Complete surgical revascularization: Different definitions, same impact?

BACKGROUND: There are several different definitions of complete revascularization on coronary surgery across the literature. Despite the importance of this definition, there is no agreement on which one has the most impact. The aim of this study was to evaluate which definition of complete surgical revascularization correlates with early and late outcomes. METHODS: All consecutive patients submitted to isolated CABG from 2012 to 2016 with previous myocardial scintigraphy were evaluated. EXCLUSION CRITERIA: emergent procedures and previous cardiac surgery procedures. The population of 162 patients, follow-up complete in 100% patients; median 5.5; IQR: 4.4-6.9 years. Each and all of the 162 patients were classified as complying or not with the four different definitions: numerical, functional, anatomical conditional, and anatomical unconditional. Perioperative outcome: MACCE; long-term outcomes: survival and repeat revascularization. Univariable and multivariable analyses were developed to detect predictors of outcomes. RESULTS: Complete functional revascularization was a predictor of increased survival (HR: 0.47; CI 95: 0.226-0.969; p = .041). No other definitions showed effect on follow-up mortality. Age and cardiac dysfunction increased long-term mortality. The definition of complete revascularization did not have an impact on MACCE or the need for revascularization CONCLUSIONS: A uniformly accepted definition of complete coronary revascularization is lacking. This study raises awareness about the importance of viability guidance for CABG.

Tetraplegia after branched frozen elephant trunk implantation for acute type A aortic dissection.

A 58-year-old male patient presented with acute type A aortic dissection. Complete arch and ascending aorta replacement were performed using a Thoraflex Hybrid prosthesis. The left subclavian artery was ligated and the remaining supra-aortic trunks were reimplanted using the branches of the prosthesis. After an uneventful early postoperative period, sudden onset of hypotension and bradycardia occurred, with severe vasoplegia, requiring vasopressors. Ischemia of the upper left limb and compartment syndrome ensued, leading to left carotid subclavian bypass. After discontinuation of sedation, tetraplegia was noted due to spinal cord ischemia from C3 to C7.

Cardiac Surgery in Patients with Dialysis-dependent End Stage Renal Failure: Single Centre Experience.

BACKGROUND: Patients under dialysis have a high cardiovascular risk and they are at increased risk when submitted to cardiac surgery. AIM OF THE STUDY: to evaluate morbidity, early and late mortality, and predictive factors of mortality in patients under dialysis who underwent cardiac surgery. METHODS: A retrospective observational study was performed including all dialysis dependent patients who underwent cardiac surgery (coronary, valvular or combined procedures) in our institution between 2007 and 2014. A population of 95 consecutive patients was obtained (no exclusions). Perioperative variables and predictors of mortality were analysed and the endpoints were early and late mortality. Propensity score matching, with a control group of patients with creatinine clearance >90mL/min, was performed by logistic regression, with a 1:1 matching. Kaplan Meier curves were performed for late mortality. RESULTS: Early mortality was 9.4% (EuroSCORE II 4.1%). In univariate analysis, mean time of cardiopulmonary bypass (CPB) (p=0.016) and EuroSCORE II (p=0.02) were related with early mortality. In a multivariate analysis model, combined procedures (OR 138.09; CI95% 1.82-10498.4; p=0.03) and CCS (Canadian Cardiovascular Society) 3-4 (OR 70.951; CI 95% 1.32-3810.11; p=0.037) were predictors of mortality. In multivariable analysis, CPB time >152 min was a predictor of early mortality (p=0.001). After propensity score matching, 30 day, one year and late mortality were higher in the dialysis group. CONCLUSIONS: Early and late mortality were significantly higher in dialysis dependent patients. Predictive factors of mortality were CPB time and EuroSCORE II in univariable analysis, and CCS 3-4 and combined procedures in multivariable analysis.

Patient prosthes is mismatch in stented biologic aortic valve prosthesis: 10 years' results.

