A 30-Year-Old Woman With Arthralgia, Progressive Dyspnea, and a Syncope Episode.

CASE PRESENTATION: A 30-year-old White woman with presumed rheumatoid arthritis accompanied by CT scan evidence of eosinophilic pneumonitis was referred to the ED by her rheumatologist for an investigation of the progression of dyspnea. Approximately 6 months before, the patient reported experiencing diffuse interphalangeal arthralgias (both proximal and distal) that affected the wrists, knees, and feet. These symptoms were accompanied by Modified Medical Research Council scale grade 2 dyspnea. During the initial assessment, the patient exhibited slight pallor and had no indications of inflammatory activity in the joints. Furthermore, the cardiovascular physical examination and the auto-antibody laboratory profile yielded normal results. However, a wrist ultrasound scan revealed evidence of active synovitis; a chest CT scan displayed multifocal bilateral ground-glass opacities and mild thickening of the interlobular septa. These findings suggested the presence of eosinophilic disease or an acute interstitial process related to collagen vascular disease. Consequently, the patient's treatment commenced with a weekly dose of methotrexate (10 mg). Despite the intervention, 2 months later, the patient returned, reporting persistent arthralgia and a worsening of dyspnea, now classified as Modified Medical Research Council scale grade 3. Subsequently, the rheumatologist referred her to the ED for further assessment. During the initial emergency evaluation, the patient experienced a syncope episode accompanied by orthostatic prodromal symptoms that included dizziness, nausea, and malaise.

Comparison of the internal thoracic artery flow dissected by video endoscopy or conventional technique.

PURPOSE: To compare the blood flow in the internal thoracic artery when dissected endoscopically in a conventional manner, in addition to develop a reliable experimental training model for the surgical team. METHODS: Paired experimental study. Ten pigs were operated and had both internal thoracic arteries dissected, the right with a conventional technique and the left by video endoscopy. The main outcomes to be studied were flow, length, and time of dissection of each vessel. RESULTS: Blood flow measurements were performed with mean heart rate of 100 ± 16 bpm and mean arterial pressure of 89.7 ± 13 mm Hg. The mean blood flow of endoscopic dissection of the internal thoracic artery was 170.2 ± 66.3 mL/min and by direct view was 180.8 ± 70.5 (p = 0.26). Thus, there was no statistically significant difference between the flows, showing no inferiority between the methods. CONCLUSIONS: The minimally invasive dissection of the internal thoracic artery was shown to be not inferior to the dissection by open technique in relation to the blood flow in the present experimental model. In addition, the model that we replicated was shown to be adequate for the development of the learning curve and improvement of the endoscopic abilities.

Comparison of the internal thoracic artery flow dissected by video endoscopy or conventional technique

ABSTRACT Purpose: To compare the blood flow in the internal thoracic artery when dissected endoscopically in a conventional manner, in addition to develop a reliable experimental training model for the surgical team. Methods: Paired experimental study. Ten pigs were operated and had both internal thoracic arteries dissected, the right with a conventional technique and the left by video endoscopy. The main outcomes to be studied were flow, length, and time of dissection of each vessel. Results: Blood flow measurements were performed with mean heart rate of 100 ± 16 bpm and mean arterial pressure of 89.7 ± 13 mm Hg. The mean blood flow of endoscopic dissection of the internal thoracic artery was 170.2 ± 66.3 mL/min and by direct view was 180.8 ± 70.5 (p = 0.26). Thus, there was no statistically significant difference between the flows, showing no inferiority between the methods. Conclusions: The minimally invasive dissection of the internal thoracic artery was shown to be not inferior to the dissection by open technique in relation to the blood flow in the present experimental model. In addition, the model that we replicated was shown to be adequate for the development of the learning curve and improvement of the endoscopic abilities.

Infective endocarditis profile, prognostic factors and in-hospital mortality: 6-year trends from a tertiary university center in South America.

