Medical School, Cardiovascular Surgery, and Education: how we do it in Brazil's scenario?

Abstract Choosing a surgical specialty can be a hard decision for a medical student. Several studies present data showing that most medical students fear the surgical field and end up switching to another specialty. For cardiovascular surgery, the scenario is very similar. In the last decades, the interest in cardiovascular surgery has been decreasing worldwide and the cardiothoracic surgical societies across the globe have been trying to understand the factors that push away medical students and general surgical residents from the specialty. In this regard, our work aims to focus on describe the access of students to cardiovascular surgery, especially during medical school, as well as to provide a brief report of our current data regarding the specialty.

Medical School, Cardiovascular Surgery, and Education: how we do it in Brazil's scenario?

Choosing a surgical specialty can be a hard decision for a medical student. Several studies present data showing that most medical students fear the surgical field and end up switching to another specialty. For cardiovascular surgery, the scenario is very similar. In the last decades, the interest in cardiovascular surgery has been decreasing worldwide and the cardiothoracic surgical societies across the globe have been trying to understand the factors that push away medical students and general surgical residents from the specialty. In this regard, our work aims to focus on describe the access of students to cardiovascular surgery, especially during medical school, as well as to provide a brief report of our current data regarding the specialty.

Medical School, Cardiovascular Surgery, and Education: how we do it in Brazil's scenario?

Abstract: Choosing a surgical specialty can be a hard decision for a medical student. Several studies present data showing that most medical students fear the surgical field and end up switching to another specialty. For cardiovascular surgery, the scenario is very similar. In the last decades, the interest in cardiovascular surgery has been decreasing worldwide and the cardiothoracic surgical societies across the globe have been trying to understand the factors that push away medical students and general surgical residents from the specialty. In this regard, our work aims to focus on describe the access of students to cardiovascular surgery, especially during medical school, as well as to provide a brief report of our current data regarding the specialty. Keywords: Medical School. Students, Medical. Cardiac Surgery. Internship and Residency. Specialties, Surgical. Medicine.

Coronary artery bypass surgery in Brazil: analysis of the national reality through the bypass registry

Abstract Introduction: Coronary artery bypass grafting (CABG) is the most frequently performed heart surgery in Brazil. Recent international guidelines recommend that national societies establish a database on the practice and results of CABG. In anticipation of the recommendation, the BYPASS Registry was introduced in 2015. Objective: To analyze the profile, risk factors and outcomes of patients undergoing CABG in Brazil, as well as to examine the predominant surgical strategy, based on the data included in the BYPASS Registry. Methods: A cross-sectional study of 2292 patients undergoing CABG surgery and cataloged in the BYPASS Registry up to November 2018. Demographic data, clinical presentation, operative variables, and postoperative hospital outcomes were analyzed. Results: Patients referred to CABG in Brazil are predominantly male (71%), with prior myocardial infarction in 41.1% of cases, diabetes in 42.5%, and ejection fraction lower than 40% in 9.7%. The Heart Team indicated surgery in 32.9% of the cases. Most of the patients underwent cardiopulmonary bypass (87%), and cardioplegia was the strategy of myocardial protection chosen in 95.2% of the cases. The left internal thoracic artery was used as a graft in 91% of the cases; the right internal thoracic artery, in 5.6%; and the radial artery in 1.1%. The saphenous vein graft was used in 84.1% of the patients, being the only graft employed in 7.7% of the patients. The median number of coronary vessels treated was 3. Operative mortality was 2.8%, and the incidence of cerebrovascular accident was 1.2%. Conclusion: CABG data in Brazil provided by the BYPASS Registry analysis are representative of our national reality and practice. This database constitutes an important reference for indications and comparisons of therapeutic procedures, as well as to propose subsequent models to improve patient safety and the quality of surgical practice in the country.

Coronary Artery Bypass Surgery in Brazil: Analysis of the National Reality Through the BYPASS Registry.