OBJECTIVES: The goal of this study is to establish the relation between aortic bio prosthesis, patient prosthesis mismatch (PPM) and short-term mortality and morbidity as well as and long-term mortality. METHODS: This is a single center retrospective study with 812 patients that underwent isolated stented biologic aortic valve replacement between 2007 and 2016. The projected indexed orifice area was calculated using the in vivo previously published values. Outcomes were evaluated with the indexed effective orifice area (iEOA) as a continuous variable and/or nominal variable. Multivariable models were developed including clinically relevant co-variates. RESULTS: In the study population 65.9% (n=535) had no PPM, 32.6% (n=265) had moderate PPM and 1.5% (n=12) severe PPM. PPM was related with diabetes (OR:1.738, CI95:1.333-2.266; p<0.001), heart failure (OR:0.387, CI95:0.155-0.969; p=0.043) and older age (OR:1.494, CI95:1.171-1.907; p=0.001). iEOA was not an independent predictor of in-hospital mortality (OR 1.169, CI 0.039-35.441) or MACCE (OR 2.753, CI 0.287-26.453). Long term survival is significantly inferior with lower iEOA (HR 0.116, CI 0.041-0.332) and any degree of PPM decreases survival when compared with no PPM (Moderate: HR 1.542, CI 1.174-2.025; Severe HR 4.627, CI 2.083-10.276). CONCLUSIONS: PPM appears to have no impact on short-term outcomes including mortality and morbidity. At ten years follow-up, moderate or severe PPM significantly reduces the long-term survival.

Benign Presentation of a Potentially Fatal Disease.

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital cardiovascular defect that can range from being fatal early in life to presenting in adulthood asymptomatically. We report the case of a teenager whose diagnosis was incidental and underwent surgery, consisting in coronary artery button transfer, with excellent result.

A origem anómala da artéria coronária esquerda a partir da artéria pulmonar é uma cardiopatia congénita que pode ser fatal precocemente ou apresentar-se na vida adulta de forma assintomática. Apresentamos o caso clínico de um adolescente cujo diagnóstico foi incidental e que foi submetido a cirurgia, com translocação da artéria coronária, com excelente resultado.

Pulmonary Hypertension in Valvular Heart Disease Surgery: Risk and Prognosis.

INTRODUCTION: Left heart disease is the most common cause of pulmonary hypertension (PH), and when present is associated with higher surgical risk. OBJECTIVES: Analyze the effect of PH severity on morbidity, early and late mortality in patients with pulmonary artery systolic pressure (PASP) over 30mmHg that underwent valvular heart surgery. METHODS: Retrospective observational study including all patients with PH, defined as PASP>30 mmHg that underwent isolated valvular heart surgery, between 2007 and 2016. Exclusion criteria were: active endocarditis, congenital heart disease, transcatheter aortic valve implantation, reoperations and emergent surgery. The study population included 607 patients with a mean age of 69.6 years and a mean PASP of 52.5 mmHg. Mean follow-up for all-cause mortality was 4.4(0-11) years in 99.7% of patients. MACCE (Major Adverse Cardiac and Cerebrovascular event) was defined as at least one of the following: in-hospital mortality, stroke, post-operative myocardial infarction, severe arrhythmia or multiple organ failure. PASP was evaluated as a continuous variable. Simple and multivariable logistic regression was performed to evaluate the in-hospital mortality and MACCE. Cox regression was used for long term follow-up and one-sample log-rank test for comparison with age adjusted general population. RESULTS: The in-hospital mortality was 3.2% and PASP was an independent predictor on univariable analysis (OR:1.06; 95%CI:1.03- 1.09; p<0.001). On multivariable logistic regression PH remains an independent predictor of in- -hospital mortality (OR:1.08; 95%CI:1.04-1.12; p<0.001) in addition to age (OR:1.08; 95%CI:1.01-1.17; p=0.044). MACCE was observed in 11.4% and PASP was an independent predictor on univariable analysis (OR:1.03; 95%CI:1.01- 1.04; p<0.001). On multivariable logistic regression PASP remains an independent predictor of MACCE (OR:1.02; 95%CI:1.01-1.04; p=0.011) as well as hemodialysis (OR:7.16; 95%CI:1.73-29.63; p=0.007). The independent predictors of long term mortality were male gender (p=0.011), older age (p<0.001), higher body mass index (p=0.013), urgent surgery (p=0.027), pulmonary disease (p=0.042) and more than one valve procedure (p=0.004 for 2 valves and p=0.006 for 3 valves). PASP was not an independent predictor of long term mortality (p=0.142). Compared with an age adjusted general population, patients with PH had a significantly lower survival rate(p<0.001), more evident 4 years after the procedure. CONCLUSIONS: Higher PASP is a risk factor for in-hospital mortality and MACCE, but there was no significant impact on long term mortality.

