Clinical-care protocol for preventing mediastinitis after coronary artery bypass graft surgery: A quality improvement initiative from a private hospital.

BACKGROUND: Surgical site infections after cardiac surgery are associated with severe outcomes, including reoperation and death. We aimed to describe the effect of a standardized clinical-care protocol for preventing mediastinitis in patients who underwent coronary artery bypass graft surgery (CABG). METHODS: In a hospital certified by Joint Commission International, all patients who underwent CABG from January 2011 to December 2016 were compared in two periods according to the moment of implementation of a standardized clinical-care protocol for prevention of mediastinitis (CCPPM): pre-protocol (January 2011-December 2012) and post-protocol (January 2013-December 2016). The CCPPM consisted of the patient using a kit containing chlorhexidine 2% for bathing, mupirocin 20 mg/g for nasal topical use and chlorhexidine 0.12% for oral hygiene for 5 days before surgery, in addition to prophylaxis with a glycopeptide antimicrobial and strict glucose control (110-140 mg/dL) during surgery and immediate postoperative. RESULTS: We evaluated 1760 patients who underwent CABG in both periods. The occurrence of mediastinitis before protocol implementation was 1.44% (10 of 692 CABG). After the implementation of the protocol, there was an important reduction in the incidence of mediastinitis to 0.09% (1 of 1068 CABG) (P = 0.002). Although we did not observe a significant difference in mortality between the groups (2.3% vs 1%, P = 0.77), there was fewer in-hospital mortality due to mediastinitis after the CCPPM (0.2% vs 0%, P < 0.001). CONCLUSION: Implementation of a standardized CCPPM was associated with a significant reduction in the incidence of mediastinitis after CABG and reduction of mortality in the group of patients with mediastinitis.

Selective atrial vagal denervation guided by spectral mapping to treat advanced atrioventricular block.

AIMS: Asymptomatic nocturnal long ventricular pauses are usually detected accidentally and it has been suggested that they may lead to sudden death. Identification of predisposing factors could prevent cardiovascular events. METHODS AND RESULTS: We report the case of a patient with frequent asymptomatic nocturnal ventricular pauses of 3-11 s, characteristic of a vagally mediated atrioventricular (AV) block. Echocardiography, treadmill test, thyroid function test levels, and polysomnogram were normal. In an attempt to reduce the risk, it was decided that an atrial vagal denervation induced by radiofrequency (RF) ablation (cardioneuroablation) could be useful. Spectral mapping was used to localize endocardial vagal innervation in the right and left aspects of the inter-atrial septum, responsible for the sinus node and AV node modulation, and RF pulses were applied in those sites only. After finishing the procedure, significant changes were observed in the heart rate (66-90 b.p.m.), atrial-His interval (115-74 ms), Wenckebach cycle length (820-570 ms), and sinus node recovery time (1100-760 ms). Follow-up Holter recording demonstrated that the number of ventricular pauses had reduced from 438 to 0. Heart rate and time domain characteristics were compatible with vagal denervation. CONCLUSION: Ablation of the endocardial vagal innervation sites seems to be safe and efficient in reducing the frequency and the length of the ventricular pauses. It was possible by identifying certain spectral components of the atrial electrogram, resulting in a conservative approach.

Impact of Chest Pain Protocol with Access to Telemedicine on Implementation of Pharmacoinvasive Strategy in a Private Hospital Network.

