Anesthetic protocol for right ventricular dysfunction management in heart transplantation: systematic review, development and validation.

BACKGROUND: Right Ventricular Dysfunction (RVD) is the most frequent intraoperative hemodynamic complication in Heart Transplantation (HTx). RVD occurs in 0.04-1.0% of cardiac surgeries with cardiotomy and in 20-50% of HTx, with mortality up to 75%. No consensus has been established for how anesthesiologists should manage RVD, with management methods many times remaining unvalidated. METHODS: We conducted a systematic review, following PRISMA guidelines, to create an anesthetic protocol to manage RVD in HTx, using databases that include PubMed and Embase, until September 2018 based on inclusion and exclusion criteria. The articles screening for the systematic review were done two independent reviewers, in case of discrepancy, we consulted a third independent reviewer. Based on the systematic review, the anesthetic protocol was developed. The instrument selected to perform the validation of the protocol was AGREE II, for this purpose expert anesthetists were recruited to do this process. The minimum arbitration score for domains validation cutoff of AGREE II is arbitered to 70%. This study was registered at PROSPERO (115600). RESULTS: In the systematic review, 152 articles were included. We present the protocol in a flowchart with six steps based on goal-directed therapy, invasive monitoring, and transesophageal echocardiogram. Six experts judged the protocol and validated it. CONCLUSION: The protocol has been validated by experts and new studies are needed to assess its applicability and potential benefits on major endpoints.

Chagas Cardiomyopathy in Latin America Review.

PURPOSE OF REVIEW: Chagas cardiomyopathy is a major public health disease in Latin America and, due to migration, is becoming a worldwide health and economic burden. This review sought to present the clinical and epidemiological aspects of Chagas cardiomyopathy, as well as some specific features and principles of treatment. We also retrospectively assessed our institutional experience with mechanical circulatory support in refractory heart failure due to Chagas cardiomyopathy over a 10-year period. RECENT FINDINGS: The role of antiparasitic treatment in patients with heart failure due to Chagas cardiomyopathy is controversial. Heart transplantation, although formerly contraindicated, is currently established as an important therapeutic option. Also, the favorable characteristics of Chagas patients, such as younger age, little comorbidity, and no reoperations or severe pulmonary hypertension, could be an advantage for a mechanical circulatory support indication in advanced heart failure due to Chagas cardiomyopathy. Despite the absence of large evidence-based data, much has been accomplished since Carlos Chagas' discovery one century ago. Our institutional experience shows that mechanical circulatory support in Chagas patients is associated with more successful bridging to heart transplantation when compared to non-Chagas patients.

Proposal of an Integrated Health Care Network System for Patients with Congenital Heart Defects.

The perspective of the integrated health system has a network of care with multiple integration dimensions among subsystems as nuclear representation, relating the clinical aspects and governance to the representations and collective values. The normative integration aims to ensure coherence between the system of representations and values of society simultaneously with the interfaces of clinical and functional integration. It builds a bridge with governance, which allows, through their skills, management of all system components, encouraging cooperation, communication and information, in order to ensure the population under their responsibility to access excellence services, exceeding their expectations. The integration of care consists of a durable coordination of clinical practices for those who suffer from health problems in order to ensure continuity and full range of the required professional services and organizations, coordinated in time and space, in accordance with the available knowledge. It is possible to establish the type of health equipment for each level of care for patients with congenital heart diseases. This strategy intends to offer timely care in appropriate moments and places, efficiently, operating cooperatively an interdependently, with ongoing exchange of its resources. Thus, situational integration establishes the system connection with the assessment environment that proposes to carry out value judgment, guided by an objective worldview, about an intervention or any of its components, in order to objectify the decision making.

Proposal of an integrated health care network system for patients with congenital heart defects

ABSTRACT The perspective of the integrated health system has a network of care with multiple integration dimensions among subsystems as nuclear representation, relating the clinical aspects and governance to the representations and collective values. The normative integration aims to ensure coherence between the system of representations and values of society simultaneously with the interfaces of clinical and functional integration. It builds a bridge with governance, which allows, through their skills, management of all system components, encouraging cooperation, communication and information, in order to ensure the population under their responsibility to access excellence services, exceeding their expectations. The integration of care consists of a durable coordination of clinical practices for those who suffer from health problems in order to ensure continuity and full range of the required professional services and organizations, coordinated in time and space, in accordance with the available knowledge. It is possible to establish the type of health equipment for each level of care for patients with congenital heart diseases. This strategy intends to offer timely care in appropriate moments and places, efficiently, operating cooperatively an interdependently, with ongoing exchange of its resources. Thus, situational integration establishes the system connection with the assessment environment that proposes to carry out value judgment, guided by an objective worldview, about an intervention or any of its components, in order to objectify the decision making.

