Markers of Tissue Perfusion as Predictors of Adverse Outcomes in Patients with Left Ventricular Dysfunction Undergoing Coronary Artery Bypass Surgery. / Marcadores de Perfusão Tecidual como Preditores de Desfechos Adversos em Pacientes com Disfunção Ventricular Esquerda Submetidos à Revascularização Miocárdica (Bypass Coronário).

BACKGROUND: Cardiac surgery patients may be exposed to tissue hypoperfusion and anaerobic metabolism. OBJECTIVE: To verify whether the biomarkers of tissue hypoperfusion have predictive value for prolonged intensive care unit (ICU) stay in patients with left ventricular dysfunction who underwent coronary artery bypass surgery. METHODS: After approval by the institution's Ethics Committee and the signing of informed consent, 87 patients with left ventricular dysfunction (ejection fraction < 50%) undergoing coronary artery bypass surgery were enrolled. Hemodynamic and metabolic biomarkers were collected at five time points: after anesthesia, at the end of the surgery, at ICU admission, and at six and twelve hours after. An analysis of variance for repeated measures followed by a Bonferroni post hoc test was used for repeated, continuous variables (hemodynamic and metabolic variables) to determine differences between the two groups over the course of the study period. The level of statistical significance adopted was 5%. RESULTS: Thirty-eight patients (43.7%) who presented adverse outcomes were older, higher Euro score (p<0.001), and elevated ΔpCO2 as analyzed 12 hours after ICU admission (p<0.01), while increased arterial lactate concentration at 6 hours postoperatively was found to be a negative predictive factor (p<0.01). CONCLUSIONS: Euro SCORE, six-hour postoperative arterial lactate, 12-hour postoperative ΔPCO2, and eRQ are independent predictors of adverse outcomes in patients with left ventricular dysfunction after cardiac surgery.

FUNDAMENTO: Pacientes submetidos à cirurgia cardíaca podem estar expostos à hipoperfusão tecidual e metabolismo anaeróbico. OBJETIVO: Verificar se os biomarcadores de hipoperfusão tecidual têm valor preditivo para permanência prolongada na Unidade de Terapia Intensiva (UTI) em pacientes com disfunção ventricular esquerda submetidos à cirurgia de bypass da artéria coronária. MÉTODOS: Após aprovação pelo comitê de ética institucional e assinatura do termo de consentimento, 87 pacientes com disfunção ventricular esquerda (fração de ejeção <50%) submetidos à cirurgia de bypass coronário foram incluídos. Biomarcadores hemodinâmicos e metabólicos foram coletados em cinco momentos: após anestesia, ao final da cirurgia, na admissão na UTI, e a seis e 12 horas depois. Uma análise de variância para medidas repetidas seguida de um teste post-hoc de Bonferroni foi usado para variáveis contínuas repetidas (variáveis metabólicas e hemodinâmicas) para determinar diferenças entre os dois grupos ao longo do estudo. O nível de significância adotado foi de 5%. RESULTADOS: Trinta e oito pacientes (43,7%) que apresentaram desfechos adversos eram mais velhos, apresentaram um Euroscore mais alto (p<0,001), e gradiente venoarterial de CO2 (ΔPCO2) elevado, analisados 12 horas após a admissão na UTI (p<0,01), enquanto uma concentração de lactato arterial aumentada seis horas após a cirurgia foi um fator preditivo negativo (p<0,01). CONCLUSÕES: EuroSCORE, lactato arterial seis horas após a cirurgia, ΔPCO212 horas após a cirurgia e QRe são preditores independentes de desfechos adversos em pacientes com disfunção ventricular esquerda após cirurgia cardíaca.

Human Saphenous Vein Endothelial Cell Isolation and Exposure to Controlled Levels of Shear Stress and Stretch.

