The arrival of COVID-19 in Brazil and the impact on coronary artery bypass surgery.

BACKGROUND AND AIM OF THE STUDY: This study analyzed the arrival of coronavirus disease 2019 (COVID-19) in Brazil and its impact on coronary artery bypass grafting (CABG) surgery. METHODS: Patients undergoing isolated CABG in six hospitals in Brazil were divided into two periods: pre-COVID-19 (March-May 2019, N = 468) and COVID-19 era (March-May 2020, N = 182). Perioperative data were included on a dedicated REDCap platform. Patients with clinical and tomographic criteria and/or PCR (+) for severe acute respiratory syndrome coronavirus 2 infection were considered COVID-19 (+). Logistic regression analysis was performed to create a multiple predictive model for mortality after CABG in COVID-19 era. RESULTS: Compared to 2019, in 2020, CABG surgeries had a 2.8-fold increased mortality risk (95% confidence interval [CI]: 1-7.6, p = .041), patients who evolved with COVID-19 had a 11-fold increased mortality risk (95% CI: 2.2-54.9, p < .003), rates of morbidities and readmission to the intensive care unit. The surgical volume was decreased by 60%. The model to predict mortality after CABG in the COVID-19 era was validated with good calibration (Hosmer-Lemeshow = 1.43) and discrimination (receiver operating characteristic = 0.78). CONCLUSION: The COVID-19 pandemic had an adverse impact on mortality, morbidity and volume of patients undergoing CABG.

Increased number of ventricular septal rupture cases after acute myocardial infarction in 2020.

INTRODUCTION: Ventricular septal rupture (VSR) is a serious mechanical complication after acute coronary syndrome and is related to high mortality. Even with advances in the management of acute myocardial infarction (AMI) such as reperfusion therapies, complication rates are still high. During quarantine, patients presenting mechanical complications after AMI have increased in our institution. METHODS: From a retrospective database analysis in our institution between the years 2004 and 2020, we identified 37 cases of VSR after AMI. Four chronic cases were excluded from our analysis. The primary endpoint was to identify baseline characteristics that increased 30-day mortality. RESULTS: Among 33 acute cases of VSR, 24 cases were submitted to surgery. The 30-day mortality of the operated patients was 45.8%. From 2004 to 2019 our average number of operations of VSR was 1.9 cases/year with an increase to 4 cases/year in 2020. Diabetes mellitus, age, cardiogenic shock, and use of intra-aortic balloon pump were associated with significantly increased mortality using logistic regression. CONCLUSION: We reported an increased number of mechanical complication cases from April to September 2020, compared to our historical records. Despite therapeutic advances, mortality rates remain high. Although the number of cases is small to conclude that the pandemic was responsible for this augmentation, we believe that it is related to the decreased number of patients seeking medical assistance.

Platelet Reactivity in Patients With Acute Coronary Syndromes Awaiting Surgical Revascularization.

BACKGROUND: Dual antiplatelet therapy is recommended for patients with acute coronary syndromes (ACS). Approximately 10% to 15% of these patients will undergo coronary artery bypass graft (CABG) surgery for index events, and current guidelines recommend stopping clopidogrel at least 5 days before CABG. This waiting time has clinical and economic implications. OBJECTIVES: This study aimed to evaluate if a platelet reactivity-based strategy is noninferior to standard of care for 24-h post-CABG bleeding. METHODS: In this randomized, open label noninferiority trial, 190 patients admitted with ACS with indications for CABG and on aspirin and P2Y12 receptor inhibitors, were assigned to either control group, P2Y12 receptor inhibitor withdrawn 5 to 7 days before CABG, or intervention group, daily measurements of platelet reactivity by Multiplate analyzer (Roche Diagnostics GmbH, Vienna, Austria) with CABG planned the next working day after platelet reactivity normalization (pre-defined as ≥46 aggregation units). RESULTS: Within the first 24 h of CABG, the median chest tube drainage was 350 ml (interquartile range [IQR]: 250 to 475 ml) and 350 ml (IQR: 255 to 500 ml) in the intervention and control groups, respectively (p for noninferiority <0.001). The median waiting period between the decision to undergo CABG and the procedure was 112 h (IQR: 66 to 142 h) and 136 h (IQR: 112 to 161 h) (p < 0.001), respectively. In the intention-to-treat analysis, a 6.4% decrease in the median in-hospital expenses was observed in the intervention group (p = 0.014), with 11.2% decrease in the analysis per protocol (p = 0.003). CONCLUSIONS: A strategy based on platelet reactivity-guided is noninferior to the standard of care in patients with ACS awaiting CABG regarding peri-operative bleeding, significantly shortens the waiting time to CABG, and decreases hospital expenses. (Evaluation of Platelet Aggregability in the Release of CABG in Patients With ACS With DAPT; NCT02516267).