Evolução clínica e capacidade funcional de pacientes com cardiomiopatia dilatada após quatro anos do transplante / Clinical and functional capacity of patients with dilated cardiomyopathy after four years of transplantation

OBJETIVO: Avaliar a evolução do paciente miocardiopata após transplante (Tx) cardíaco, analisando sua sobrevida, complicações trans e pós-operatórias e respostas cardiovasculares após cerca de quatro anos do procedimento cirúrgico. MÉTODOS: A pesquisa foi realizada no período de fevereiro a maio de 2011, com pacientes submetidos a Tx cardíaco no Hospital Dr. Carlos Alberto Studart Gomes - Hospital de Messejana (HDM). A amostra foi composta de todos os pacientes transplantados no ano de 2007 no referido hospital. Inicialmente, foi aplicada uma ficha de avaliação, coletando dados dos prontuários, sobre a evolução do paciente no período trans e pós-operatório até a alta hospitalar. Após a coleta dessas informações, os pacientes foram submetidos ao teste da caminhada dos seis minutos (TC6). Os valores encontrados na distância percorrida foram comparados aos valores de referência esperados para a população utilizando a equação de Enright e Sherrill. RESULTADOS: Do total de 24 pacientes que realizaram Tx cardíaco no HDM no ano de 2007, 14 foram avaliados e 10 excluídos do estudo. Com relação às complicações, no período transoperatório, a mais evidenciada foi a disfunção do ventrículo direito (64,3%) e, no pós-operatório, quadro de taquicardia (64,3%). Analisando o TC6 observou-se diminuição de 11,6% na distância percorrida quando comparada à distância estimada (486 ± 55 m, 550 ± 59 m, respectivamente). CONCLUSÃO: Os resultados obtidos neste estudo perante o TC6 evidenciam que as respostas cardiovasculares dos pacientes avaliados estão abaixo do estimado, contudo dentro da faixa de normalidade estabelecida.

OBJECTIVE: To evaluate patient with cardiomyopathy's progress after cardiac transplant, by analyzing his survival, complications and cardiovascular responses after nearly four years of surgery. METHODS: The survey was conducted from February to May 2011, with patients undergoing cardiac transplantation at Dr. Carlos Alberto Studart Gomes Hospital - Messejana Hospital (HDM). The sample consisted of all transplanted patients in 2007 in this hospital. Initially an evaluation form developed by the researchers, which was based on collected data from patients' medical records, was applied, about trans and postoperative period. After collecting these informations, patients underwent the six-minute walk test (6WT). The marks found in walking distance were compared with reference marks expected for this population by using Enright and Sherrill's equation. RESULTS: From all the 24 patients who underwent cardiac transplantation in HDM in 2007, 14 were evaluated and 10 were excluded. Regarding the complications, in the trans-operatory period, the most evident was the right ventricular dysfunction (64.3%) and tachycardia (64.3%) was more evident on the postoperative period. Analyzing the 6WT it was observed a decrease of 11.6% in walking distance when compared with the estimated distance (486 ± 55 m, 550 ± 59 m, respectively). CONCLUSION: Survival of heart transplant patients was equivalent to about 70%. The results of this study before the 6WT showed that patients' cardiovascular responses are below the estimated, nevertheless within the normal range established.

Importance of anemia in the chronic Cardiorenal syndrome: effects on renal function after heart transplantation.