Elective and urgent coronary surgery in octogenarians.

OBJECTIVES: To analyze the influence of surgical myocardial revascularization on early and late mortality in octogenarians and compare the survival rates with age adjusted general population. METHODS: Between 2007 and 2014, 182 octogenarian patients underwent elective or urgent coronary artery bypass grafting surgery. Logistic regression was performed to evaluate the in-hospital mortality predictors. The comparison of long term survival between our population and age adjusted general population was made using one-sample log-rank test. RESULTS: The in-hospital mortality was 4,4% and its predictors on univariable analysis were non sinus rhythm (p=0,001), acute coronary syndrome less than 7 days prior to surgery (p=0,021), ejection fraction less than 50% (p=0,04) and the need for conversion to on pump surgery (p=0,04). On multivariate logistic regression non sinus rhythm and acute myocardial infarction less than 7 days before surgery were independent predictors of in-hospital mortality. Follow-up at one-year showed survival rate of 86,2% and at five years 58,4%. There was no significant difference in survival rates between the study group and the age adjusted standard population (p=0,96). The group was divided in two groups: (1) complete revascularization and (2) incomplete revascularization. There was no significant difference in survival (p=0,32 and p=0,19, respectively) compared to the age adjusted standard population. CONCLUSIONS: Coronary artery bypass grafting in octogenarians is safe and has an important impact on long term survival, with five-year survival being similar to the age adjusted standard population.

Objetivos: Analisar o impacto da revascularização miocárdica cirúrgica na mortalidade precoce e tardia em octogená- rios e comparar a sobrevida com a população geral ajustada para a idade. Métodos: Entre 2007 e 2014, 182 octogenários foram submetidos a cirurgia de revascularização miocárdica eletiva ou urgente. Utilizou-se regressão logística para avaliar os preditores de mortalidade intra-hospitalar. A comparação da sobre- vivência a longo prazo entre a população em estudo e a população ajustada para a idade efetuou-se com o teste one sample log-rank. Resultados: A mortalidade intra-hospitalar foi 4,4% e os seus preditores, na análise univariável, foram ritmo não sinusal (p=0,001), síndrome coronário agudo menos de 7 dias antes da cirurgia (p=0,021), fração de ejeção menos de 50% (p=0,04) e conversão em cirurgia on pump (p=0,04). Na análise multivariada, o ritmo não sinusal e síndrome coronário agudo menos de 7 dias antes da cirurgia foram preditores independentes de mortalidade intra-hospitalar. No seguimento a um ano a sobrevivência foi de 86,2% e a cinco anos de 58,4%. Não se verificou diferença significativa na sobrevivência entre o grupo de estudo e a população geral ajustada para a idade (p=0,96). A população em estudo foi dividida em dois grupos: (1) revascula- rização completa e (2) revascularização incompleta. Não se verificou diferença significativa (p=0,32 e p=0,19, respetivamente) quando comparados com a população geral ajustada para a idade. Conclusão: A cirurgia de revascularização miocárdica em octogenários é segura e tem um importante impacto na sobrevida a longo prazo, com sobrevivência a cinco anos semelhante à população geral ajustada para a idade.

Endoscopic Vein Harvesting - How Do We Do It?

The saphenous vein graft (SVG) remains the most used conduit as a second graft in Coronary Artery Bypass Grafting (CABG).1 Traditionally, surgeons harvest SVG with an open approach, making a long incision along the medial part of the leg or thigh. This procedure can potentially result in important complications, such as delayed wound healing, postoperative pain and infection.2 Thus, less invasive techniques for vessel harvesting have grown in popularity. Endoscopic vein harvesting (EVH) is a minimally invasive harvesting procedure, which only requires a short incision, leading to less wound complications and a faster return to normal daily activities. This article intends to describe how we do EVH technique in our centre, from the preparation of the patient to the postoperative period and share some tips and tricks from our experience.

Perioperative care in infective endocarditis.