Coronary artery bypass graft (CABG) surgery is a procedure to revascularize ischemic myocardium. Saphenous vein remains used as a CABG conduit despite the reduced long-term patency compared to arterial conduits. The abrupt increase of hemodynamic stress associated with the graft arterialization results in vascular damage, especially the endothelium, that may influence the low patency of the saphenous vein graft (SVG). Here, we describe the isolation, characterization, and expansion of human saphenous vein endothelial cells (hSVECs). Cells isolated by collagenase digestion display the typical cobblestone morphology and express endothelial cell markers CD31 and VE-cadherin. To assess the mechanical stress influence, protocols were used in this study to investigate the two main physical stimuli, shear stress and stretch, on arterialized SVGs. hSVECs are cultured in a parallel plate flow chamber to produce shear stress, showing alignment in the direction of the flow and increased expression of KLF2, KLF4, and NOS3. hSVECs can also be cultured in a silicon membrane that allows controlled cellular stretch mimicking venous (low) and arterial (high) stretch. Endothelial cells' F-actin pattern and nitric oxide (NO) secretion are modulated accordingly by the arterial stretch. In summary, we present a detailed method to isolate hSVECs to study the influence of hemodynamic mechanical stress on an endothelial phenotype.

Immediate Results after Multiple Arterial Grafts in Coronary Artery Bypass Graft Surgery in the São Paulo State: Cross Cohort Study. / Resultados Imediatos após Múltiplos Enxertos Arteriais em Cirurgia de Revascularização Miocárdica no Estado de São Paulo: Estudo de Coorte.

BACKGROUND: The short-term results after using arterial grafts still raise questions and doubts for medical society. OBJECTIVE: To compare the immediate outcomes of patients undergoing single arterial graft versus multiple arterial grafts coronary artery bypass grafting surgery. METHODS: Cross-sectional cohort study in the São Paulo Registry of Cardiovascular Surgery II (REPLICCAR II). Perioperative data from 3122 patients were grouped by the number of arterial grafts used, and their outcomes were compared: reoperation, deep sternal wound infection (DSWI), stroke, acute kidney injury, prolonged intubation (>24 hours), short hospital stay (<6 days), prolonged hospital stay (>14 days), morbidity and mortality. Propensity Score Matching (PSM) matched 1062 patients, adjusted for the mortality risk. RESULTS: After PSM, the single arterial graft group showed patients with advanced age, more former smokers, hypertension, diabetes, stable angina, and previous myocardial infarction. In the multiple arterial grafts, there was a predominance of males, recent pneumonia, and urgent surgeries. After the procedure, there was a higher incidence of pleural effusion (p=0.042), pneumonia (p=0.01), reintubation (p=0.006), DSWI (p=0.007), and sternal debridement (p=0.015) in the multiple arterial grafts group, however, less need for blood transfusion (p=0.005), extremity infections (p=0.002) and shorter hospital stays (p=0.036). Bilateral use of the internal thoracic artery was not related to increased DSWI rate, but glycosylated hemoglobin >6.40% (p=0.048). CONCLUSION: Patients undergoing the multiarterial technique had a higher incidence of pulmonary complications, and DSWI, where glycosylated hemoglobin ≥6.40%, had a greater influence on the infectious outcome than the choice of grafts.

FUNDAMENTO: Os resultados a curto prazo após o uso de enxertos arteriais ainda suscitam questionamentos e dúvidas na sociedade médica. OBJETIVO: Comparar os resultados imediatos de pacientes submetidos à cirurgia de revascularização do miocárdio com enxerto arterial único versus enxertos arteriais múltiplos. MÉTODOS: Estudo de coorte transversal no Registro Paulista de Cirurgia Cardiovascular II (REPLICCAR II). Os dados perioperatórios de 3122 pacientes foram agrupados pelo número de enxertos arteriais utilizados e seus desfechos foram comparados: reoperação, infecção profunda da ferida torácica (IPFT), acidente vascular cerebral, lesão renal aguda, intubação prolongada (>24 horas), tempo de internação curta (<6 dias), tempo de internação prolongada (>14 dias), morbidade e mortalidade. O Propensity Score Matching (PSM) correspondeu a 1062 pacientes, ajustado para o risco de mortalidade. RESULTADOS: Após PSM, o grupo enxerto arterial único apresentou pacientes com idade avançada, mais ex-fumantes, hipertensos, diabéticos, portadores de angina estável e infarto do miocárdio prévio. Nos enxertos arteriais múltiplos houve predomínio do sexo masculino, pneumonia recente e cirurgias de urgência. Após o procedimento, houve maior incidência de derrame pleural (p=0,042), pneumonia (p=0,01), reintubação (p=0,006), IPFT (p=0,007) e desbridamento esternal (p=0,015) no grupo de enxertos multiarteriais, porém, menor necessidade de hemotransfusão (p=0,005), infecções de extremidades (p=0,002) e menor tempo de internação (p=0,036). O uso bilateral da artéria torácica interna não foi relacionado ao aumento da taxa de IPFT, e sim a hemoglobina glicosilada >6,40% (p=0,048). CONCLUSÃO: Pacientes submetidos a técnica multiarterial apresentaram maior incidência de complicações pulmonares e IPFT, sendo que a hemoglobina glicosilada ≥6,40% teve maior influência no resultado infeccioso do que a escolha dos enxertos.