Late clinical outcomes of myocardial hybrid revascularization versus coronary artery bypass grafting for complex triple-vessel disease: Long-term follow-up of the randomized MERGING clinical trial.

OBJECTIVES: This article aimed to compare the outcomes after hybrid revascularization with conventional coronary artery bypass grafting (CABG) surgery. BACKGROUND: The concept of hybrid coronary revascularization combines the advantages of CABG and percutaneous coronary intervention to improve the treatment of patients with complex multivessel disease. METHODS: The Myocardial hybrid revascularization versus coronary artERy bypass GraftING for complex triple-vessel disease-MERGING study is a pilot randomized trial that allocated 60 patients with complex triple-vessel disease to treatment with hybrid revascularization or conventional CABG (2:1 ratio). The primary outcome was the composite of all-cause death, myocardial infarction, stroke, or unplanned repeat revascularization at 2 years. RESULTS: Clinical and anatomical characteristics were similar between groups. After a mean follow-up of 802 ± 500 days, the primary endpoint rate was 19.3% in the hybrid arm and 5.9% in the CABG arm (p = NS). The incidence of unplanned revascularization increased over time in both groups, reaching 14.5 versus 5.9% in the hybrid and in the CABG groups, respectively (p = .4). Of note, in the hybrid group, there were no reinterventions driven by the occurrence of stent restenosis. CONCLUSIONS: Hybrid myocardial was feasible but associated with increasing rates of major adverse cardiovascular events during 2 years of clinical follow-up, while the control group treated with conventional surgery presented with low rates of complications during the same period. In conclusion, before more definitive data arise, hybrid revascularization should be applied with careful attention in practice, following a selective case-by-case indication.

Does prior coronary angioplasty affect outcomes of surgical coronary revascularization? Insights from the STICH trial.

BACKGROUND: The STICH trial showed superiority of coronary artery bypass plus medical treatment (CABG) over medical treatment alone (MED) in patients with left ventricular ejection fraction (LVEF) ≤35%. In previous publications, percutaneous coronary intervention (PCI) prior to CABG was associated with worse prognosis. OBJECTIVES: The main purpose of this study was to analyse if prior PCI influenced outcomes in STICH. METHODS AND RESULTS: Patients in the STICH trial (n = 1212), followed for a median time of 9.8 years, were included in the present analyses. In the total population, 156 had a prior PCI (74 and 82, respectively, in the MED and CABG groups). In those with vs. without prior PCI, the adjusted hazard-ratios (aHRs) were 0.92 (95% CI = 0.74-1.15) for all-cause mortality, 0.85 (95% CI = 0.64-1.11) for CV mortality, and 1.43 (95% CI = 1.15-1.77) for CV hospitalization. In the group randomized to CABG without prior PCI, the aHRs were 0.82 (95% CI = 0.70-0.95) for all-cause mortality, 0.75 (95% CI = 0.62-0.90) for CV mortality and 0.67 (95% CI = 0.56-0.80) for CV hospitalization. In the group randomized to CABG with prior PCI, the aHRs were 0.76 (95% CI = 0.50-1.15) for all-cause mortality, 0.81 (95% CI = 0.49-1.36) for CV mortality and 0.61 (95% CI = 0.41-0.90) for CV hospitalization. There was no evidence of interaction between randomized treatment and prior PCI for any endpoint (all adjusted p > 0.05). CONCLUSION: In the STICH trial, prior PCI did not affect the outcomes of patients whether they were treated medically or surgically, and the superiority of CABG over MED remained unchanged regardless of prior PCI. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov; Identifier: NCT00023595.

Predictive performance of six mortality risk scores and the development of a novel model in a prospective cohort of patients undergoing valve surgery secondary to rheumatic fever.

BACKGROUND: Mortality prediction after cardiac procedures is an essential tool in clinical decision making. Although rheumatic cardiac disease remains a major cause of heart surgery in the world no previous study validated risk scores in a sample exclusively with this condition. OBJECTIVES: Develop a novel predictive model focused on mortality prediction among patients undergoing cardiac surgery secondary to rheumatic valve conditions. METHODS: We conducted prospective consecutive all-comers patients with rheumatic heart disease (RHD) referred for surgical treatment of valve disease between May 2010 and July of 2015. Risk scores for hospital mortality were calculated using the 2000 Bernstein-Parsonnet, EuroSCORE II, InsCor, AmblerSCORE, GuaragnaSCORE, and the New York SCORE. In addition, we developed the rheumatic heart valve surgery score (RheSCORE). RESULTS: A total of 2,919 RHD patients underwent heart valve surgery. After evaluating 13 different models, the top performing areas under the curve were achieved using Random Forest (0.982) and Neural Network (0.952). Most influential predictors across all models included left atrium size, high creatinine values, a tricuspid procedure, reoperation and pulmonary hypertension. Areas under the curve for previously developed scores were all below the performance for the RheSCORE model: 2000 Bernstein-Parsonnet (0.876), EuroSCORE II (0.857), InsCor (0.835), Ambler (0.831), Guaragna (0.816) and the New York score (0.834). A web application is presented where researchers and providers can calculate predicted mortality based on the RheSCORE. CONCLUSIONS: The RheSCORE model outperformed pre-existing scores in a sample of patients with rheumatic cardiac disease.