BACKGROUND: Cardiorenal syndrome has been recently divided into 5 categories, according to acute or chronic evolution and primary organ dysfunction. Anemia can also accompany this disorder, leading to a more complex situation. This study aims to analyze the renal outcomes of patients, specifically patients with chronic Cardiorenal syndrome, with or without anemia, long-term after heart transplantation. MATERIAL/METHODS: This was a retrospective cohort study on chronic Cardiorenal syndrome patients submitted to heart transplantation. Patients were divided according to presence of anemia and renal dysfunction before heart transplantation. RESULTS: A total of 108 patients (92 males) with the mean age of 45±12 years were included. The etiologies of the heart failure were hypertensive dilated myocardiopathy (66%), ischemic (14%) and Chagasic (12%). Before the heart transplantation, 51 patients had an eGFR less than 60 mL/min. From these, 24 had concomitant anemia. One year after the transplantation, patients with previous isolated renal dysfunction ameliorates eGFR (45±11 vs. 65±26 mL/min, p<0.001), while those patients with previous renal dysfunction and anemia presented no improvement (eGFR 44±14 vs. 47±13 mL/min, p=0.619) 1 year after heart transplantation. Moreover, higher hemoglobin was an independent predictor of eGFR improvement after heart transplantation when associated with previous renal dysfunction (OR 1.8; CI 1.2-3.6, p<0.01 for each hemoglobin increment of 1 g/dL). CONCLUSIONS: Patients with isolated Cardiorenal syndrome presented partial renal function recovery after heart transplantation, while the presence of cardiorenal anemia was a marker of renal function non-recovery 1 year after heart transplantation.

Clinical and functional capacity of patients with dilated cardiomyopathy after four years of transplantation.

OBJECTIVE: To evaluate patient with cardiomyopathy's progress after cardiac transplant, by analyzing his survival, complications and cardiovascular responses after nearly four years of surgery. METHODS: The survey was conducted from February to May 2011, with patients undergoing cardiac transplantation at Dr. Carlos Alberto Studart Gomes Hospital - Messejana Hospital (HDM). The sample consisted of all transplanted patients in 2007 in this hospital. Initially an evaluation form developed by the researchers, which was based on collected data from patients' medical records, was applied, about trans and postoperative period. After collecting these informations, patients underwent the six-minute walk test (6WT). The marks found in walking distance were compared with reference marks expected for this population by using Enright and Sherrill's equation. RESULTS: From all the 24 patients who underwent cardiac transplantation in HDM in 2007, 14 were evaluated and 10 were excluded. Regarding the complications, in the trans-operatory period, the most evident was the right ventricular dysfunction (64.3%) and tachycardia (64.3%) was more evident on the postoperative period. Analyzing the 6WT it was observed a decrease of 11.6% in walking distance when compared with the estimated distance (486 ± 55 m, 550 ± 59 m, respectively). CONCLUSION: Survival of heart transplant patients was equivalent to about 70%. The results of this study before the 6WT showed that patients' cardiovascular responses are below the estimated, nevertheless within the normal range established.

Pulmonary artery banding: a simple procedure? A critical analysis at a tertiary center.

OBJECTIVE: Although pulmonary artery banding (PAB) seems to be a technically simple procedure it presents several peculiarities and is related to a significant morbidity and mortality. The aim of this study is to analyze the experience of a tertiary hospital on the PAB by assessing and correlating many aspects related to the procedure. METHODS: Between January 2000 and December 2008, 61 patients undergone PAB due to congenital heart disease with increased pulmonary blood flow at Messejana Heart Hospital were assessed as for mortality, complications, stay in mechanical ventilation and need for intensive care unit (ICU), use of vasoactive drugs, difficulties in the adjustment on the banding and reoperations. Some statistical analyzes were performed to compare the subgroups. RESULTS: In 46.8% of the patients the intended pressoric adjustment was not achieved and in 6.5% it was necessary another surgery to readjust the banding. The mean time of mechanical ventilation was 14.1+/-49.6 days and ICU 14.16+/-10.92 days. In 82.6% of the patients vasoactives drugs were administrated for 10.3+/-12.79 days. Severe complications were noted in 49.15% of patients and cardiac insufficiency was the most common one with an incidence of 44%. The mortality rate was 8.2% and it was not influenced by weight or associated procedures with the PAB neither if univentricular or biventricular heart disease. CONCLUSION: The PAB can be performed with acceptable mortality rates compatible with the ones of the world literature. Nevertheless, the adjustment of the banding is difficult to be assessed during the surgery by making the procedure complex and justifying the high incidence of complications and long stay in ICU. It wasn't found any specific risk factor significant to mortality neither uni- or biventricular heart disease.