Additional improvement in regional myocardial ischemia after intracardiac injection of bone marrow cells during CABG surgery.

Background: Post-procedure residual ischemia is associated with worse prognosis in patients with coronary artery diasease (CAD). Objective: We evaluated whether autologous bone marrow-derived cells (BMC) contribute to additional reduction in regional stress-induced myocardial ischemia (SIMI) in patients undergoing incomplete coronary artery bypass graft surgery (CABG). Methods: In a double-blind, randomized, placebo-controlled trial, we enrolled 143 patients (82% men, 58 ± 11 years) with stable CAD and not candidates for complete CABG. They received 100 million BMC (n = 77) or placebo (n = 66) injected into ischemic non-revascularized segments during CABG. The primary outcome was improvement on SIMI quantified as the area at risk in injected segments assessed by cardiovascular magnetic resonance (CMR) 1, 6, and 12 months after CABG. Results: The reduction in global SIMI after CABG was comparable (p = 0.491) in both groups indicating sustained beneficial effects of the surgical procedure over 12 month period. In contrast, we observed additional improvement in regional SIMI in BMC treated group (p = 0.047). Baseline regional SIMI values were comparable [18.5 (16.2-21.0) vs. 18.5 (16.5-20.7)] and reached the lowest values at 1 month [9.74 (8.25; 11.49) vs. 12.69 (10.84; 14.85)] for BMC and placebo groups, respectively. The ischemia's improvement from baseline represented a 50% difference in regional SIMI in favor of the BMC transplanted group at 30 days. We found no differences in clinical and LVEF% between groups during the 12 month follow-up period. The 1 month rate of major adverse cerebral and cardiovascular events (MACCE) (p = 0.34) and all-cause mortality (p = 0.08) did not differ between groups 1 month post intervention. Conclusion: We provided evidence that BMC leads to additional reduction in regional SIMI in chronic ischemic patients when injected in segments not subjected to direct surgical revascularization. This adjuvant therapy deserves further assessment in patients with advanced CAD especially in those with microcirculation dysfunction. Clinical trial registration: https://clinicaltrials.gov/, identifier NCT01727063.

MiRNA-30d and miR-770-5p as potential clinical risk predictors of Vasoplegic Syndrome in Patients undergoing on-pump coronary artery bypass grafting.

The aims of this study were to perform pre-surgery miRNA profiling of patients who develop Vasoplegic syndrome (VS) after coronary artery bypass grafting (CABG) and identify those miRNAs that could be used as VS prognostic tools and biomarkers. The levels of 754 microRNAs (miRNAs) were measured in whole blood samples from a cohort of patients collected right before the coronary artery bypass grafting (CABG) surgery. We compared the miRNA levels of those who developed VS (VASO group) with those who did not (NONVASO group) after surgery. Six miRNAs (hsa-miR-548c-3p, -199b-5p, -383-5p -571 -183-3p, -30d-5p) were increased and two (hsa-1236-3p, and hsa-miR770-5p) were decreased in blood of VASO compared to NONVASO groups. Receiver Operating Characteristic (ROC) curve analysis revealed that a combination of the miRNAs, hsa-miR-30d-5p and hsa-miR-770-5p can be used as VS predictors (AUC = 0.9615, p < 0.0001). The computational and functional analyses were performed to gain insights into the potential role of these dysregulated miRNAs in VS and have identified the "Apelin Liver Signaling Pathway" as the canonical pathway containing the most target genes regulated by these miRNAs. The expression of the combined miRNAs hsa-miR-30d and hsa-miR-770-5p allowed the ability to distinguish between patients who could and could not develop VS, representing a potential predictive biomarker of VS.