Do We Need to Personalize Renal Function Assessment in the Stratification of Patients Undergoing Cardiac Surgery? / É Necessário Personalizar a Avaliação da Função Renal na Estratificação de Pacientes Submetidos à Cirurgia Cardíaca?

Abstract Background: Renal dysfunction is an independent predictor of morbidity and mortality in cardiac surgery. For a better assessment of renal function, calculation of creatinine clearance (CC) may be necessary. Objective: To objectively evaluate whether CC is a better risk predictor than serum creatinine (SC) in patients undergoing cardiac surgery. Methods: Analysis of 3,285 patients registered in a prospective, consecutive and mandatory manner in the Sao Paulo Registry of Cardiovascular Surgery (REPLICCAR) between November 2013 and January 2015. Values of SC, CC (Cockcroft-Gault) and EuroSCORE II were obtained. Association analysis of SC and CC with morbidity and mortality was performed by calibration and discrimination tests. Independent multivariate models with SC and CC were generated by multiple logistic regression to predict morbidity and mortality following cardiac surgery. Results: Despite the association between SC and mortality, it did not calibrate properly the risk groups. There was an association between CC and mortality with good calibration of risk groups. In mortality risk prediction, SC was uncalibrated with values > 1.35 mg /dL (p < 0.001). The ROC curve showed that CC is better than SC in predicting both morbidity and mortality risk. In the multivariate model without CC, SC was the only predictor of morbidity, whereas in the model without SC, CC was not only a mortality predictor, but also the only morbidity predictor. Conclusion: Compared with SC, CC is a better parameter of renal function in risk stratification of patients undergoing cardiac surgery.

Resumo Fundamentos: Disfunção renal é preditor independente de morbimortalidade após cirurgia cardíaca. Para uma melhor avaliação da função renal, o cálculo do clearance de creatinina (CC) pode ser necessário. Objetivo: Avaliar objetivamente se o CC é melhor que a creatinina sérica (CS) para predizer risco nos pacientes submetidos à cirurgia cardíaca. Métodos: Análise em 3285 pacientes do Registro Paulista de Cirurgia Cardiovascular (REPLICCAR) incluídos de forma prospectiva, consecutiva e mandatória entre novembro de 2013 e janeiro de 2015. Foram obtidos valores de CS, CC (Cockcroft-Gault) e do EuroSCORE II. Análise de associações da CS e do CC com morbimortalidade foi realizada mediante testes de calibração e discriminação. Por regressão logística múltipla, foram criados modelos multivariados independentes com CS e com CC para predição de risco de morbimortalidade após cirurgia cardíaca. Resultados: Apesar da associação entre a CS e morbimortalidade, essa não calibrou adequadamente os grupos de risco. Houve associação entre o CC e morbimortalidade com boa calibração dos grupos de risco. Na predição do risco de mortalidade, a CS ficou descalibrada com valores >1,35 mg/dL (p < 0,001). A curva ROC revelou que o CC é superior à CS na predição de risco de morbimortalidade. No modelo multivariado sem CC, a CS foi a única preditora de morbidade, enquanto que no modelo sem a CS, o CC foi preditor de mortalidade e o único preditor de morbidade. Conclusão: Para avaliação da função renal, o CC é superior que a CS na estratificação de risco dos pacientes submetidos a cirurgia cardíaca.

Do We Need to Personalize Renal Function Assessment in the Stratification of Patients Undergoing Cardiac Surgery?

BACKGROUND: Renal dysfunction is an independent predictor of morbidity and mortality in cardiac surgery. For a better assessment of renal function, calculation of creatinine clearance (CC) may be necessary. OBJECTIVE: To objectively evaluate whether CC is a better risk predictor than serum creatinine (SC) in patients undergoing cardiac surgery. METHODS: Analysis of 3,285 patients registered in a prospective, consecutive and mandatory manner in the Sao Paulo Registry of Cardiovascular Surgery (REPLICCAR) between November 2013 and January 2015. Values of SC, CC (Cockcroft-Gault) and EuroSCORE II were obtained. Association analysis of SC and CC with morbidity and mortality was performed by calibration and discrimination tests. Independent multivariate models with SC and CC were generated by multiple logistic regression to predict morbidity and mortality following cardiac surgery. RESULTS: Despite the association between SC and mortality, it did not calibrate properly the risk groups. There was an association between CC and mortality with good calibration of risk groups. In mortality risk prediction, SC was uncalibrated with values > 1.35 mg /dL (p < 0.001). The ROC curve showed that CC is better than SC in predicting both morbidity and mortality risk. In the multivariate model without CC, SC was the only predictor of morbidity, whereas in the model without SC, CC was not only a mortality predictor, but also the only morbidity predictor. CONCLUSION: Compared with SC, CC is a better parameter of renal function in risk stratification of patients undergoing cardiac surgery.

Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review.

OBJECTIVES: To evaluate the effects of goal-directed therapy on outcomes in high-risk patients undergoing cardiac surgery. DESIGN: A prospective randomized controlled trial and an updated metaanalysis of randomized trials published from inception up to May 1, 2015. SETTING: Surgical ICU within a tertiary referral university-affiliated teaching hospital. PATIENTS: One hundred twenty-six high-risk patients undergoing coronary artery bypass surgery or valve repair. INTERVENTIONS: Patients were randomized to a cardiac output-guided hemodynamic therapy algorithm (goal-directed therapy group, n = 62) or to usual care (n = 64). In the goal-directed therapy arm, a cardiac index of greater than 3 L/min/m was targeted with IV fluids, inotropes, and RBC transfusion starting from cardiopulmonary bypass and ending 8 hours after arrival to the ICU. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite endpoint of 30-day mortality and major postoperative complications. Patients from the goal-directed therapy group received a greater median (interquartile range) volume of IV fluids than the usual care group (1,000 [625-1,500] vs 500 [500-1,000] mL; p < 0.001], with no differences in the administration of either inotropes or RBC transfusions. The primary outcome was reduced in the goal-directed therapy group (27.4% vs 45.3%; p = 0.037). The goal-directed therapy group had a lower occurrence rate of infection (12.9% vs 29.7%; p = 0.002) and low cardiac output syndrome (6.5% vs 26.6%; p = 0.002). We also observed lower ICU cumulative dosage of dobutamine (12 vs 19 mg/kg; p = 0.003) and a shorter ICU (3 [3-4] vs 5 [4-7] d; p < 0.001) and hospital length of stay (9 [8-16] vs 12 [9-22] d; p = 0.049) in the goal-directed therapy compared with the usual care group. There were no differences in 30-day mortality rates (4.8% vs 9.4%, respectively; p = 0.492). The metaanalysis identified six trials and showed that, when compared with standard treatment, goal-directed therapy reduced the overall rate of complications (goal-directed therapy, 47/410 [11%] vs usual care, 92/415 [22%]; odds ratio, 0.40 [95% CI, 0.26-0.63]; p < 0.0001) and decreased the hospital length of stay (mean difference, -5.44 d; 95% CI, -9.28 to -1.60; p = 0.006) with no difference in postoperative mortality: 9 of 410 (2.2%) versus 15 of 415 (3.6%), odds ratio, 0.61 (95% CI, 0.26-1.47), and p = 0.27. CONCLUSIONS: Goal-directed therapy using fluids, inotropes, and blood transfusion reduced 30-day major complications in high-risk patients undergoing cardiac surgery.

InsCor: a simple and accurate method for risk assessment in heart surgery.

BACKGROUND: Risk scores show difficulties to attain the same performance in different populations. OBJECTIVE: To create a simple and accurate risk assessment model for patients submitted to surgery due to coronary and/or valvular disease at Instituto do Coração da Universidade de São Paulo (InCor-HCFMUSP). METHODS: Between 2007 and 2009, 3,000 patients were submitted to surgical procedure due to coronary artery and/or valvular disease at InCor-HCFMUSP. From this record, data of 2/3 of the patients were used for model development (bootstrap technique), and 1/3 for internal validation of the model. The performance of the model (InsCor) was compared to the 2000 Bernstein-Parsonnet (2000BP) and EuroSCORE (ES) complexes. RESULTS: Only 10 variables were selected: age > 70 years, female sex; coronary revascularization + valve, myocardial infarction < 90 days; reoperation; surgical treatment of aortic valve; surgical treatment of tricuspid valve; creatinine < 2mg/dL; ejection fraction < 30%, and events. The Hosmer Lemeshow test for the InsCor was 0.184, indicating excellent calibration. The area under the ROC curve was 0.79 for the InsCor, 0.81 for the ES and 0.82 for 2000BP, confirming that the models are good and have similar discrimination. CONCLUSIONS: The InsCor and ES performed better than 2000BP at all stages of validation, but the new model, in addition to showing identification with the local risk factors, is simpler and more objective for mortality prediction in patients undergoing surgery due to coronary and/or valvular disease at InCor-HCFMUSP.