BACKGROUND: Brazilian registries have shown a gap between evidence-based therapies and real treatments. We aim to compare the use of the pharmacoinvasive strategy and mortality in patients with ST elevation myocardial infarction (STEMI) transferred pre- and post-chest pain protocol with access to telemedicine (CPPT) in a private hospital network. MATERIALS AND METHODS: A CPPT was implemented in 22 private emergency departments in 2012. Emergency physicians and nurses of all facilities were trained to disseminate the information to comply with a chest pain protocol focusing on reperfusion therapy (pharmacoinvasive strategy) for STEMI. To conduct clinical discussions using telemedicine, a cardiologist from a reference hospital in cardiology (RHC) was available 24 h/day, 7 days/week. Using the database of all consecutive admissions, we compared the data of patients with STEMI transferred to the RHC in 2011 (pre-CPPT) and 2013-2014 (post-CPPT). RESULTS: We included 376 patients (113 pre-CPPT and 263 post-CPPT) with STEMI. All patients admitted in the RHC were transferred from the 22 emergency departments. Comparing pre-CPPT and post-CPPT, we did not find differences regarding age, gender, hypertension, dyslipidemia, diabetes, smoking, previous myocardial infarction, or Killip classification. However, the use of CPPT was associated with a greater use of pharmacoinvasive strategy (55.8% versus 38%; p = 0.002) and a trend toward lower in-hospital mortality (3% versus 8%; p = 0.06). CONCLUSIONS: The implementation of a CPPT was associated with a significant increase in the use of pharmacoinvasive strategy in patients with STEMI and a trend toward reduced in-hospital mortality in a private hospital network.

Atypical chest pain due to multiple coronary arteries fistulas occluded with percutaneous interlock coils: A case report.

Coronary artery fistulas, although rare, should be included in the differential diagnosis of atypical chest pain, generally unveiled by cardiac catheterization or multidetector computed tomography. Such anatomical findings in conjunction with detectable ischemia and severe symptoms should prompt their closure. Transcatheter closure of fistulas is an attractive alternative to surgery, especially with the novel devices such as the interlock fibered detachable coils, which can be safely and effectively performed in a variety of circumstances, including the coronary arteries with tortuous anatomies. We present a case of atypical chest pain and large burden of ischemia in the stress scintigraphy, due to multiple coronary fistulas to the bronchial arteries successfully occluded with percutaneous interlock coils. .

Chest Pain Network with Support of Telemedicine: Impact on Reperfusion Therapy and Clinical Outcomes After 8 Years of Experience.

Background: Different approaches of evaluation by cardiologists using telemedicine have the potential of improving care of patients with ST elevation myocardial infarction (STEMI). Objective: To compare the use of pharmacoinvasive strategy and associated clinical outcomes (heart failure [HF] and mortality) among patients with STEMI before and after a program of telemedicine and also according to the level of support by telemedicine. Methods: A chest pain network with the support of a cardiologist through telemedicine was implemented in 2012 in 22 emergency departments without a local cardiac catheterization laboratory. Initially (phase 1 of telemedicine), the decision to discuss the case with the cardiologist was based on the judgment of the emergency physician. At the end of 2018, the use of telemedicine was modified and a dedicated cardiologist was available continuously to discuss systematically all suspected cases (phase 2 of telemedicine). The use of fibrinolytics and the rates of HF and in-hospital mortality were compared among three different periods: pretelemedicine (2011), and phase 1 and phase 2 of the telemedicine program. Results: We evaluated 1034 STEMI patients and after comparing the three phases, we did not find significant differences regarding age, gender, and comorbidities. The use of fibrinolytics before transferring STEMI patients to a percutaneous coronary intervention center (pharmacoinvasive strategy) increased after telemedicine implementation (38% vs. 65.2%; p < 0.01), which was associated with a lower rate of HF (23.9% vs. 14.4%; p = 0.01) and death (7.9% vs. 4.0%; p = 0.05). The in-hospital mortality was lower in phase 2 with systematic evaluation by telemedicine compared with pretelemedicine (7.9% vs. 3.3%; p = 0.04). Conclusion: The implementation of a systematic and organized chest pain protocol, including telemedicine support, was associated with a significant increase in the use of pharmacoinvasive strategy and better clinical patient outcomes in patients with STEMI. Our findings provide important insights on how to improve the management of this high-risk population, reducing the gap between evidence and clinical practice.

Acute Myocarditis Associated with Acute Myocardial Infarction.

Concomitant acute myocarditis and acute coronary thrombosis is a rare presentation of acute chest pain in the emergency department, although the association between acute infections with a variety of pathogens and an increased risk of myocardial infarction has been reported. A case of acute myocardial infarction associated with acute myocarditis caused by coronavirus 229E in a middle-aged man without risk factors for coronary artery disease is described here. Coronary CT angiography with late enhancement protocol revealed areas of myocarditis and infarction, and cardiac MRI and coronary angiography were then performed. © RSNA, 2021.