Resultados Imediatos após Múltiplos Enxertos Arteriais em Cirurgia de Revascularização Miocárdica no Estado de São Paulo: Estudo de Coorte / Immediate Results after Multiple Arterial Grafts in Coronary Artery Bypass Graft Surgery in the São Paulo State: Cross Cohort Study

Resumo Fundamento Os resultados a curto prazo após o uso de enxertos arteriais ainda suscitam questionamentos e dúvidas na sociedade médica. Objetivo Comparar os resultados imediatos de pacientes submetidos à cirurgia de revascularização do miocárdio com enxerto arterial único versus enxertos arteriais múltiplos. Métodos Estudo de coorte transversal no Registro Paulista de Cirurgia Cardiovascular II (REPLICCAR II). Os dados perioperatórios de 3122 pacientes foram agrupados pelo número de enxertos arteriais utilizados e seus desfechos foram comparados: reoperação, infecção profunda da ferida torácica (IPFT), acidente vascular cerebral, lesão renal aguda, intubação prolongada (>24 horas), tempo de internação curta (<6 dias), tempo de internação prolongada (>14 dias), morbidade e mortalidade. O Propensity Score Matching (PSM) correspondeu a 1062 pacientes, ajustado para o risco de mortalidade. Resultados Após PSM, o grupo enxerto arterial único apresentou pacientes com idade avançada, mais ex-fumantes, hipertensos, diabéticos, portadores de angina estável e infarto do miocárdio prévio. Nos enxertos arteriais múltiplos houve predomínio do sexo masculino, pneumonia recente e cirurgias de urgência. Após o procedimento, houve maior incidência de derrame pleural (p=0,042), pneumonia (p=0,01), reintubação (p=0,006), IPFT (p=0,007) e desbridamento esternal (p=0,015) no grupo de enxertos multiarteriais, porém, menor necessidade de hemotransfusão (p=0,005), infecções de extremidades (p=0,002) e menor tempo de internação (p=0,036). O uso bilateral da artéria torácica interna não foi relacionado ao aumento da taxa de IPFT, e sim a hemoglobina glicosilada >6,40% (p=0,048). Conclusão Pacientes submetidos a técnica multiarterial apresentaram maior incidência de complicações pulmonares e IPFT, sendo que a hemoglobina glicosilada ≥6,40% teve maior influência no resultado infeccioso do que a escolha dos enxertos.

Abstract Background The short-term results after using arterial grafts still raise questions and doubts for medical society. Objective To compare the immediate outcomes of patients undergoing single arterial graft versus multiple arterial grafts coronary artery bypass grafting surgery. Methods Cross-sectional cohort study in the São Paulo Registry of Cardiovascular Surgery II (REPLICCAR II). Perioperative data from 3122 patients were grouped by the number of arterial grafts used, and their outcomes were compared: reoperation, deep sternal wound infection (DSWI), stroke, acute kidney injury, prolonged intubation (>24 hours), short hospital stay (<6 days), prolonged hospital stay (>14 days), morbidity and mortality. Propensity Score Matching (PSM) matched 1062 patients, adjusted for the mortality risk. Results After PSM, the single arterial graft group showed patients with advanced age, more former smokers, hypertension, diabetes, stable angina, and previous myocardial infarction. In the multiple arterial grafts, there was a predominance of males, recent pneumonia, and urgent surgeries. After the procedure, there was a higher incidence of pleural effusion (p=0.042), pneumonia (p=0.01), reintubation (p=0.006), DSWI (p=0.007), and sternal debridement (p=0.015) in the multiple arterial grafts group, however, less need for blood transfusion (p=0.005), extremity infections (p=0.002) and shorter hospital stays (p=0.036). Bilateral use of the internal thoracic artery was not related to increased DSWI rate, but glycosylated hemoglobin >6.40% (p=0.048). Conclusion Patients undergoing the multiarterial technique had a higher incidence of pulmonary complications, and DSWI, where glycosylated hemoglobin ≥6.40%, had a greater influence on the infectious outcome than the choice of grafts.