InsCor: um método simples e acurado para avaliação do risco em cirurgia cardíaca / InsCor: a simple and accurate method for risk assessment in heart surgery

FUNDAMENTO: Escores de risco apresentam dificuldades para obter o mesmo desempenho em diferentes populações. OBJETIVO: Criar um modelo simples e acurado para avaliação do risco nos pacientes operados de doença coronariana e/ou valvar no Instituto do Coração da Universidade de São Paulo (InCor-HCFMUSP). MÉTODOS: Entre 2007 e 2009, 3.000 pacientes foram operados consecutivamente de doença coronariana e/ou valvar no InCor-HCFMUSP. Desse registro, dados de 2/3 dos pacientes foram utilizados para desenvolvimento do modelo (técnica de bootstrap) e de 1/3 para validação interna do modelo. O desempenho do modelo (InsCor) foi comparado aos complexos 2000 Bernstein-Parsonnet (2000BP) e EuroSCORE (ES). RESULTADOS: Apenas 10 variáveis foram selecionadas: Idade > 70 anos; sexo feminino; cirurgia de revascularização coronariana + valva; infarto de miocárdio < 90 dias; reoperação; tratamento cirúrgico da valva aórtica; tratamento cirúrgico da valva tricúspide; creatinina < 2mg/dL; fração de ejeção < 30%; e eventos. O teste de Hosmer Lemeshow para o InsCor foi de 0,184, indicando uma excelente calibração. A área abaixo da curva ROC foi de 0,79 para o InsCor, 0,81 para o ES e 0,82 para o 2000BP, confirmando que os modelos são bons e similares na discriminação. CONCLUSÕES: O InsCor e o ES tiveram melhor desempenho que o 2000BP em todas as fases da validação; pórem o novo modelo, além de se identificar com os fatores de risco locais, é mais simples e objetivo para a predição de mortalidade nos pacientes operados de doença coronariana e/ou valvar no InCor-HCFMUSP.

BACKGROUND: Risk scores show difficulties to attain the same performance in different populations. OBJECTIVE: To create a simple and accurate risk assessment model for patients submitted to surgery due to coronary and/or valvular disease at Instituto do Coração da Universidade de São Paulo (InCor-HCFMUSP). METHODS: Between 2007 and 2009, 3,000 patients were submitted to surgical procedure due to coronary artery and/or valvular disease at InCor-HCFMUSP. From this record, data of 2/3 of the patients were used for model development (bootstrap technique), and 1/3 for internal validation of the model. The performance of the model (InsCor) was compared to the 2000 Bernstein-Parsonnet (2000BP) and EuroSCORE (ES) complexes. RESULTS: Only 10 variables were selected: age > 70 years, female sex; coronary revascularization + valve, myocardial infarction < 90 days; reoperation; surgical treatment of aortic valve; surgical treatment of tricuspid valve; creatinine < 2mg/dL; ejection fraction < 30%, and events. The Hosmer Lemeshow test for the InsCor was 0.184, indicating excellent calibration. The area under the ROC curve was 0.79 for the InsCor, 0.81 for the ES and 0.82 for 2000BP, confirming that the models are good and have similar discrimination. CONCLUSIONS: The InsCor and ES performed better than 2000BP at all stages of validation, but the new model, in addition to showing identification with the local risk factors, is simpler and more objective for mortality prediction in patients undergoing surgery due to coronary and/or valvular disease at InCor-HCFMUSP.

Coronary artery bypass grafting in acute myocardial infarction: analysis of predictors of in-hospital mortality.

OBJECTIVE: Coronary artery bypass grafting (CABG) during the acute phase of infarction (AMI) is associated with increased operative risk. The aim of this study was to determine predictors of in-hospital mortality in patients undergoing CABG in AMI. METHODS: During three years, all patients undergoing CABG in AMI were retrospectively analyzed of the institutional database. Sixty variables per patient were evaluated: 49 preoperative variables from the 2000 Bernstein-Parsonnet and EuroSCORE models, 4 preoperative variables not considered in these models (time between AMI and CABG, maximum CKMB, Troponin maximum and ST-segment elevation) and 7 intraoperative variables [(cardiopulmonary bypass (CPB), CPB time, type of cardioplegia, endarterectomy, number of grafts, use of internal thoracic artery and complete revascularization]. Univariate and multivariate analysis for the outcome of in hospital mortality were performed. RESULTS: The mean time between AMI and CABG was 3.8 ± 3 days. The overall mortality was 19%. In the multivariate analysis: age > 65 years OR [16.5 (CI 1.8 to 152), P= 0.013]; CPB > 108 minutes [OR 40 (CI 2.7 to 578), P= 0.007], creatinine> 2 mg/dl [OR 35.5 (CI 1.7 to 740), P= 0.021] and systolic pulmonary pressure > 60 mmHg [OR 31 (CI 1.6 to 591), P= 0.022] were predictors of in-hospital mortality. CONCLUSION: Conventional preoperative variables such as age > 65 years, creatinine > 2 mg/dl and systolic pulmonary pressure > 60 mmHg were predictive of in-hospital mortality in patients underwent CABG in AMI.