A Coronary Artery Anomaly Presenting as Acute Coronary Syndrome: A Case Report.

BACKGROUND Coronary artery anomalies (CAAs) are rare congenital malformations with different clinical presentations and pathophysiological mechanisms. These anomalies are frequently the cause of sudden death in young patients. Most CAAs are incidental findings owing to the lack of symptoms; however, they may be associated with acute coronary syndrome in rare cases. CASE REPORT We describe the case of a 47-year-old man who presented with a 1-day history of progressive typical chest pain and elevated troponin levels. The patient underwent a coronary angiography, which unveiled the anomalous origin of the left main coronary artery arising from the right coronary artery, with an interarterial course between the ascending aorta and the pulmonary artery, without coronary artery disease. Coronary computed tomography angiography confirmed the CAA and its relationship with the symptoms. An uneventful coronary artery bypass graft was undertaken, and at the 1-year follow-up, the patient was asymptomatic, with a normal stress test. CONCLUSIONS This case depicts the presentation of atypical acute coronary syndrome in a young patient with a rare CAA. In such patients, coronary angiography and coronary computed tomography angiography are essential tools to confirm the diagnosis and to determine treatment. Although controversial, in young individuals presenting CAA with an interarterial course, such as the left main coronary artery arising from the right coronary artery, coronary artery bypass graft may be an important treatment option to avoid sudden death in the future.

Safe and effective protocol for discharge 3 days after cardiac surgery.

The Enhanced Recovery After Surgery (ERAS) protocol affected traditional cardiac surgery processes and COVID-19 is expected to accelerate its scalability. The aim of this study was to assess the impact of an ERAS-based protocol on the length of hospital stay after cardiac surgery. From January 2019 to June 2020, 664 patients underwent consecutive cardiac surgery at a Latin American center. Here, 46 patients were prepared for a rapid recovery through a multidisciplinary institutional protocol based on the ERAS concept, the "TotalCor protocol". After the propensity score matching, 46 patients from the entire population were adjusted for 12 variables. Patients operated on the TotalCor protocol had reduced intensive care unit time (P < 0.025), postoperative stay (P ≤ 0.001) and length of hospital stay (P ≤ 0.001). In addition, there were no significant differences in the occurrence of complications and death between the two groups. Of the 10-central metrics of TotalCor protocol, 6 had > 70% adherences. In conclusion, the TotalCor protocol was safe and effective for a 3-day discharge after cardiac surgery. Postoperative atrial fibrillation and renal failure were predictors of postoperative stay > 5 days.

Cost Modifications during the Early Years of the Use of the National Cardiovascular Data Registry for Quality Improvement.

OBJECTIVES: Quality improvement (QI) initiatives based on data from international registries have been reported previously; however, there is a lack of information on the impact on the costs of medical care associated with the use of these tools. METHODS: Patients admitted due to myocardial infarction (MI), included in the ACTION Registry® and CathPCI Registry®, in a private Brazilian hospital (i.e., the reference hospital) were analyzed. The costs of care of these patients were compared to the costs of MI admissions in nine similar hospitals not included in the same QI program. Regression models were used to analyze the cost change over time between the two groups of hospitals. Readmission rates were compared using logistic regression, adjusting for the same variables as in the cost model. RESULTS: Overall, the annual medical cost inflation in Brazil was higher than the annual cost trend in the reference hospital during the period of analysis. Moreover, the annual in-hospital costs indicate that the reference hospital has a statistically significant 6% lower cost trend for patients with acute MI, compared to patients with the same diagnostic code in the comparison hospitals group, in an adjusted analysis (p-value=0.041). Using multivariable analysis, the readmission rates were also found to be significantly lower in the reference hospital than in the comparison hospitals, with an odds ratio of 0.68 (p-value=0.042). CONCLUSION: The use of the NCDR® as a benchmark to guide QI programs outside the United States was associated with the positive impact of bending the cost curve to below that of national medical inflation and the comparison hospitals' costs, with a lower incidence of hospital readmission.

Acute Coronary Syndrome After Ondansetron Administration in a Pregnant Woman: Kounis Syndrome?