BACKGROUND: Infective endocarditis (IE) remains an expressive health problem with high morbimortality rates. Despite its importance, epidemiological and microbiological data remain scarce, especially in developing countries. AIM: This study aims to describe IE epidemiological, clinical, and microbiological profile in a tertiary university center in South America, and to identify in-hospital mortality rate and predictors. METHODS: An observational, retrospective study of 167 patients, who fulfilled modified Duke's criteria during a six-year enrollment period, from January 2010 to December 2015. The primary outcome was defined as in-hospital mortality analyzed according to treatment received (clinical vs surgical). Multivariate analysis identified mortality predictors. RESULTS: The median age was 60 years (Q1 -Q3 50-71), and 66% were male. Echocardiogram demonstrated vegetations in 90.4%. An infective agent was identified in 76.6%, being Staphylococcus aureus (19%), Enterococcus (12%), coagulase-negative staphylococci (10%), and Streptococcus viridans (9.6%) the most prevalent. Overall in-hospital mortality was 41.9%, varying from 49.4% to 34.1%, in clinical and surgical patients, respectively (P = .047). On multivariate analysis, diabetes mellitus (odds ratio [OR], 2.5), previous structural heart disease (OR, 3.1), and mitral valve infection (OR, 2.1) were all-cause death predictors. Surgical treatment was the only variable related to a better outcomes (OR, 0.45; 95% Confidence Interval, 0.2-0.9). CONCLUSION: This study presents IE profile and all-cause mortality in a large patient's cohort, comprising a 6-years' time window, a rare initiative in developing countries. Elderly and male patients predominated, while S. aureus was the main microbiological agent. Patients conservatively treated presented higher mortality than surgically managed ones. Epidemiological studies from developing countries are essential to increase IE understanding.

Adverse Events and Risk Factors of Blood Transfusion in Cardiovascular Surgery: A Prospective Cohort Study

Abstract Background: Hemodilution, transoperative bleeding and cardiopulmonary bypass (CPB) are some of the factors associated with high transfusion rates in cardiac surgery. Objective: To analyze the incidence of blood transfusion and early postoperative outcomes in cardiac surgery patients. Methods: Cohort study of patients undergoing cardiac surgery in a university hospital, consecutively enrolled from May 2015 to February 2017. Data were prospectively collected and comparisons were made between two patients' groups: transfused and not transfused. Student's t-test, chi-square test, and logistic regression were used, and a p-value < 0.05 was considered significant. Results: Among the 271 patients evaluated, 100 (37%) required transfusion in the transoperative (32.1%) and/or postoperative periods (19.5%). The following predictors of transfusion were identified by multivariate analysis: EuroScore II (OR 1.2); chronic kidney disease (CKD) (OR 3.2); transoperative bleeding ≥ 500 mL (OR 6.7); baseline hemoglobin (Hb) ≤ 10 g/dL (OR 11.5); activated partial thromboplastin time (aPTT) (OR 1.1) and CPB duration (OR 1.03). Transfusion was associated with prolonged mechanical ventilation (≥ 24h) (2.4% vs. 23%), delirium (5.9% vs. 18%), bronchopneumonia (1.2% vs. 16%), acute renal failure (3.5% vs. 25%), acute on CKD (0.6% vs. 8%), stroke or transient ischemic attack (1.8% vs. 8%), intensive care unit stay ≥ 72 h (36% vs. 57%), longer hospital stay (8 ± 4 days vs. 16 ± 15 days), as well as increased early mortality (1.75% vs. 15%). Conclusion: EuroScore II, CKD, major transoperative bleeding, preoperative Hb and aPTT values and CPB time were independent predictors of transfusion, which was associated with a higher rate of adverse outcomes, including early mortality.

Design and implementation of a fully electronic surgery database based on Google tools: an initial experience in cardiovascular surgery. / Criação e implementação de um banco de dados cirúrgico totalmente informatizado baseado nas ferramentas Google: experiência inicial em cirurgia cardiovascular.