Patients undergoing surgery for acute infective endocarditis are among those with the highest risk. Their preoperative condition has significant impact on outcomes. There are specific issues related with the preoperative situation, intraoperative findings, and postoperative management. In this narrative review, focus is placed on the most critical aspects in the perioperative period including the management and weaning from mechanical ventilation, the management of vasoplegia, the management of the chest open, antithrombotic therapy, transfusion, coagulopathy, management of atrial fibrillation, the duration of antibiotic therapy, and pacemaker implantation.

A complex case of bacterial pericarditis caused by a new pathogenic agent.

Dermabacter hominis is a gram-positive facultative anaerobic agent. It is a human skin colonizer that can be responsible for opportunistic infections in immunocompromised patients. To date, the infections caused by this agent are related to bone, joint, eye, peritoneal dialysis catheters, abscesses or infected vascular grafts. Overall, it has a favorable outcome with good response to vancomycin, teicoplanin or linezolide, and so it has not been considered a concerning pathogenic agent. We present the first case in scientific literature with isolation of D. hominis in pericardial fluid in the setting of infectious bacterial pericarditis, with an aggressive course and poor evolution.

Repair of a gigantic ascending aortic pseudoaneurysm - A challenging approach.

Aortic pseudoaneurysms can be a potentially fatal, yet rare, complication of heart surgery. Surgery is indicated but is high risk during sternotomy. Therefore, careful planning is required. We report the case of a 57-year-old patient who underwent heart surgery twice in the past and who presented with an ascending aortic pseudoaneurysm. A successful repair of the pseudoaneurysm was performed under deep hypothermia, left ventricular apical venting, periods of circulatory arrest and endoaortic balloon occlusion.

Infective Endocarditis: A Prospective Registry Of Surgical Lesions.

INTRODUCTION: Infective endocarditis morbidity and mortality remains high. Surgery is performed in about half of endocarditis cases, being the ideal setting to evaluate endocarditis lesions. The aim of this study was to register and describe endocarditis lesions found during surgery; find predictors of morbidity and mortality and correlate lesions found in echocardiogram vs. surgery. MATERIALS AND METHODS: One hundred consecutive patients with endocarditis lesions seen during surgery were included between June 2014 and August 2018. Pathological lesions were coded prospectively using a coding form published by Pettersson et al. Other data were collected retrospectively. RESULTS: Prosthetic endocarditis accounted for 23% of cases. Embolic events had occurred in 41% of cases, mainly to the brain (22%). The most frequent lesions found in echocardiogram were vegetations (77%). Vegetations and valve integrity anomalies were the main lesions described during surgery (70% and 71% respectively). Invasion was present in 39% of patients. In-hospital mortality was 9%. In univariable analysis, predictors of early mortality included chronic kidney disease (P= .005), prosthetic valve endocarditis (P <.001), EuroSCORE II (P <.001) and valve integrity anomalies (P=.016). Predictors of embolic events included aortic valve vegetations seen during surgery (P= .026). Sensitivity and specificity of echocardiogram findings for identification of vegetations were 84% and 40%, for valve integrity anomalies 42% and 97% and for invasion 54% and 95%, respectively. CONCLUSIONS: Diversity of lesions found in endocarditis precludes obtaining significant predictors of morbidity or mortality with small numbers of patients. Echocardiogram lacks sensitivity for valve integrity anomalies and invasion but is highly specific.

Triple valve surgery: long-term follow-up from a single centre.

AIMS: The aims of this study were to analyze early and late outcomes of TVS and identify predictors of short and long- term poor prognosis. METHODS: Single centre retrospective study with 130 patients who underwent TVS between 2007 and 2020. Most of the patients were female (72.3%), mean age of 64.4 years; 61.1% were in New York Heart Association class III/IV, with a EuroSCORE II of 7.5%. Univariable and Multivariable analyses were undertaken to identify predictors of perioperative mortality and morbidity and long-term mortality. RESULTS: In-hospital mortality was 10.8%, of which 7.6% were due to a cardiac cause. Diabetes Mellitus was an in- dependent predictor of increased perioperative mortality. This group had 27.7% rate of major perioperative complications. Elevated systolic pulmonary pressure and obesity were predictors of early morbidity. All-cause mortality was 43.1% for 14 years. The survival at 1, 5 and 10 years was 83%, 60% and 43%, respectively. Diabetes Mellitus was a risk factor for long-term mortality. CONCLUSIONS: Patients undergoing TVS have a high surgical risk making TVS an operation associated with high mor- tality and morbidity. This research suggests Diabetes Mellitus, pulmonary hypertension and obesity as risk factors for mortality in TVS.