INTRODUCTION: Coronary artery bypass grafting (CABG) is the most frequently performed heart surgery in Brazil. Recent international guidelines recommend that national societies establish a database on the practice and results of CABG. In anticipation of the recommendation, the BYPASS Registry was introduced in 2015. OBJECTIVE: To analyze the profile, risk factors and outcomes of patients undergoing CABG in Brazil, as well as to examine the predominant surgical strategy, based on the data included in the BYPASS Registry. METHODS: A cross-sectional study of 2292 patients undergoing CABG surgery and cataloged in the BYPASS Registry up to November 2018. Demographic data, clinical presentation, operative variables, and postoperative hospital outcomes were analyzed. RESULTS: Patients referred to CABG in Brazil are predominantly male (71%), with prior myocardial infarction in 41.1% of cases, diabetes in 42.5%, and ejection fraction lower than 40% in 9.7%. The Heart Team indicated surgery in 32.9% of the cases. Most of the patients underwent cardiopulmonary bypass (87%), and cardioplegia was the strategy of myocardial protection chosen in 95.2% of the cases. The left internal thoracic artery was used as a graft in 91% of the cases; the right internal thoracic artery, in 5.6%; and the radial artery in 1.1%. The saphenous vein graft was used in 84.1% of the patients, being the only graft employed in 7.7% of the patients. The median number of coronary vessels treated was 3. Operative mortality was 2.8%, and the incidence of cerebrovascular accident was 1.2%. CONCLUSION: CABG data in Brazil provided by the BYPASS Registry analysis are representative of our national reality and practice. This database constitutes an important reference for indications and comparisons of therapeutic procedures, as well as to propose subsequent models to improve patient safety and the quality of surgical practice in the country.

Modified Hybrid Procedure in Hypoplastic Left Heart Syndrome: Initial Experience of a Center in Northeastern Brazil.

INTRODUCTION:: Although it only corresponds to 2.5% of congenital heart defects, hypoplastic left heart syndrome (HLHS) is responsible for more than 25% of cardiac deaths in the first week of life. Palliative surgery performed after the second week of life is considered an important risk factor in the treatment of HLHS. OBJECTIVE:: The aim of this study is to describe the initial experience of a medical center in Northeastern Brazil with a modified off-pump hybrid approach for palliation of HLHS. METHODS:: From November 2012 through November 2015, the medical records of 8 patients with HLHS undergoing hybrid procedure were retrospectively evaluated in a tertiary private hospital in Northeastern Brazil. The modified off-pump hybrid palliation consisted of stenting of the ductus arteriosus guided by fluoroscopy without contrast and banding of the main pulmonary artery branches. Demographic and clinical variables were recorded for descriptive analysis. RESULTS:: Eight patients were included in this study, of whom 37.5% were female. The median age and weight at the time of the procedure was 2 days (p25% and p75% = 2 and 4.5 days, respectively) and 3150 g (p25% and p75% = 3077.5 g and 3400 g, respectively), respectively. The median length in intensive care unit stay was 6 days (p25% and p75% = 3.5% and 8 days, respectively). There were no in-hospital deaths. Four patients have undergone to the second stage of the surgical treatment of HLHS. CONCLUSION:: In this series, the initial experience with the modified off-pump hybrid procedure showed to be safe, allowing a low early mortality rate among children presenting HLHS.

Modified hybrid procedure in hypoplastic left heart syndrome: initial experience of a center in northeastern Brazil