OBJECTIVE: to describe, in a practical and step-by-step manner, the construction of a fully electronic platform for data collection, storage, and analysis, initially proposed for cardiovascular surgery, with interfaces that are reproducible and applicable to other surgical specialties, as well as to present the initial work experience with this instrument in cardiac surgery and the preliminary results obtained after its implementation in a Brazilian tertiary university hospital. METHODS: the platform was developed based on Google tools, which are free, easy to use, and widely accessible. From the beginning of this initiative, in May 2015, to the preliminary analysis, in February 2017, data from 271 consecutive patients submitted to cardiovascular surgery were prospectively recorded and preliminarily analyzed. RESULTS: the initiative was implemented with full success, with 100% of patients included and without loss of any variable, in a database composed of more than 500 variables. The most frequent immediate postoperative complications were: atrial fibrillation (22.5%), bronchopneumonia (10.7%), delirium (10.3%), acute renal failure (10%), stroke (5%), and death (7%). Comparing mortality rates in the first and second years of the initiative, a reduction from 10.8% to 4% (p=0.042), respectively, was evidenced. CONCLUSION: the new proposal of data collection and storage presented in this work was fully feasible and effective. It may be useful to other surgical specialties that wish to develop methods to evaluate success and postoperative complication rates, as well as quality improvement programs.

OBJETIVO: descrever de maneira prática e detalhada a criação de uma plataforma totalmente informatizada para coleta, armazenamento e análise de dados, inicialmente proposta para cirurgia cardiovascular, com interfaces reprodutíveis e aplicáveis a outras especialidades cirúrgicas, bem como, apresentar a experiência inicial de trabalho com esta ferramenta e os resultados preliminares obtidos após sua implementação em um hospital universitário terciário brasileiro. MÉTODOS: a plataforma foi desenvolvida com base nas ferramentas Google, gratuitas, de fácil utilização e amplamente acessíveis. Desde o início desta iniciativa, em maio de 2015, até a análise preliminar, em fevereiro de 2017, dados de 271 pacientes, consecutivos, submetidos à cirurgia cardiovascular foram prospectivamente recordados e analisados. RESULTADOS: a iniciativa foi implementada com pleno sucesso, com 100% dos pacientes incluídos e sem perda de qualquer variável em um banco de dados composto por mais de 500 variáveis. As complicações pós-operatórias imediatas mais frequentes foram: fibrilação atrial (22,5%), broncopneumonia (10,7%), delirium (10,3%), insuficiência renal aguda (10%), acidente vascular encefálico (5%) e morte (7%). Comparando-se as taxas de mortalidade no primeiro e segundo anos da iniciativa, uma redução de 10,8% para 4% (p=0,042), respectivamente, foi evidenciada. CONCLUSÃO: a nova proposta de coleta e armazenamento de dados apresentada neste trabalho mostrou-se plenamente factível e efetiva. Por serem gratuitas, de fácil manuseio e universalmente acessíveis, estas ferramentas podem ser úteis a outras especialidades cirúrgicas que desejem desenvolver métodos de avaliação de sucesso e complicações pós-operatórios, bem como, programas de melhoria de qualidade.

Criação e implementação de um banco de dados cirúrgico totalmente informatizado baseado nas ferramentas Google: experiência inicial em cirurgia cardiovascular / Design and implementation of a fully electronic surgery database based on Google tools: an initial experience in cardiovascular surgery

RESUMO Objetivo: descrever de maneira prática e detalhada a criação de uma plataforma totalmente informatizada para coleta, armazenamento e análise de dados, inicialmente proposta para cirurgia cardiovascular, com interfaces reprodutíveis e aplicáveis a outras especialidades cirúrgicas, bem como, apresentar a experiência inicial de trabalho com esta ferramenta e os resultados preliminares obtidos após sua implementação em um hospital universitário terciário brasileiro. Métodos: a plataforma foi desenvolvida com base nas ferramentas Google, gratuitas, de fácil utilização e amplamente acessíveis. Desde o início desta iniciativa, em maio de 2015, até a análise preliminar, em fevereiro de 2017, dados de 271 pacientes, consecutivos, submetidos à cirurgia cardiovascular foram prospectivamente recordados e analisados. Resultados: a iniciativa foi implementada com pleno sucesso, com 100% dos pacientes incluídos e sem perda de qualquer variável em um banco de dados composto por mais de 500 variáveis. As complicações pós-operatórias imediatas mais frequentes foram: fibrilação atrial (22,5%), broncopneumonia (10,7%), delirium (10,3%), insuficiência renal aguda (10%), acidente vascular encefálico (5%) e morte (7%). Comparando-se as taxas de mortalidade no primeiro e segundo anos da iniciativa, uma redução de 10,8% para 4% (p=0,042), respectivamente, foi evidenciada. Conclusão: a nova proposta de coleta e armazenamento de dados apresentada neste trabalho mostrou-se plenamente factível e efetiva. Por serem gratuitas, de fácil manuseio e universalmente acessíveis, estas ferramentas podem ser úteis a outras especialidades cirúrgicas que desejem desenvolver métodos de avaliação de sucesso e complicações pós-operatórios, bem como, programas de melhoria de qualidade.