We report on a pregnant woman with acute coronary syndrome probably caused by an allergic reaction to ondansetron. It also discusses the pathophysiology, main allergic triggers, clinical presentation, and management of Kounis syndrome. (Level of Difficulty: Beginner.).

Clinical outcomes and need for intensive care after non-ST-segment-elevation myocardial infarction.

BACKGROUND: The decision on whether non-ST-segment elevation myocardial infarction (NSTEMI) patients should be admitted to intensive care units (ICU) takes into account several factors including hospital routines. The Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU score was developed to predict complications requiring ICU care post-NSTEMI. METHODS: We described patient characteristics and clinical outcomes of 1263 NSTEMI patients admitted to a private hospital in Sao Paulo, Brazil, from 2014 to 2018. We also aimed to retrospectively identify NSTEMI patients who might not have needed to be admitted to the ICU based on the ACTION ICU risk score. We defined complications requiring ICU care post-NSTEMI as cardiac arrest, cardiogenic shock, stroke, re-infarction, death, heart block requiring pacemaker placement, respiratory failure, or sepsis. RESULTS: Mean age was 62.3 years and 35.8% were female. A total of 94.6% of NSTEMI patients were admitted to the ICU. Most NSTEMI patients (91.9%) underwent coronary angiography. Percutaneous coronary intervention was performed in 47.1% and coronary artery bypass graft surgery in 10.3%. Complications requiring ICU care occurred in 62 patients (4.9%). In-hospital mortality rate was 1.3%. Overall, 70.4% had an ACTION ICU score ≤ 5. The C-statistics for the ACTION risk score to predict complications was 0.55 (95% confidence interval 0.47-0.63). CONCLUSIONS: Complications requiring ICU care were infrequent in a cohort of NSTEMI patients who were routinely admitted to the ICU over a 4-year period. The ACTION risk score had low accuracy in the prediction of complications requiring ICU care in our population.

Improvement in quality indicators using NCDR® registries: First international experience.

BACKGROUND: The National Cardiovascular Data Registry (NCDR®) Database is commonly used for quality-improvement initiatives in North America, but little is known about the application of this tool in other regions of the world. METHODS: All consecutive patients admitted due to myocardial infarction (MI) and/or undergoing percutaneous coronary intervention (PCI) from January 2012 until December 2015 in a Brazilian private cardiovascular hospital were included respectively in ACTION REGISTRY®-GWTG™ and CathPCI Registry®. Meetings including all hospital staff were performed quarterly to discuss every NCDR® report. Quality improvement initiatives were developed based on the reports which were also used for evaluation of changes after the interventions. The following indicators were considered a priority 1) Door-to-ECG and door-to-balloon (D2B) times; 2) PCI appropriateness; 3) length of stay; 4) delivery of guideline-based medication. Changes in the quality of care with respect to the over time were assessed using linear and logistic regression for continuous and binary outcomes, respectively. RESULTS: A total of 1.382 patients were included in the ACTION REGISTRY®-GWTG™ and 3.179 patients in the CathPCI Registry®. In the ACTION registry, the overall AMI performance composite of quality indicators improved along the 4 years from 95.0% to 99.6% (p for trend <0.001). The percentage of appropriate/uncertain PCI in acute and elective scenario increased along the years from 91.1% and 70.9% to 96.6% and 84.7%, respectively (p for trend <0.001). CONCLUSION: The present novel experience using the NCDR® registries as benchmarks to guide quality-improvement programs in an international site was associated with improvement in quality indicators.

Cost modifications during the early years of the use of the national cardiovascular data registry for quality improvement