Quality improvement program in Latin America decreases mortality after cardiac surgery: a before-after intervention study.

BACKGROUND: The current challenge of cardiac surgery (CS) is to improve outcomes in adverse scenarios. The aim of this study was to assess the impact of a quality improvement program (QIP) on hospital mortality in the largest CS center in Latin America. METHODS: Patients were divided into two groups: before (Jan 2013-Dec 2015, n = 3534) and after establishment of the QIP (Jan 2017-Dec 2019, n = 3544). The QIP consisted of the implementation of 10 central initiatives during 2016. The procedures evaluated were isolated coronary artery bypass grafting surgery (CABG), mitral valve surgery, aortic valve surgery, combined mitral and aortic valve surgery, and CABG associated with heart valve surgery. Propensity Score Matching (PSM) was used to adjust for inequality in patients' preoperative characteristics before and after the implementation of QIP. A multivariate logistic regression model was built to predict hospital mortality and validated using discrimination and calibration metrics. RESULTS: The PMS paired two groups using 5 variables, obtaining 858 patients operated before (non-QIP) and 858 patients operated after the implementation of the QIP. When comparing the QIP versus Non-QIP group, there was a shorter length of stay in all phases of hospitalization. In addition, the patients evolved with less anemia (P = 0.001), use of intra-aortic balloon pump (P = 0.003), atrial fibrillation (P = 0.001), acute kidney injury (P < 0.001), cardiogenic shock (P = 0.011), sepsis (P = 0.046), and hospital mortality (P = 0.001). In the multiple model, among the predictors of hospital mortality, the lack of QIP increased the chances of mortality by 2.09 times. CONCLUSION: The implementation of a first CS QIP in Latin America was associated with a reduction in length of hospital stay, complications and mortality after the cardiac surgeries analyzed.

Transit-time flow measurement parameters after protamine infusion in CABG surgeries.

OBJECTIVE: The objective of this study is to evaluate protamine sulfate effects on graft's blood flow by comparing transit-time flow measurement (TTFM) values before and after protamine administration. METHODS: This is an observational study with data collected between years 2018 and 2020. Immediate graft patency was evaluated using TTFM. Only patients with TTFM parameters registered before and after protamine infusion were included. The main three parameters studied were:  mean graft flow  (MGF),  pulsatility index (PI), and  diastolic flow (DF). In the first analysis, all conduits were evaluated regardless of the surgical technique used. In a second analysis, on-pump and off-pump groups were compared. Evaluated grafts were left internal thoracic artery, saphenous vein graft (SVG), radial artery, and right internal thoracic artery. Since SVG was numerically the most used graft, an exclusive analysis was created. RESULTS: Our study included 575 patients, resulting in a total of 1686 grafts, mean 2.93 grafts/patient. Off-pump surgery was performed in 158 patients. Before protamine infusion, inadequate TTFM parameters were observed in 3.8% of grafts. Overall, after protamine administration, MGF decreased in all grafts, but its reduction was not statistically significant. PI values increased in the SVG and DF values reduced in LIMA grafts. SVG group analysis showed that after protamine PI values were higher in OM1 and RCA. DF values increased in RCA. The comparison between off and on-pump surgeries, showed that in off-pump cases TTFM measures did not present statistically significant differences. CONCLUSION: Significant variations were observed in TTFM values before and after protamine administration. Although different, those values remained within the normal reference ranges. We recommend that flow measurement should be performed before protamine infusion.

Adherence to the cardiac surgery checklist decreased mortality at a teaching hospital: A retrospective cohort study.