Abstract Introduction: Although it only corresponds to 2.5% of congenital heart defects, hypoplastic left heart syndrome (HLHS) is responsible for more than 25% of cardiac deaths in the first week of life. Palliative surgery performed after the second week of life is considered an important risk factor in the treatment of HLHS. Objective: The aim of this study is to describe the initial experience of a medical center in Northeastern Brazil with a modified off-pump hybrid approach for palliation of HLHS. Methods: From November 2012 through November 2015, the medical records of 8 patients with HLHS undergoing hybrid procedure were retrospectively evaluated in a tertiary private hospital in Northeastern Brazil. The modified off-pump hybrid palliation consisted of stenting of the ductus arteriosus guided by fluoroscopy without contrast and banding of the main pulmonary artery branches. Demographic and clinical variables were recorded for descriptive analysis. Results: Eight patients were included in this study, of whom 37.5% were female. The median age and weight at the time of the procedure was 2 days (p25% and p75% = 2 and 4.5 days, respectively) and 3150 g (p25% and p75% = 3077.5 g and 3400 g, respectively), respectively. The median length in intensive care unit stay was 6 days (p25% and p75% = 3.5% and 8 days, respectively). There were no in-hospital deaths. Four patients have undergone to the second stage of the surgical treatment of HLHS. Conclusion: In this series, the initial experience with the modified off-pump hybrid procedure showed to be safe, allowing a low early mortality rate among children presenting HLHS.

The Brazilian Registry of Adult Patient Undergoing Cardiovascular Surgery, the BYPASS Project: Results of the First 1,722 Patients.

Objective: To report the early results of the BYPASS project - the Brazilian registrY of adult Patient undergoing cArdiovaScular Surgery - a national, observational, prospective, and longitudinal follow-up registry, aiming to chart a profile of patients undergoing cardiovascular surgery in Brazil, assessing the data harvested from the initial 1,722 patients. Methods: Data collection involved institutions throughout the whole country, comprising 17 centers in 4 regions: Southeast (8), Northeast (5), South (3), and Center-West (1). The study population consists of patients over 18 years of age, and the types of operations recorded were: coronary artery bypass graft (CABG), mitral valve, aortic valve (either conventional or transcatheter), surgical correction of atrial fibrillation, cardiac transplantation, mechanical circulatory support and congenital heart diseases in adults. Results: 83.1% of patients came from the public health system (SUS), 9.6% from the supplemental (private insurance) healthcare systems; and 7.3% from private (out-of -pocket) clinic. Male patients comprised 66%, 30% were diabetics, 46% had dyslipidemia, 28% previously sustained a myocardial infarction, and 9.4% underwent prior cardiovascular surgery. Patients underwent coronary artery bypass surgery were 54.1% and 31.5% to valve surgery, either isolated or combined. The overall postoperative mortality up to the 7th postoperative day was 4%; for CABG was 2.6%, and for valve operations, 4.4%. Conclusion: This first report outlines the consecution of the Brazilian surgical cardiac database, intended to serve primarily as a tool for providing information for clinical improvement and patient safety and constitute a basis for production of research protocols.

The brazilian registry of adult patient undergoing cardiovascular surgery, the bypass project: results of the first 1,722 patients

Abstract Objective: To report the early results of the BYPASS project - the Brazilian registrY of adult Patient undergoing cArdiovaScular Surgery - a national, observational, prospective, and longitudinal follow-up registry, aiming to chart a profile of patients undergoing cardiovascular surgery in Brazil, assessing the data harvested from the initial 1,722 patients. Methods: Data collection involved institutions throughout the whole country, comprising 17 centers in 4 regions: Southeast (8), Northeast (5), South (3), and Center-West (1). The study population consists of patients over 18 years of age, and the types of operations recorded were: coronary artery bypass graft (CABG), mitral valve, aortic valve (either conventional or transcatheter), surgical correction of atrial fibrillation, cardiac transplantation, mechanical circulatory support and congenital heart diseases in adults. Results: 83.1% of patients came from the public health system (SUS), 9.6% from the supplemental (private insurance) healthcare systems; and 7.3% from private (out-of -pocket) clinic. Male patients comprised 66%, 30% were diabetics, 46% had dyslipidemia, 28% previously sustained a myocardial infarction, and 9.4% underwent prior cardiovascular surgery. Patients underwent coronary artery bypass surgery were 54.1% and 31.5% to valve surgery, either isolated or combined. The overall postoperative mortality up to the 7th postoperative day was 4%; for CABG was 2.6%, and for valve operations, 4.4%. Conclusion: This first report outlines the consecution of the Brazilian surgical cardiac database, intended to serve primarily as a tool for providing information for clinical improvement and patient safety and constitute a basis for production of research protocols.