Cirurgia de revascularização miocárdica na fase aguda do infarto: análise dos fatores preditores de mortalidade intra-hospitalar / Coronary artery bypass grafting in acute myocardial infarction: analysis of predictors of in-hospital mortality

OBJETIVO: A cirurgia de revascularização miocárdica (CRM) na fase aguda do infarto do miocárdio (IAM) está associada a aumento do risco operatório. O objetivo do estudo foi determinar fatores preditores de mortalidade intra-hospitalar nos pacientes submetidos a CRM no IAM. MÉTODOS: Durante três anos, todos os pacientes submetidos a CRM no IAM foram analisados retrospectivamente, utilizando o banco de dados institucional. Sessenta variáveis por paciente foram avaliadas: 49 variáveis pré-operatórias provenientes dos escores 2000 Bernstein-Parsonnet e EuroSCORE; 4 variáveis pré-operatórias não consideradas por esses escores (tempo entre o IAM e a CRM, valor máximo de CKMB, valor máximo de troponina e supradesnivelamento do segmento ST) e 7 variáveis intraoperatórias [uso de circulação extracorpórea (CEC), tempo de CEC, tipo de cardioplegia, endarterectomia, número de enxertos, uso da artéria torácica interna e revascularização completa]. Análise univariada e multivariada para o desfecho mortalidade intra-hospitalar foram realizadas. RESULTADOS: O tempo médio entre o IAM e a CRM foi de 3,8 ± 3 dias. A mortalidade global foi 19%. Na análise multivariada: idade > 65 anos [OR 16,5 (IC 1,8-152), P=0,013]~˜ CEC >108 minutos [OR 40 (IC 2,7-578), P=0,007], creatinina > 2 mg/dl [OR 35,5 (IC 1,7-740), P=0,021] e pressão pulmonar sistólica > 60 mmHg [OR 31(IC 1,6-591), P=0,022] foram preditores de mortalidade intra-hospitalar. CONCLUSÃO: Variáveis pré-operatórias clássicas como idade > 65 anos, creatinina > 2 mg/dl e pressão pulmonar sistólica > 60 mmHg foram preditoras de mortalidade intra-hospitalar nos pacientes operados de revascularização miocárdica na fase aguda do infarto.

OBJECTIVE: Coronary artery bypass grafting (CABG) during the acute phase of infarction (AMI) is associated with increased operative risk. The aim of this study was to determine predictors of in-hospital mortality in patients undergoing CABG in AMI. METHODS: During three years, all patients undergoing CABG in AMI were retrospectively analyzed of the institutional database. Sixty variables per patient were evaluated: 49 preoperative variables from the 2000 Bernstein-Parsonnet and EuroSCORE models, 4 preoperative variables not considered in these models (time between AMI and CABG, maximum CKMB, Troponin maximum and ST-segment elevation) and 7 intraoperative variables [(cardiopulmonary bypass (CPB), CPB time, type of cardioplegia, endarterectomy, number of grafts, use of internal thoracic artery and complete revascularization]. Univariate and multivariate analysis for the outcome of in hospital mortality were performed. RESULTS: The mean time between AMI and CABG was 3.8 ± 3 days. The overall mortality was 19%. In the multivariate analysis: age > 65 years OR [16.5 (CI 1.8 to 152), P= 0.013]; CPB > 108 minutes [OR 40 (CI 2.7 to 578), P= 0.007], creatinine> 2 mg/dl [OR 35.5 (CI 1.7 to 740), P= 0.021] and systolic pulmonary pressure > 60 mmHg [OR 31 (CI 1.6 to 591), P= 0.022] were predictors of in-hospital mortality. CONCLUSION: Conventional preoperative variables such as age > 65 years, creatinine > 2 mg/dl and systolic pulmonary pressure > 60 mmHg were predictive of inhospital mortality in patients underwent CABG in AMI.

The 2000 Bernstein-Parsonnet score and EuroSCORE are similar in predicting mortality at the Heart Institute, USP.

OBJECTIVE: To evaluate the performance of 2000 Bernstein-Parsonnet (2000BP) and additive EuroSCORE (ES) for predicting surgical mortality at the Heart Institute, University of São Paulo. METHODS: A prospective observational design. Seven hundred and seventy four patients were operated for coronary artery bypass graft, valve or combined procedure between May and October, 2007, were analyzed. The mortality was estimated with the 2000BP and ES. The correlation between expected mortality and observed mortality was validated through calibration and discrimination test. RESULTS: The patients were stratified into five groups for the 2000BP and three for the ES. The Hosmer-Lemeshow test for 2000BP (P = 0.70) and for ES (P = 0.39) indicate a good calibration. The ROC curve for the 2000BP = 0.84 and for the ES = 0.81 confirms that the models are good predictors (P<0.001). CONCLUSION: Both models are similar and adequate in predicting surgical mortality at the InCor-USP.