OBJECTIVE: To evaluate the impact of adherence to the cardiac surgical checklist on mortality at the teaching hospital. METHODS: A retrospective cohort study after the implementation of the cardiac surgical safety checklist in a reference hospital in Latin America. All patients undergoing coronary artery bypass surgery and/or heart valve surgery from 2013 to 2019 were analyzed. After the implementation of the project InCor-Checklist "Five steps to safe cardiac surgery" in 2015, the correlation between adherence and completeness of this instrument with surgical mortality was assessed. The EuroSCORE II was used as a reference to assess the risk of expected mortality for patients. Cross-sectional questionnaires were during the implementation of the InCor-Checklist. To perform the correlation, Pearson's coefficient was calculated using R software. RESULTS: Since 2013, data from 8139 patients have been analyzed. The average annual mortality was 5.98%. In 2015, the instrument was used in only 58% of patients; in contrast, it was used in 100% of patients in 2019. There was a decrease in surgical mortality from 8.22% to 3.13% for the same group of procedures. The results indicate that the greater the checklist use, the lower the surgical mortality (r = 88.9%). In addition, the greater the InCor-Checklist completeness, the lower the surgical mortality (r = 94.1%). CONCLUSION: In the formation of the surgical patient safety culture, the implementation and adherence to the InCor-Checklist "Five steps to safe cardiac surgery" was associated with decreased mortality after cardiac surgery.

Endovascular therapeutic hypothermia adjunctive to percutaneous coronary intervention in acute myocardial infarction: realistic simulation as a game changer.

BACKGROUND: Endovascular therapeutic hypothermia (ETH) reduces the damage by ischemia/reperfusion cell syndrome in cardiac arrest and has been studied as an adjuvant therapy to percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI). New available advanced technology allows cooling much faster, but there is paucity of resources for training to avoid delays in door-to-balloon time (DTB) due to ETH and subsequently coronary reperfusion, which would derail the procedure. The aim of the study was to describe the process for the development of a simulation, training & educational protocol for the multidisciplinary team to perform optimized ETH as an adjunctive therapy for STEMI. METHODS AND RESULTS: We developed an optimized simulation protocol using modern mannequins in different realistic scenarios for the treatment of patients undergoing ETH adjunctive to PCI for STEMIs starting from the emergency room, through the CathLab, and to the intensive care unit (ICU) using the Proteus® Endovascular System (Zoll Circulation Inc™, San Jose, CA, USA). The primary endpoint was door-to-balloon (DTB) time. We successfully trained 361 multidisciplinary professionals in realistic simulation using modern mannequins and sham situations in divisions of the hospital where real patients would be treated. The focus of simulation and training was logistical optimization and educational debriefing with strategies to reduce waste of time in patient's transportation from different departments, and avoiding excessive rewarming during transfer. Afterwards, the EHT protocol was successfully validated in a trial randomizing 50 patients for 18 minutes cooling before coronary recanalization at the target temperature of 32 ± 1.0 ∘C or PCI-only. A total of 35 patients underwent ETH (85.7% [30/35] in 90 ± 15 minutes), without delays in the mean door-to-balloon time for primary PCI when compared to 15 control group patients (92.1 minutes versus 87 minutes, respectively; p = 0.509). CONCLUSIONS: Realistic simulation, intensive training and educational debriefing for the multidisciplinary team propitiated feasible endovascular therapeutic hypothermia as an adjuvant therapy to primary PCI in STEMI. CLINICALTRIALS: gov: NCT02664194.

Adherence to the cardiac surgery checklist decreased mortality at a teaching hospital: A retrospective cohort study

Abstract Objectives To evaluate the impact of adherence to the cardiac surgical checklist on mortality at the teaching hospital. Methods A retrospective cohort study after the implementation of the cardiac surgical safety checklist in a reference hospital in Latin America. All patients undergoing coronary artery bypass surgery and/or heart valve surgery from 2013 to 2019 were analyzed. After the implementation of the project InCor-Checklist "Five steps to safe cardiac surgery" in 2015, the correlation between adherence and completeness of this instrument with surgical mortality was assessed. The EuroSCORE II was used as a reference to assess the risk of expected mortality for patients. Cross-sectional questionnaires were during the implementation of the InCor-Checklist. To perform the correlation, Pearson's coefficient was calculated using R software. Results Since 2013, data from 8139 patients have been analyzed. The average annual mortality was 5.98%. In 2015, the instrument was used in only 58% of patients; in contrast, it was used in 100% of patients in 2019. There was a decrease in surgical mortality from 8.22% to 3.13% for the same group of procedures. The results indicate that the greater the checklist use, the lower the surgical mortality (r = 88.9%). In addition, the greater the InCor-Checklist completeness, the lower the surgical mortality (r = 94.1%). Conclusion In the formation of the surgical patient safety culture, the implementation and adherence to the InCor-Checklist "Five steps to safe cardiac surgery" was associated with decreased mortality after cardiac surgery. HIGHLIGHTS Checklists avoid human errors and are commonly used in high-reliability industries. The "InCor Checklist" was associated with decreased mortality over time. Adherence, completeness, and sustainability within public policies are necessary.