[Aortic arch surgery with bilateral cerebral perfusion by isolation of brachiocephalic trunk and left carotid artery]. / Cirurgia do arco aórtico com perfusão cerebral bilateral pelo isolamento do tronco braquiocefálico e da artéria carótida esquerda.

OBJECTIVE: To evaluate the results of a technique described by Carreira et al. using bilateral antegrade selective cerebral perfusion by isolating the brachiocephalic trunk and the left carotid artery. METHODS: Fifteen patients were operated between June 2005 and September 2007. Data analysis were performed using Epi Info and statistical significance was set at p<0.05. RESULTS: Of the 15 patients, 53.3% were male; mean age was 59.86+/-15.4 years; 60% presented with type A acute aortic dissection; 6.7% type B; and 33.3% aneurysm of aorta and arch. Mean CPB and aortic clamping time was 177.6+/-39.4 and 135.9+/-34.0 minutes, respectively. In this group, 86.7% were not submitted to total circulatory arrest, with mean unilateral and bilateral selective cerebral perfusion time of 10.9+/-2.0 and 57.2+/-21.2 minutes, respectively. Mean hypothermic temperature was 23.0+/-2.9 masculineC. Two had left subclavian artery ligature, 60% used separated aortic grafts, and four used aortic endoprosthesis. Three (20%) patients died, all of them in the acute aortic dissection group. There were no neurological complications. The mean follow up time was 11.7+/-9.6 months. Regarding mortality, none of the parameters were statistically significant (p>0.05). CONCLUSION: The technique of bilateral selective cerebral perfusion described by Carreira et al. can be performed by others and presents similar results to the international literature. The excellent neurological outcome and easy bleeding control on surgical sutures lines are the major advantages of this new procedure.

Resultados de uma nova técnica para cirurgia do arco aórtico com uso de perfusão encefálica anterógrada bilateral pelo isolamento do tronco braquiocefálico e artéria carótida esquerda / Results of a new technique for aortic arch surgery using bilateral antegrade encephalic perfusion by isolation of brachiocephalic trunk left carotid artery

Fundamentos: perfusão encefálica anterógrada bilateral(PEAB) é o melhor método de neuroproteção nas cirurgias que envolvem o arco aórtico. Objetivos: Analisar os resultados cirúrgicos e em médio prazo da cirurgia no arco aórtico,utilizando a técnica descrita por Carreira et al. Métodos: Avaliaram-seos dados de 16 pacientes operados entre junho2005 e novembro2007 pela seguinte técnica:uso de prótese de dacron de 10mm ou 12mm no tronco braquiocefálico(TBC) para canulação arterial.Clampeamento do TBC permite PCA unilateral durante o isolamento.PEAB começa após remoção do clamp(500-1000ml/min)(50-70mmHg)(20-25ºC).Ao final, a prótese do isolamento é então incorporada à prótese aórtica. Resultados:8 pacientes masculinos,média de idade 59,5+-14,9 anos, 75% hipertensos. Onze operados devido à dissecção aguda e 5 por aneurisma.Médias de tempo de circulação extracorpórea,anóxia,PEA bilateral,PEA unilareral e temperatura na hipotermia foram, respectivamente:175,3+-36,0min, 135,2+-30,7min, 22,4+-3,2ºC,55,5+-20,3min e 9,9+-3,4min.Houve preservação da válvula aórtica em 93,8%; 5 pacientes receberam implante de endoprótese aórtica.Complicações foram: fibrilação atrial-56,3%;insuficiência renal aguda-31,3%;pneumonia e delirium-18,8%mediastinite e paresia temporária-6,3%;e diálise-12,5%.Médias da drenagem, tempo de entubação, permanência hospitalar e CTI foram,respectivamente:1207,2+-600,3ml,17,7+-20,1 hs,14,3+-10,6 diase 6,5+-7,1 dias. Mortalidade em 3 pacientes (18,8%), todos com dissecção aguda. Não aconteceram eventos neurológicos com média de 11,9+-10,2, meses de seguimento. Os parâmetros não apresentaram associção com mortalidade p>0,05.Conclusão: A técnica do isolameto é segura e apresenta bons resultados neurológicos imediatos e tardios.