Bandagem da artéria pulmonar: uma cirurgia simples? Uma análise crítica em um centro terciário / Pulmonary artery banding: a simple procedure? A critical analysis at a tertiary center

OBJETIVO: A bandagem da artéria pulmonar (BAP) é um procedimento tecnicamente simples, mas envolto em várias peculiaridades que o fazem apresentar elevadas taxas de morbidade e mortalidade. O objetivo deste estudo é analisar a experiência de um hospital de referência na bandagem da artéria pulmonar, avaliando e correlacionando diversas variáveis relacionadas ao procedimento. MÉTODOS: Entre janeiro de 2000 e dezembro de 2008, 61 pacientes submetidos a BAP por cardiopatia congênita de hiperfluxo no Hospital do Coração de Messejana-Fortaleza/CE foram avaliados quanto a mortalidade, complicações, permanência em ventilação mecânica (VM) e terapia intensiva (UTI), uso de drogas vasoativas, dificuldade de ajustes transoperatórios e reoperações para reajuste. Análise estatística foi realizada para comparações entre subgrupos. RESULTADOS: Em 46,8 por cento dos pacientes, não se conseguiu o ajuste pressórico pretendido e 6,5 por cento precisaram ser reoperados para reajustes. O tempo médio UTI e VM foi 14,16 ± 10,92 dias e 14,1 ± 49,6 dias, respectivamente. Em 82,6 por cento dos pacientes foram administradas drogas vasoativas por 10,30 ± 12,79 dias. Complicações graves incidiram em 49,15 por cento dos pacientes, com predominância da insuficiência cardíaca (44 por cento). A taxa de mortalidade foi de 8,2 por cento, não influenciada por peso, procedimentos associados ou cardiopatia univentricular ou biventricular. CONCLUSÃO: Neste estudo, a BAP foi realizada com taxas de mortalidade aceitáveis, compatíveis com a literatura mundial. No entanto, os ajustes transoperatórios são de difícil análise, tornando o procedimento complexo e justificando elevados índices de complicações, resultando em longa permanência em UTI. Nenhuma variável isolada representou significante fator de risco, dentre as quais, fisiologia uni ou biventricular

OBJECTIVE: Although pulmonary artery banding (PAB) seems to be a technically simple procedure it presents several peculiarities and is related to a significant morbidity and mortality. The aim of this study is to analyze the experience of a tertiary hospital on the PAB by assessing and correlating many aspects related to the procedure. METHODS: Between January 2000 and December 2008, 61 patients undergone PAB due to congenital heart disease with increased pulmonary blood flow at Messejana Heart Hospital were assessed as for mortality, complications, stay in mechanical ventilation and need for intensive care unit (ICU), use of vasoactive drugs, difficulties in the adjustment on the banding and reoperations. Some statistical analyzes were performed to compare the subgroups. RESULTS: In 46.8 percent of the patients the intended pressoric adjustment was not achieved and in 6.5 percent it was necessary another surgery to readjust the banding. The mean time of mechanical ventilation was 14.1±49.6 days and ICU 14.16±10.92 days. In 82.6 percent of the patients vasoactives drugs were administrated for 10.3±12.79 days. Severe complications were noted in 49.15 percent of patients and cardiac insufficiency was the most common one with an incidence of 44 percent. The mortality rate was 8.2 percent and it was not influenced by weight or associated procedures with the PAB neither if univentricular or biventricular heart disease. CONCLUSION: The PAB can be performed with acceptable mortality rates compatible with the ones of the world literature. Nevertheless, the adjustment of the banding is difficult to be assessed during the surgery by making the procedure complex and justifying the high incidence of complications and long stay in ICU. It wasn't found any specific risk factor significant to mortality neither uni- or biventricular heart disease

Uso do óxido nítrico inalatório no tratamento da crise hipertensiva pulmonar no pós-operatório de transplante cardíaco / Inhalation the nitric oxide in therapy hypertension and pulmonary therapy