OBJECTIVES: Quality improvement (QI) initiatives based on data from international registries have been reported previously; however, there is a lack of information on the impact on the costs of medical care associated with the use of these tools. METHODS: Patients admitted due to myocardial infarction (MI), included in the ACTION Registry® and CathPCI Registry®, in a private Brazilian hospital (i.e., the reference hospital) were analyzed. The costs of care of these patients were compared to the costs of MI admissions in nine similar hospitals not included in the same QI program. Regression models were used to analyze the cost change over time between the two groups of hospitals. Readmission rates were compared using logistic regression, adjusting for the same variables as in the cost model. RESULTS: Overall, the annual medical cost inflation in Brazil was higher than the annual cost trend in the reference hospital during the period of analysis. Moreover, the annual in-hospital costs indicate that the reference hospital has a statistically significant 6% lower cost trend for patients with acute MI, compared to patients with the same diagnostic code in the comparison hospitals group, in an adjusted analysis (p-value=0.041). Using multivariable analysis, the readmission rates were also found to be significantly lower in the reference hospital than in the comparison hospitals, with an odds ratio of 0.68 (p-value=0.042). CONCLUSION: The use of the NCDR® as a benchmark to guide QI programs outside the United States was associated with the positive impact of bending the cost curve to below that of national medical inflation and the comparison hospitals' costs, with a lower incidence of hospital readmission.

Improving Indicators in a Brazilian Hospital Through Quality-Improvement Programs Based on STS Database Reports.

OBJECTIVE: To report the initial changes after quality-improvement programs based on STS-database in a Brazilian hospital. METHODS: Since 2011 a Brazilian hospital has joined STS-Database and in 2012 multifaceted actions based on STS reports were implemented aiming reductions in the time of mechanical ventilation and in the intensive care stay and also improvements in evidence-based perioperative therapies among patients who underwent coronary artery bypass graft surgeries. RESULTS: All the 947 patients submitted to coronary artery bypass graft surgeries from July 2011 to June 2014 were analyzed and there was an improvement in all the three target endpoints after the implementation of the quality-improvement program but the reduction in time on mechanical ventilation was not statistically significant after adjusting for prognostic characteristics. CONCLUSION: The initial experience with STS registry in a Brazilian hospital was associated with improvement in most of targeted quality-indicators.

The influence of aerobic fitness status on ventilatory efficiency in patients with coronary artery disease.

OBJECTIVE: To test the hypotheses that 1) coronary artery disease patients with lower aerobic fitness exhibit a lower ventilatory efficiency and 2) coronary artery disease patients with lower initial aerobic fitness exhibit greater improvements in ventilatory efficiency with aerobic exercise training. METHOD: A total of 123 patients (61.0±0.7 years) with coronary artery disease were divided according to aerobic fitness status into 3 groups: group 1 (n = 34, peak VO2<17.5 ml/kg/min), group 2 (n = 67, peak VO2>17.5 and <24.5 ml/kg/min) and group 3 (n = 22, peak VO2>24.5 ml/kg/min). All patients performed a cardiorespiratory exercise test on a treadmill. Ventilatory efficiency was determined by the lowest VE/VCO2 ratio observed. The exercise training program comprised moderate-intensity aerobic exercise performed 3 times per week for 3 months. Clinicaltrials.gov: NCT02106533 RESULTS: Before intervention, group 1 exhibited both lower peak VO2 and lower ventilatory efficiency compared with the other 2 groups (p<0.05). After the exercise training program, group 1 exhibited greater improvements in aerobic fitness and ventilatory efficiency compared with the 2 other groups (group 1: ▵ = -2.5±0.5 units; group 2: ▵ = -0.8±0.3 units; and group 3: ▵ = -1.4±0.6 units, respectively; p<0.05). CONCLUSIONS: Coronary artery disease patients with lower aerobic fitness status exhibited lower ventilatory efficiency during a graded exercise test. In addition, after 3 months of aerobic exercise training, only the patients with initially lower levels of aerobic fitness exhibited greater improvements in ventilatory efficiency.

Left Main Ostial Compression in a Patient with Pulmonary Hypertension: Dynamic Findings by IVUS.