Os escores 2000 Bernstein-Parsonnet e EuroSCORE são similares na predição da mortalidade no Instituto do Coração-USP / The 2000 Bernstein-Parsonnet score and EuroSCORE are similar in predicting mortality at the Heart Institute, USP

OBJETIVO: Avaliar o desempenho do 2000 Bernstein-Parsonnet (2000BP) e EuroSCORE aditivo (ES) na predição de mortalidade cirúrgica no Instituto do Coração da Universidade de São Paulo (InCor-USP). MÉTODOS: Desenho prospectivo e observacional. Setecentos e quarenta e quatro pacientes consecutivos submetidos à cirurgia de revascularização miocárdica, valvar ou associada, entre maio e outubro de 2007, foram analisados. A mortalidade foi calculada com os escores 2000BP e ES. A correlação entre mortalidade estimada e mortalidade observada foi validada mediante testes de calibração e discriminação. RESULTADOS: Os pacientes foram estratificados em cinco grupos para o 2000BP e três para o ES. O teste de Hosmer Lemeshow para o 2000BP (P = 0,70) e para o ES (P = 0,39) indica uma boa calibração. A curva ROC para o 2000BP = 0,84 e para o ES = 0,81 confirma que os modelos são bons preditores (P < 0,001). CONCLUSÃO: Ambos os modelos são similares e adequados na predição de mortalidade cirúrgica no InCor-USP.

OBJECTIVE: To evaluate the performance of 2000 Bernstein-Parsonnet (2000BP) and additive EuroSCORE (ES) for predicting surgical mortality at the Heart Institute, University of São Paulo. METHODS: A prospective observational design. Seven hundred and seventy four patients were operated for coronary artery bypass graft, valve or combined procedure between May and October, 2007, were analyzed. The mortality was estimated with the 2000BP and ES. The correlation between expected mortality and observed mortality was validated through calibration and discrimination test. RESULTS: The patients were stratified into five groups for the 2000BP and three for the ES. The Hosmer-Lemeshow test for 2000BP (P = 0.70) and for ES (P = 0.39) indicate a good calibration. The ROC curve for the 2000BP = 0.84 and for the ES = 0.81 confirms that the models are good predictors (P<0.001). CONCLUSION: Both models are similar and adequate in predicting surgical mortality at the InCor-USP.

Keratinocyte growth factor: a new mesothelial targeted therapy to reduce postoperative pericardial adhesions.

BACKGROUND: Several methods have been utilized to prevent pericardial and retrosternal adhesions, but none of them evaluated the mesothelial regenerative hypothesis. There are evidences that the mesothelial trauma reduces pericardial fibrinolytic capability and induces an adhesion process. Keratinocyte growth factor (KGF) has proven to improve mesothelial cells proliferation. This study investigated the influence of keratinocyte growth factor in reducing post-surgical adhesions. METHODS: Twelve pigs were operated and an adhesion protocol was employed. Following a stratified randomization, the animals received a topical application of KGF or saline. At 8 weeks, intrapericardial adhesions were evaluated and a severity score was established. The time spent to dissect the adhesions and the amount of sharp dissection used, were recorded. Histological sections were stained with sirius red and morphometric analyses were assessed with a computer-assisted image analysis system. RESULTS: The severity score was lower in the KGF group than in the control group (11.5 vs 17, p=0.005). The dissection time was lower in the KGF group (9.2+/-1.4 min vs 33.9+/-9.2 min, p=0.004) and presented a significant correlation with the severity score (r=0.83, p=0.001). A significantly less sharp dissection was also required in the KGF group. Also, adhesion area and adhesion collagen were significantly lower in the KGF group than in the control group. CONCLUSION: The stimulation of pericardial cells with KGF reduced the intensity of postoperative adhesions and facilitated the re-operation. This study suggests that the mesothelial regeneration is the new horizon in anti-adhesion therapies.

Deposition of free cholesterol in the blood vessels of patients with coronary artery disease: a possible novel mechanism for atherogenesis.

A cholesterol-rich nanoemulsion (LDE) that mimics the composition of low-density lipoprotein (LDL) acquires apoE in the plasma and is taken-up by the cells by LDL receptors. In this study, to verify whether free cholesterol (FC) and the cholesteryl ester (CE) components of LDL are taken-up differently by the vessels. LDE labeled with (3)H-cholesterol and (14)C-cholesteryl oleate was injected into 20 coronary artery disease patients 24 h before a scheduled myocardial coronary artery bypass grafting. The plasma kinetics of both radiolabels was determined from plasma samples collected over 24 h, and fragments of vessels discarded during surgery were collected and analyzed for radioactivity. LDE FC was removed faster than CE. The radioactive counting of LDE CE was greater than that of LDE FC in the blood, but the uptake of FC was markedly greater than that of CE in all fragments: fivefold greater in the aorta (p = 0.04), fourfold greater in the internal thoracic artery (p = 0.03), tenfold greater in the saphenous vein (p = 0.01) and threefold in the radial artery (p = 0.05). In conclusion, the greater removal from plasma of FC compared with CE and the remarkably greater vessel tissue uptake of FC compared with CE suggests that, in the plasma, FC dissociates from the nanoemulsion particles and precipitates in the vessels. Considering LDE as an artificial nanoemulsion model for LDL, our results suggest that dissociation of FC from lipoprotein particles and deposition in the vessel wall may play a role as an independent mechanism in atherogenesis.

