratory insufficiency in a 72 year lady who underwent successful surgical repair.
Keywords: Aged; Thorax/surgery; Thoracic wall/abnormalities; Diaphragm/abnormalities
Left internal thoracic artery and saphenous vein as a composite graft: 8-year angiographic follow-up study
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
The use of a composite graft with left internal thoracic artery (LITA) and arterial or saphenous vein (SV) grafts can allow the complete revascularization of the left coronary system (LCS) without cardiopulmonary bypass (CPB) and without ascending aorta manipulation (AAM), in order to reduce some complications in the immediate postoperative. This study shows 8-year angiographic follow-up results of two patients underwent no-touch aorta off-pump coronary artery bypass grafting (CABG) using LITA and SV as a composite graft to supply LCS.
Keywords: Myocardial revascularization; Coronary angiography; Saphenous vein; Mammary arteries
CLINICAL-SURGICAL CORRELATION
Bidirectional Glenn procedure without cardiopulmonary bypass in a patient with left juxtaposed atrial appendages
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
MULTIMEDIA
Technical option for temporary coronary clamping in off pump coronary surgery
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
NEWS
Dr. Paulo Pêgo-Fernandes presents an unpublished study at the Congress of STS
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025
LETTERS TO THE EDITOR
Letters to the Editor
Braz J Cardiovasc Surg 25;
Publish in: 8/2/2025