ABSTRACT Objective: to describe, in a practical and step-by-step manner, the construction of a fully electronic platform for data collection, storage, and analysis, initially proposed for cardiovascular surgery, with interfaces that are reproducible and applicable to other surgical specialties, as well as to present the initial work experience with this instrument in cardiac surgery and the preliminary results obtained after its implementation in a Brazilian tertiary university hospital. Methods: the platform was developed based on Google tools, which are free, easy to use, and widely accessible. From the beginning of this initiative, in May 2015, to the preliminary analysis, in February 2017, data from 271 consecutive patients submitted to cardiovascular surgery were prospectively recorded and preliminarily analyzed. Results: the initiative was implemented with full success, with 100% of patients included and without loss of any variable, in a database composed of more than 500 variables. The most frequent immediate postoperative complications were: atrial fibrillation (22.5%), bronchopneumonia (10.7%), delirium (10.3%), acute renal failure (10%), stroke (5%), and death (7%). Comparing mortality rates in the first and second years of the initiative, a reduction from 10.8% to 4% (p=0.042), respectively, was evidenced. Conclusion: the new proposal of data collection and storage presented in this work was fully feasible and effective. It may be useful to other surgical specialties that wish to develop methods to evaluate success and postoperative complication rates, as well as quality improvement programs.

Aortic Valve Replacement Combined with Ascending Aortic Aneurysmectomy in a Patient with Sickle Cell Disease: a Case Report.

Sickle cell anemia is a haematological disorder characterized by multiple vaso-occlusive complications, resulting in a reduced life expectancy. These patients are exposed to several triggering factors for sickle cell crises when they are submitted to cardiovascular surgeries with extracorporeal circulation. Therefore, meticulous care and perioperative management are required. This paper reports a successful case of combined cardiovascular surgery - aortic valve replacement and ascending aortic aneurysmectomy - with no serious post-operative complications. In this report, we emphasize the peculiarities of perioperative care in patients with sickle cell anemia.

Aortic valve replacement combined with ascending aortic aneurysmectomy in a patient with sickle cell disease: a case report

Abstract Sickle cell anemia is a haematological disorder characterized by multiple vaso-occlusive complications, resulting in a reduced life expectancy. These patients are exposed to several triggering factors for sickle cell crises when they are submitted to cardiovascular surgeries with extracorporeal circulation. Therefore, meticulous care and perioperative management are required. This paper reports a successful case of combined cardiovascular surgery - aortic valve replacement and ascending aortic aneurysmectomy - with no serious post-operative complications. In this report, we emphasize the peculiarities of perioperative care in patients with sickle cell anemia.

Performance evaluation of phase angle and handgrip strength in patients undergoing cardiac surgery: Prospective cohort study.

BACKGROUND AND AIMS: The phase angle (PA), derived from bioelectrical impedance analysis (BIA), has been interpreted as a cell membrane integrity indicator, while handgrip strength (HGS) has been used as a prognostic indicator in certain clinical situations, such as in cardiac, oncologic patients with renal disease, hemodialysis patients, HIV-positive patients, and liver disease patients. In addition to prognostic scores, body changes due to surgical procedures indicate the importance of measuring muscle function and cell integrity. This study aimed to evaluate the behaviour of PA and HGS in patients undergoing cardiac surgery and associate these factors with clinical outcomes and prognosis. METHODS: This was a prospective cohort study of 50 consecutively recruited patients (aged ≥18 years) undergoing cardiac surgery. Measures PA and HGS were at three set points: preoperative, at hospital discharge and three months postoperative. The following data were collected: time of cardiopulmonary bypass (CPB), ischemia, mechanical ventilation (MV), Intensive Care Unit (ICU) length of stay (LOS) and hospital LOS after surgery; the EuroSCORE was also calculated. RESULTS: A decrease in PA was observed between the preoperative and the two postoperative stages (p<0.001). There was a reduction in HGS between the preoperative and hospital discharge assessments (p<0.001) and a recovery three months postoperative (p<0.001). The MV and EuroSCORE were inversely associated with PA and HGS in all three assessments. The PA was correlated with EuroSCORE in the first assessment (p=0.007) and in the second and third assessments (p<0.001), as well as with MV in all three assessments (p<0.001). The HGS was correlated with EuroSCORE and MV in the first and second assessments (p<0.001) and in the third assessment (p=0.010 and p=0.018, respectively). CONCLUSION: PA and HGS appear to be related to MV time, ICU LOS and hospital LOS after surgery in patients undergoing cardiac surgery.