Cirurgia do arco aórtico com perfusão cerebral bilateral pelo isolamento do tronco braquiocefálico e da artéria carótida esquerda / Aortic arch surgery with bilateral cerebral perfusion by isolation of brachiocephalic trunk and left carotid artery

OBJETIVO: Estudar os resultados da técnica descrita por Carreira et al. com utilização de perfusão cerebral seletiva bilateral (PCSAB) pelo isolamento do tronco braquiocefálico e artéria carótida esquerda. MÉTODOS: Quinze pacientes foram operados consecutivamente entre de junho de 2005 e setembro de 2007. Os dados foram analisados por programa informatizado Epi Info e significância estatística com p<0,05. RESULTADOS: No grupo analisado, 53,3 por cento dos pacientes eram do sexo masculino e a idade média era de 59,86±15,4 anos. Com relação à doença de base, 60 por cento dos pacientes apresentavam dissecção aguda do tipo A, 6,7 por cento tipo B e 33,3 por cento aneurisma da aorta e arco. O tempo médio de CEC e de anoxia foi de 177,6±39,4 e 135,9±34,0 minutos, respectivamente. Nesse grupo, 86,7 por cento dos pacientes não foram submetidos a parada circulatória total, com tempo médio de PCSA unilateral e bilateral de 10,9±2,0 e 57,2±21,2 minutos, respectivamente. A temperatura média da hipotermia foi de 23,0±2,9ºC. A artéria subclávia esquerda foi ligada em dois (13,3 por cento) pacientes, e nove (60 por cento) foram submetidos a anastomoses proximal e distal com tubos separados. Utilizou-se endoprótese vascular na aorta descendente em quatro (26,7 por cento) pacientes. Três (20 por cento) pacientes morreram, todos do subgrupo de dissecção aguda. Nenhum dos sobreviventes apresentou seqüelas neurológicas, com média de acompanhamento tardio de 11,7±9,6 meses. Nenhum dos fatores estudados apresentou relação estatisticamente significativa com a mortalidade (p>0,05). CONCLUSÃO: A técnica de PCSAB é reprodutível e apresenta resultados semelhantes aos da literatura mundial. A excelente evolução neurológica e o fácil controle de sangramentos nas linhas de sutura podem ter contribuído com os resultados obtidos.

OBJECTIVE: To evaluate the results of a technique described by Carreira et al. using bilateral antegrade selective cerebral perfusion by isolating the brachiocephalic trunk and the left carotid artery. METHODS: Fifteen patients were operated between June 2005 and September 2007. Data analysis were performed using Epi Info and statistical significance was set at p<0.05. RESULTS: Of the 15 patients, 53.3 percent were male; mean age was 59.86±15.4 years; 60 percent presented with type A acute aortic dissection; 6.7 percent type B; and 33.3 percent aneurysm of aorta and arch. Mean CPB and aortic clamping time was 177.6±39.4 and 135.9±34.0 minutes, respectively. In this group, 86.7 percent were not submitted to total circulatory arrest, with mean unilateral and bilateral selective cerebral perfusion time of 10.9±2.0 and 57.2±21.2 minutes, respectively. Mean hypothermic temperature was 23.0±2.9ºC. Two had left subclavian artery ligature, 60 percent used separated aortic grafts, and four used aortic endoprosthesis. Three (20 percent) patients died, all of them in the acute aortic dissection group. There were no neurological complications. The mean follow up time was 11.7±9.6 months. Regarding mortality, none of the parameters were statistically significant (p>0.05). CONCLUSION: The technique of bilateral selective cerebral perfusion described by Carreira et al. can be performed by others and presents similar results to the international literature. The excellent neurological outcome and easy bleeding control on surgical sutures lines are the major advantages of this new procedure.