Effectiveness of the maze procedure using cooled-tip radiofrequency ablation in patients with permanent atrial fibrillation and rheumatic mitral valve disease.

BACKGROUND: Although the Cox-Maze III procedure is effective for treating permanent atrial fibrillation (AF), its high complexity limits its use. The Saline-Irrigated Cooled-tip Radiofrequency Ablation (SICTRA) System is an alternative source of energy used to ablate AF. The aim of this study was to evaluate the effectiveness of the SICTRA for the treatment of permanent AF in patients with rheumatic mitral valve (MV) disease. METHODS AND RESULTS: Between February 2002 and April 2003, 70 patients with permanent AF and rheumatic MV disease were randomly assigned to undergo a modified Maze III procedure using SICTRA associated with MV surgery (group A) or MV surgery alone (group B). Groups A and B were similar in terms of baseline characteristics. The in-hospital mortality rate was 2.3% (1 death) in group A versus 0% (no deaths) in group B (P>0.99). The additional time required for the left-sided radiofrequency ablation in group A was 14.2+/-5.1 minutes and for right-sided ablation was 12.3+/-4.2 minutes. The mean postoperative follow-up periods were 13.8+/-3.4 and 11.5+/-7.3 months, respectively, in groups A and B. The overall mid-term survival rate was 95.1% in group A and 92.8% in group B (P>0.99). The cumulative rates of sinus rhythm were 79.4% in group A and 26.9% in group B (P=0.001). Doppler echocardiography documented biatrial transport function in 90.3% of group A patients in sinus rhythm. CONCLUSIONS: The SICTRA is effective for treating permanent AF associated with rheumatic MV disease.

Ação inibitória da Interleucina - 1ß sobre a proliferação de células musculares lisas cultivadas a partir de veias safenas humanas / Inhibitory action of the Interleukin 1ß over the cellular proliferation of smooth muscle cells cultivated from human saphenous veins

INTRODUÇAO: A veia safena é um enxerto coronário eficiente. Porém, sua patência pode ser limitada por desenvolvimento de aterosclerose. Estudos experimentais "ex vivo", por nós realizados anteriormente, demonstraram apoptose (ensaio de TUNEL) em veias safenas humanas cultivadas sob pressão arterial por 24 horas. Nessas veias safenas, a expressão gênica da Interleucina-1ß avaliada por RT-PCR em tempo real, também mostrou-se elevada. Não há ainda consenso sobre a ação moduladora das citocinas sobre proliferação/apoptose das células musculares lisas das veias safenas. OBJETIVO: Avaliar a influência da Interleucina -1ß na proliferação inicial de cultura de células primárias de músculo liso de veia safena humana. MÉTODO: Foram cultivadas células primárias de músculo liso de seis diferentes veias safenas humanas (em triplicata). O meio de cultura foi o DMEM, suplementado com 10 por cento de soro fetal bovino. O grupo controle não recebeu Interleucina - 1ß. Nos demais grupos, as células cultivadas receberam, respectivamente, 0,1; 1; 10 e 100 ng/mL de Interleucina - 1ß. A proliferação celular foi avaliada através da quantificação de timidina triciada [ H], incorporada às células recém-proliferadas. RESULTADOS: O tratamento com Interleucina - 1ß diminuiu a proliferação celular, a saber: Grupo controle (sem Interleucina - 1ß): definiu-se esse grupo como apresentando 100±4,5 por cento de proliferação celular. Nos demais grupos, a quantidade de Interleucina - 1ß administrada e a proliferação celular aferida foram, respectivamente, 0,1 ng/mL:112±0,7 por cento; 1 ng/mL:83,8±4,7 por cento; 10 ng/mL:69,1±3,8 por cento; 100 ng/mL:67,3±10,9 por cento; (p<0,01). CONCLUSÕES: Estes resultados indicam que a administração de quantidade crescente de Interleucina - 1ß inibe a proliferação de células primárias de músculo liso, cultivadas a partir de veias safenas humanas. Isso sugere que o processo de apoptose, observado já em fase precoce (um dia) de exposição do enxerto venoso a regime pressórico arterial, pode estar relacionado à ação dessa citocina.