Spontaneous Left Anterior Descending Coronary Artery Dissection Requiring Coronary Artery Bypass Surgery.

INTRODUCTION: Spontaneous coronary artery dissection is a sudden separation between the layers of a coronary artery wall, non-iatrogenic or trauma related, that has been recognized as an important cause of myocardial infarction. OBJECTIVE: To report an emblematic case, in terms of angiographic images, clinical presentation and predisposing factors, whose clinical management failure led to surgical intervention. METHODS: A previously healthy 48-year-old male farmer was admitted to the emergency room complaining of anterior chest pain described as "tearing", which started after physical exertion. Anterior wall ST-segment depression was observed in the electrocardiogram and troponin levels were increased. The patient then underwent coronary catheterization. Angiography showed a tortuous left anterior descending coronary artery with a dissection line involving proximal and middle segments, resulting in mild to moderate luminal stenosis. At first, a conservative approach was chosen. Control cardiac catheterization, 3 months later, showed dissection progression to the distal segment. RESULTS: The patient was referred to surgical treatment. Internal thoracic artery and a great saphenous vein graft were used to revascularize the target vessels. He had an uneventful postoperative course. CONCLUSION: In this report, we describe a typical clinical manifestation of an uncommon cause of acute myocardial infarction. The dissection was started by an extreme physical effort, which is a known triggering factor. Management of these cases is always challenging because there are no evidence-based therapies or guideline-based recomendations.

Spontaneous left anterior descending coronary artery dissection requiring coronary artery bypass surgery

Abstract Introduction: Spontaneous coronary artery dissection is a sudden separation between the layers of a coronary artery wall, non-iatrogenic or trauma related, that has been recognized as an important cause of myocardial infarction. Objective: To report an emblematic case, in terms of angiographic images, clinical presentation and predisposing factors, whose clinical management failure led to surgical intervention. Methods: A previously healthy 48-year-old male farmer was admitted to the emergency room complaining of anterior chest pain described as "tearing", which started after physical exertion. Anterior wall ST-segment depression was observed in the electrocardiogram and troponin levels were increased. The patient then underwent coronary catheterization. Angiography showed a tortuous left anterior descending coronary artery with a dissection line involving proximal and middle segments, resulting in mild to moderate luminal stenosis. At first, a conservative approach was chosen. Control cardiac catheterization, 3 months later, showed dissection progression to the distal segment. Results: The patient was referred to surgical treatment. Internal thoracic artery and a great saphenous vein graft were used to revascularize the target vessels. He had an uneventful postoperative course. Conclusion: In this report, we describe a typical clinical manifestation of an uncommon cause of acute myocardial infarction. The dissection was started by an extreme physical effort, which is a known triggering factor. Management of these cases is always challenging because there are no evidence-based therapies or guideline-based recomendations.

Incidence and factors associated with pericardial effusion after cardiac valve surgery