BACKGROUND: Pulmonary artery dilatation is a common feature among patients with severe pulmonary hypertension. Left main coronary artery extrinsic compression by an enlarged pulmonary artery is a rare complication and a potential cause for chest pain and sudden cardiac death in patients with pulmonary hypertension. This situation is very rare and few reports have described it. Currently, the appropriate management of these patients remains unknown. CASE REPORT: In the present report we describe the case of a 39-year-old woman who presented with a 2-year history of cardiac symptoms related to exercise. The patient underwent a 64-slice multidetector computed tomography (MDCT) coronary angiography, which showed left main coronary artery (LMCA) compression by a markedly enlarged pulmonary artery trunk (44 mm), without intraluminal stenosis or coronary artery calcium, as determined by the Agatston score. This compression was considered to be the cause of the cardiac symptoms. To confirm and plan the treatment, the patient underwent cardiac catheterization that confirmed the diagnosis of pulmonary hypertension and LMCA critical obstruction. Taking into account the paucity of information regarding the best management in these cases, the treatment decision was shared among a "heart team" that chose percutaneous coronary intervention with stent placement. An intra-vascular ultrasound was performed during the procedure, which showed a dynamic compression of the left main coronary artery. The intervention was successfully executed without any adverse events. CONCLUSIONS: This case illustrates dynamic compression of the LMCA by IVUS, visually demonstrating the mechanism of the intermittent symptoms of myocardial ischemia in this kind of patient. It also shows that percutaneous stenting technique may be an appropriate treatment for this unusual situation.

Resolution of an acute aortic syndrome with aortic valve insufficiency post-PCI.

BACKGROUND: Acute aortic syndrome is the modern term that includes aortic dissection, intramural hematoma, and symptomatic aortic ulcer. Iatrogenic coronary artery dissection extending to the aorta during percutaneous coronary intervention is a very rare but life-threatening complication. Despite some reports of spontaneous recovery, most of these patients are treated surgically as a spontaneous aortic dissection, especially if there is a complication of the aortic lesion. CASE REPORT: A 52-year-old white female was submitted to an angioplasty in the right coronary without success and the procedure was complicated by a dissection in aortic root with progressive extension to the ascending aorta. This lesion deformed the aortic valve, leaving it with an acute moderate regurgitation. Because of current use of clopidogrel and clinical stability of the patient, the local Heart Team decided to withdrawn this antiplatelet for 5 days before surgery despite the risk related to the aortic syndrome. A new echocardiogram 3 days later showed that the hematoma was reabsorbed with improvement of the aortic insufficiency. An angiotomography confirmed the reabsorption of the hematoma. The surgery was canceled and the patient was maintained in a conservative treatment and discharged. Seventeen months later, she was re-evaluated and was still asymptomatic without aortic regurgitation in the echocardiogram and showing progressive regression of the aortic hematoma in the tomography. CONCLUSIONS: Despite the conservative treatment, this case of iatrogenic aortic dissection complicated by an acute aortic regurgitation had a good evolution in a follow-up of 17 months.

Evaluation of the Society of Thoracic Surgeons score system for isolated coronary bypass graft surgery in a Brazilian population.

OBJECTIVE: Report the experience with the Society of Thoracic Surgeons scoring system in a Brazilian population submitted to isolated coronary artery bypass graft surgery. METHODS: Data were collected from January-2010 to December-2011, and analyzed to determine the performance of the Society of Thoracic Surgeons scoring system on the determination of postoperative mortality and morbidity, using the method of the receiver operating characteristic curve as well as the Hosmer-Lemeshow and the Chi-square goodness of fit tests. From the 1083 cardiac surgeries performed during the study period 659 represented coronary artery bypass graft procedures which are included in the present analysis. Mean age was 61.4 years and 77% were men. RESULTS: Goodness of fit tests have shown good calibration indexes both for mortality (X2=6.78, P=0.56) and general morbidity (X2=6.69, P=0.57). Analysis of area under the ROC-curve (AUC) demonstrated a good performance to detect the risk of death (AUC 0.76; P<0.001), renal failure (AUC 0.79; P<0.001), prolonged ventilation (AUC 0.80; P<0.001), reoperation (AUC 0.76; P<0.001) and major morbidity (AUC 0.75; P<0.001) which represents the combination of the assessed postoperative complications. STS scoring system did not present comparable results for short term hospital stay, prolonged length of hospital stay and could not be properly tested for stroke and wound infection. CONCLUSION: Society of Thoracic Surgeons scoring system presented a good calibration and discrimination in our population to predict postoperative mortality and the majority of the harmful events following coronary artery bypass graft surgery. Analysis of larger samples might be needed to further validate the use of the score system in Brazilian populations.