Fulminant Eosinophilic Myocarditis: A Rare and Life-Threatening Presentation of Eosinophilic Granulomatosis With Polyangiitis.

We describe a case of fulminant eosinophilic myocarditis as the first presentation of eosinophilic granulomatosis with polyangiitis, promptly managed with extracorporeal membrane oxygenation. This case highlights the multidisciplinary work involving all health care professionals in the acute management of these patients and discusses it from an educational point of view. (Level of Difficulty: Intermediate.).

Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients With Non-ST-Elevation Myocardial Infarction and Left Main or Multivessel Coronary Disease.

Current recommendations on the optimal revascularization strategy in Non-ST-elevation myocardial infarction (NSTEMI) with left main (LM) or multivessel coronary disease (MVD) are based upon randomized clinical trials conducted in stable coronary artery disease. In a real-world contemporary observational registry, we compared the long-term outcome of NSTEMI patients with LM/MVD (n = 1,104) submitted to coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or optimized medical therapy (OMT). The primary end point was 5-year all-cause mortality. Results were assessed in the entire population (CABG 289, PCI 399, and OMT 416) and in a propensity score-matched cohort of CABG (n = 159) and PCI (n = 159). Crude 5-year mortality rates in CABG and PCI were 25.3% versus 29.6%, respectively (unadjusted hazard ratio [HR] 1.2; 95% confidence intervals [CI] 0.9 to 1.6; p = 0.212); OMT, however, was associated with a twofold higher risk of mortality when compared with any revascularization strategy (unadjusted HR 2.0; 95% CI 1.7 to 2.5; p < 0.001). After propensity score-matching and multivariate analysis, there was a trend toward a higher incidence of the primary end point in patients who underwent PCI versus CABG (31% vs 21%; adjusted HR 1.52; 95% CI 0.93 to 2.50; p = 0.094). This was a consistent finding over subgroups deemed clinically relevant, such as in patients with LM or proximal left anterior descending disease, SYNergy between percutaneous coronary intervention with TAXus ≥23 and left ventricle ejection fraction <40%. In conclusion, in a real-world cohort of NSTEMI patients with LM/MVD, those selected for OMT had a dire outcome. Although adjusted 5-year mortality was statistically similar between revascularization strategies, there was a trend favoring CABG, which might be the preferred option in LM, proximal LAD, SYNergy between percutaneous coronary intervention with TAXus ≥23, and left ventricle ejection fraction <40% subgroups.

Simple mesothelial pericardial cyst in a rare location.

Pericardial cysts are rare and generally benign intrathoracic lesions, most frequently located in the cardiophrenic angles, but other locations have been described. We present a case of a pericardial cyst in a previously undescribed site. Our patient presented with a cyst in the interventricular septum which was discovered as an incidental finding. After surgical excision of the cyst, it was described pathologically as a simple mesothelial pericardial cyst. The explanation of this rare condition is uncertain, but some hypotheses can be outlined.

Left ventricular pseudoaneurysm - a challenging diagnosis. / Pseudoaneurisma ventricular esquerdo - um desafio diagnóstico.

Left ventricular pseudoaneurysm is a rare complication of acute myocardial infarction, associated with high mortality. However, it can present in a non-specific manner, complicating and delaying the diagnosis. The authors present the case of a 65-year-old patient, hypertensive, with no other known relevant medical history, who presented with chest pain, cough and left pleural effusion, initially attributed to a pulmonary process. However, these were in fact the result of a left ventricular pseudoaneurysm following silent acute myocardial infarction. The diagnosis was suspected on echocardiography and confirmed by cardiac magnetic resonance imaging, and the patient underwent successful surgical pseudoaneurysm repair. This case illustrates an atypical presentation of a left ventricular pseudoaneurysm, in which the manifestations resulted from pericardial and pleural extension of the inflammatory process associated with contained myocardial rupture. The case demonstrates the need for a high index of suspicion, and the value of imaging techniques to confirm it, in order to proceed with appropriate surgical treatment, and thus modify the course of the disease.