Introduction: Pericardial effusion (PE) is a postoperative complication of cardiac valve surgery, related to early hospital readmissions and death. We aimed to describe its incidence and to identify predictive factors of moderate-to-severe PE in a contemporary cohort. Methods: We retrospectively reviewed medical records of all consecutive patients submitted to cardiac valve surgery in a tertiary teaching hospital from January 2012 to July 2014, where echocardiography was routinely performed before patient discharge. Moderate-to-severe PE was defined as ≥ 10 mm of thickness, or signs of cardiac tamponade on echocardiography. Additional clinical and perioperative data were extracted from medical records using a standardized protocol. Results: Of 353 patients, 335 underwent a predischarge echocardiography. From these, 27 patients (8%; mean age: 62 years; standard deviation 12 years; 70% male) had moderate-to-severe PE. These patients had a higher prevalence of previous stroke (22% vs. 8%; p = 0.009) and oral anticoagulation (international normalized ratio > 2) prior to the surgery (11 vs. 2%; P = 0.002). In patients with moderate-to-severe PE, surgeries had longer ischemia (p < 0.001) and cardiopulmonary bypass (p < 0.001) times, and the prevalence of postoperative atrial fibrillation was higher (56% vs. 32%; p = 0.011) than in patients with absent or small PE. Hospital mortality was also higher (15% vs. 3%; p = 0.002) in patients with moderate-to-severe PE. Conclusions: Eight percent of patients submitted to cardiac valve surgery developed moderate-to-severe PE. Moreover, PE was associated with pre- and post-surgery conditions likely related to the coagulation state, though a cause-effect relationship could not be inferred. Noteworthy, this condition was associated with higher in-hospital morbidity and mortality(AU)

Comparison of clinical outcomes in patients undergoing mitral valve replacement with mechanical or biological substitutes: a 20 years cohort.

BACKGROUND: The choice of prosthesis for mitral valve replacement still remains controversial. This study assessed mortality, bleeding events and reoperation in patients who underwent mitral valve replacement surgery with biological or mechanical substitutes. METHODS: A total of 352 patients who underwent mitral valve replacement surgery between 1990 and 2008 with 5 to 23 years of follow-up were retrospectively evaluated in a cohort study. RESULTS: The 5, 10, 15 and 20 year survival rates after surgery using a mechanical substitute were 87.7%, 74.2%, 69.3% and 69.3%, respectively, while after surgery with a biological substitute, they were 87.6%, 71.0%, 64.2% and 56.6%, respectively. There was no significant difference between the two groups (p = 0.38). In the multivariate analysis, the factors associated with death were age, bleeding events and renal failure. The probabilities of remaining free of reoperation at 5, 10, 15 and 20 years after surgery using a mechanical substitute were 94.4%, 92.7%, 92.7% and 92.7%; after surgery with a bioprosthesis, they were 95.9%, 86.4%, 81.2% and 76.5%, respectively (p = 0.073). There was a significantly higher incidence of reoperation for the bioprosthetic valve replacement group (p = 0.008). The probabilities of remaining free of bleeding events at 5, 10, 15 and 20 years after surgery using a mechanical substitute were 95.0%, 91.0%, 89.6% and 89.6%, respectively, while after surgery with a bioprosthesis, they were 96.9%, 94.0%, 94.0% and 94.0%, (p = 0.267). CONCLUSIONS: The authors concluded that: 1) mortality during follow-up was statistically similar for both groups; 2) there was a greater tendency to reoperation in the bioprosthesis group; 3) the probability of remaining free from reoperation remained unchanged after 10 years' follow-up for patients with mechanical substitute valves; 4) the probability of remaining fee from bleeding events remained unchanged after 10 years' follow-up for patients given bioprostheses; 5) the baseline characteristics of patients were the greatest determinants of later mortality after surgery; 6) the type of prosthesis was not an independent predictive factor of any of the outcomes tested in the multivariate analysis.

Mediastinitis: mortality rate comparing single-stage surgical approach and preconditioning of wound.

OBJECTIVE: This study aims to compare hospital mortality rate of surgical debridement followed by primary wound closure versus surgical debridement with closure after preconditioning of the wound. METHODS: A historical cohort of 43 patients with postoperative mediastinitis type III and IV between 2000 and 2008. The diagnosis of mediastinitis was based on physical examination and laboratory tests. Patients were divided into two groups: patients who received the protocol of preconditioning of the wound (Group 2) and those who did not (Group 1). RESULTS: Of the 43 patients, 15 received the protocol and were assigned to Group 2, and 28 patients to Group 1. Myocardial revascularisation was the surgical intervention most affected by infection, accounting for 69.8% of patients in Group 1 and 64.3% in Group 2.Staphylococcus aureus was the predominant pathogen, accounting for 58.1% of all cases, 50% in Group 1 and 73.3% in Group 2. Hospital mortality rate was 42.9% in Group 1 and 20% in Group 2 (P=1.86), with relative risk of 2.14 and CI [0.714-6.043]. Among the 28 (65.1%) patients who underwent single-stage surgical approach, 12 (27.9%) underwent primary wound closure with irrigation, seven (16.3%) only primary closure, six (14%) omental flap, and three (7%) pectoralis muscle flap. CONCLUSION: Due to the lack of established guidelines, the choice of the surgical approach is based largely on low-level evidence references. Preconditioning of the wound appears to lead to a reduction in mortality in these patients, being a good surgical option.