Multivessel Woven Coronary Artery Disease.

Woven coronary disease is a rare pathology with unknown etiology. Although initially considered benign, recent publications report myocardial ischemia caused by the affected vessel. Since most patients are asymptomatic, long-term follow-up to understand its behavior is mandatory. We report a multivessel woven disease case with documented ischemia that was submitted to coronary artery bypass grafting and remained asymptomatic for two years of follow-up.

Multivessel woven coronary artery disease

Abstract Woven coronary disease is a rare pathology with unknown etiology. Although initially considered benign, recent publications report myocardial ischemia caused by the affected vessel. Since most patients are asymptomatic, long-term follow-up to understand its behavior is mandatory. We report a multivessel woven disease case with documented ischemia that was submitted to coronary artery bypass grafting and remained asymptomatic for two years of follow-up.

Correction: Mortality risk prediction in high-risk patients undergoing coronary artery bypass grafting: Are traditional risk scores accurate?

[This corrects the article DOI: 10.1371/journal.pone.0255662.].

Mortality risk prediction in high-risk patients undergoing coronary artery bypass grafting: Are traditional risk scores accurate?

BACKGROUND: The performance of traditional scores is significantly limited to predict mortality in high-risk cardiac surgery. The aim of this study was to compare the performance of STS, ESII and HiriSCORE models in predicting mortality in high-risk patients undergoing CABG. METHODS: Cross-sectional analysis in the international prospective database of high-risk patients: HiriSCORE project. We evaluated 248 patients with STS or ESII (5-10%) undergoing CABG in 8 hospitals in Brazil and China. The main outcome was mortality, defined as all deaths occurred during the hospitalization in which the operation was performed, even after 30 days. Five variables were selected as predictors of mortality in this cohort of patients. The model's performance was evaluated through the calibration-in-the-large and the receiver operating curve (ROC) tests. RESULTS: The mean age was 69.90±9.45, with 52.02% being female, 25% of the patients were on New York Heart Association (NYHA) class IV and 49.6% had Canadian Cardiovascular Society (CCS) class 4 angina, and 85.5% had urgency or emergency status. The mortality observed in the sample was 13.31%. The HiriSCORE model showed better calibration (15.0%) compared to ESII (6.6%) and the STS model (2.0%). In the ROC curve, the HiriSCORE model showed better accuracy (ROC = 0.74) than the traditional models STS (ROC = 0.67) and ESII (ROC = 0.50). CONCLUSION: Traditional models were inadequate to predict mortality of high-risk patients undergoing CABG. However, the HiriSCORE model was simple and accurate to predict mortality in high-risk patients.

Pericardial-Peritoneal Window as an Alternative Treatment for Large and Recurrent Pericardial Effusion Post-Pericardiotomy

Abstract Introduction: The presence of mild to moderate pericardial effusion after cardiac surgery is common and oral medical therapy is usually able to treat it. Larger effusions are less frequent and surgical intervention is usually necessary. However, there are some rare cases of large effusions that are recurrent even after intervention and become challenging to treat. Methods: We describe the case of a patient submitted to coronary artery bypass grafting (CABG) without any intraoperative complications, who was regularly discharged from the hospital. She was referred to our emergency department twice after surgery with large pericardial effusion that was drained. Even after those two interventions and with adequate oral medication, the large effusion recurred. Results: During follow-up, the patient had her symptoms resolved, with no need for further hospital admission. Her echocardiograms after the last intervention showed no pericardial effusion. The present surgical technique demonstrated to be easy to perform, thus it should be considered as a treatment option for these rare cases of large and repetitive effusions, which do not respond to the traditional methods. Conclusions: In challenging cases of recurrent and large pericardial effusions, the pericardial-peritoneal window is an alternative surgical technique that brings clinical improvement and diminishes the risk of cardiac tamponade.