OBJETIVO: Este trabalho relata a experiência no manuseio da crise hipertensiva pulmonar (CHP) refratária, com o uso do óxido nítrico inalatório (NOi) no pós-operatório imediato do transplante cardíaco (TC) ortotópico. MÉTODOS: De outubro/1997 a fevereiro/2002 foram realizados 31 TC em adultos, sendo incluídos pacientes com RVP < 6uW, ou < 2,5uW na prova farmacológica. Após o período de circulação extracorpórea (CEC) (M=101±21 minutos), todos fizeram uso de dobutamina, dopamina e milrinona; entretanto, frente à ausência de resposta adequada e CHP, administrou-se NOi em doses crescentes de 20 a 40ppm. Foram utilizados registros das pressões através de cateter no átrio esquerdo e no tronco da artéria pulmonar, gasometria arterial seriada e ecocardiograma transtorácico (ETT). O tempo médio de morte encefálica (ME) do doador foi de 16±5,1horas.RESULTADOS: Cinco pacientes (1 mulher), com idade média de 42 anos, fizeram uso de NOi por apresentarem critérios de CHP, todos com sinais de baixo débito cardíaco. O tempo médio de CEC foi de 150,8±34,3 minutos, a média sistólica arterial pulmonar foi de 87mmHg (75-115) e a PO2 média de 60mmHg (FiO2 100 por cento), sendo evidenciada dilatação moderada a severa do ventrículo direito no ETT. Foi administrado NOi durante uma média 35h (6-96), iniciando-se desmame após estabilização hemodinâmica. O tempo médio de ME do doador foi de 27,6±5,5horas, a internação hospitalar média foi de 63 dias (17-145), uma morte ocorreu por sepse no 17º PO e os demais pacientes estão em CF I (NYHA). CONCLUSÕES: O tempo de CEC superior a 120 minutos e tempo de ME do doador superior a 20 horas sugerem fatores de risco para CHP no período pós-operatório imediato do TC. O NOi é uma ferramenta útil no manuseio desta complicação, refratária ao tratamento convencional no POI de pacientes submetidos ao TC

Baixas doses de óxido nítrico na seleçäo dos pacientes candidatos a transplante cardíaco com hipertensäo pulmonar / Low doses of nitric oxide in the selection of candidates to heart transplantation with pulmonary hypertension

A disfunçäo do ventrículo direito no pós-operatório do transplante cardíaco é uma complicaçäo freqüente com morbimortalidade elevada. A avaliaçäo hemodinâmica pulmonar dos candidatos precisa, às vezes, do emprego de prova farmacológica com o uso de drogas endovenosas vasodilatadoras tipo nitroprussiato de sódio (NTPNa), visando reduzir os níveis de pressäo e resistência vascular pulmonar (RVP) elevados a níveis compatíveis com os protocolos de inclusäo dos Programas de Transplante Cardíaco. Valores de RVP acima de 6 unidades Wood sem droga vasodilatadora, ou acima de 2,5 com a utilizaçäo destas, excluem os pacientes do Programa. Entre janeiro de 1997 e janeiro de 2000 foram submetidos a cateterismo direito, 40 pacientes candidatos a transplante. A maioria homens, com idade média (+ or - 12 anos). As etiologias mais encontradas foram miocardiopatia dilatada idiopática (59 por cento) e miocardiopatia isquêmica (25 por cento). Todos em CF IV da NYHA, com fraçäo de ejeçäo média do ventrículo esquerdo de 0,21 (+ ou - 0,03). A monitorizaçäo do débito cardíaco (DC), pressäo da artéria pulmonar (PAP) e RVP foi feita pelo método contínuo, utilizando para isto cateter de artéria pulmonar especial. Em 5 pacientes a prova farmacológica foi interrompida devido aos efeitos sistêmicos do NTPNa com queda da PAM, RVP e DC. Todos foram submetidos a inalaçäo de óxido nítrico (NO) por máscara, a uma dose de 20 ppm durante 10 minutos. Em 3, a RVP reduziu de 7,8 (+ ou - 0,88) para 2,4 (+ ou -0,36) unidades Wood, e eles foram incluídos no Programa de Transplante. Nos outros 2, apesar de doses de NO de 20,30 e 40 ppm, a reduçäo foi de 8,4 ( + ou - 2,12) para 4,9 (+ ou - 0,42) unidades Wood, ou seja, insuficiente para serem incluídos nos Programas de Transplante. Näo tivemos óbitos, nem complicaçöes durante os procedimentos. O NO inalatório na avaliaçäo hemodinâmica dos candidatos a TC -- pelo seu efeito vasodilatador seletivo -- permite identificar aqueles com hiper-resistência vascular pulmonar, que näo respondem ao uso de drogas vasodilatadoras endovenosas convencionais, evitando que sejam excluídos dos benefícios do procedimento do TC