Mediastinitis: mortality rate comparing single-stage surgical approach and preconditioning of wound / Mediastinite: mortalidade comparando abordagem cirúrgica em tempo único e o pré-condicionamento da ferida operatória

OBJECTIVE: This study aims to compare hospital mortality rate of surgical debridement followed by primary wound closure versus surgical debridement with closure after preconditioning of the wound. METHODS: A historical cohort of 43 patients with postoperative mediastinitis type III and IV between 2000 and 2008. The diagnosis of mediastinitis was based on physical examination and laboratory tests. Patients were divided into two groups: patients who received the protocol of preconditioning of the wound (Group 2) and those who did not (Group 1). RESULTS: Of the 43 patients, 15 received the protocol and were assigned to Group 2, and 28 patients to Group 1. Myocardial revascularisation was the surgical intervention most affected by infection, accounting for 69.8% of patients in Group 1 and 64.3% in Group 2.Staphylococcus aureus was the predominant pathogen, accounting for 58.1% of all cases, 50% in Group 1 and 73.3% in Group 2. Hospital mortality rate was 42.9% in Group 1 and 20% in Group 2 (P=1.86), with relative risk of 2.14 and CI [0.714-6.043]. Among the 28 (65.1%) patients who underwent single-stage surgical approach, 12 (27.9%) underwent primary wound closure with irrigation, seven (16.3%) only primary closure, six (14%) omental flap, and three (7%) pectoralis muscle flap. CONCLUSION: Due to the lack of established guidelines, the choice of the surgical approach is based largely on low-level evidence references. Preconditioning of the wound appears to lead to a reduction in mortality in these patients, being a good surgical option.

OBJETIVO: Este estudo tem por objetivo comparar a taxa de mortalidade intra-hospitalar do debridamento cirúrgico seguido de fechamento da ferida operatória, com a do debridamento cirúrgico com fechamento após pré-condicionamento da ferida. MÉTODOS: Coorte histórica composta por 43 pacientes portadores de mediastinite pós-operatória tipo III e IV entre os anos de 2000 e 2008. O diagnóstico de mediastinite foi feito com base em exames físico e laboratoriais. Os pacientes foram divididos em dois grupos, os que seguiram o protocolo de pré-condicionamento da ferida operatória (Grupo 2) ou não (Grupo 1). RESULTADOS: Dos 43 pacientes, 15 seguiram o protocolo e foram alocados no Grupo 2. A revascularização do miocárdio foi a cirurgia mais afetada pela infecção, sendo responsável por 69,8% dos pacientes no Grupo 1 e 64,3% no Grupo 2. O Staphylococcus aureus foi o germe mais prevalente, sendo responsável por 58,1% do total dos casos, sendo 50% e 73,3%, respectivamente, nos Grupos 1 e 2. A mortalidade intra-hospitalar foi de 42,9% no Grupo 1 e de 20% no Grupo 2 (P=1,86), com risco relativo de 2,14 e IC [0,714-6,043]. Entre os 28 (65,1%) pacientes do estudo que seguiram a abordagem cirúrgica em um único tempo, 12 (27,9%) foram submetidos a fechamento primário com irrigação, sete (16,3%), a fechamento primário isolado, seis (14%), rotação de retalho de epíplon, e três (7%), interposição de retalho de músculo peitoral. CONCLUSÃO: Na ausência de uma diretriz bem estabelecida, a escolha do tipo de intervenção cirúrgica é feita utilizando-se referências com baixo nível de evidência. O pré-condicionamento da ferida operatória parece levar a redução da mortalidade nesses pacientes, sendo uma boa alternativa cirúrgica.