Prosthesis-Patient Mismatch after Surgical Aortic Valve Replacement: Neither Uncommon nor Harmless.

Prosthesis-patient mismatch (PPM) after surgical aortic valve replacement (SAVR) is an issue that has been overlooked (not to say neglected). Cardiac surgeons must bear in mind that this is a real problem that we must tackle. The purpose of this paper is to be a wake-up call to the surgical community by giving a brief overview of what PPM is, its incidence and impact on the outcomes. We also discuss the increasing role played by imaging for predicting and assessing PPM after SAVR (with which surgeons must become more acquainted) and, finally, we present some options to avoid PPM after the surgical procedure.

Prosthesis-patient mismatch after surgical aortic valve replacement: neither uncommon nor harmless

Abstract Prosthesis-patient mismatch (PPM) after surgical aortic valve replacement (SAVR) is an issue that has been overlooked (not to say neglected). Cardiac surgeons must bear in mind that this is a real problem that we must tackle. The purpose of this paper is to be a wake-up call to the surgical community by giving a brief overview of what PPM is, its incidence and impact on the outcomes. We also discuss the increasing role played by imaging for predicting and assessing PPM after SAVR (with which surgeons must become more acquainted) and, finally, we present some options to avoid PPM after the surgical procedure.

Closure of Patent Foramen Ovale versus Medical Therapy after Cryptogenic Stroke: Meta-Analysis of Five Randomized Controlled Trials with 3440 Patients.

OBJECTIVE: We aimed to determine whether patent foramen ovale closure reduces the risk of stroke, also assessing some safety outcomes. INTRODUCTION: The clinical benefit of closing a patent foramen ovale after a cryptogenic stroke has been an open question for several decades, so that it is necessary to review the current state of published medical data in this regard. METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LI-LACS, Google Scholar and reference lists of relevant articles were searched for randomized controlled trials that reported any of the following outcomes: stroke, death, major bleeding or atrial fibrillation. Five studies fulfilled our eligibility criteria and included 3440 patients (1829 for patent foramen ovale closure and 1611 for medical therapy). RESULTS: The risk ratio (RR) for stroke in the "device closure" group compared with the "medical therapy" showed a statistically significant difference between the groups, favouring the "device closure" group (RR 0.400; 95% CI 0.183-0.873, P=0.021). There was no statistically significant difference between the groups regarding the safety outcomes death and major bleeding, but we observed an increase in the risk of atrial fibrillation in the "device closure group (RR 4.000; 95% CI 2.262-7.092, P<0.001). We also observed that the larger the proportion of effective closure, the lower the risk of stroke. CONCLUSION: This meta-analysis found that stroke rates are lower with percutaneously implanted device closure than with medical therapy alone, being these rates modulated by the rates of effective closure.

Closure of patent foramen ovale versus medical therapy after cryptogenic stroke: meta-analysis of five randomized controlled trials with 3440 patients

Abstract Objective: We aimed to determine whether patent foramen ovale closure reduces the risk of stroke, also assessing some safety outcomes. Introduction: The clinical benefit of closing a patent foramen ovale after a cryptogenic stroke has been an open question for several decades, so that it is necessary to review the current state of published medical data in this regard. Methods: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LI-LACS, Google Scholar and reference lists of relevant articles were searched for randomized controlled trials that reported any of the following outcomes: stroke, death, major bleeding or atrial fibrillation. Five studies fulfilled our eligibility criteria and included 3440 patients (1829 for patent foramen ovale closure and 1611 for medical therapy). Results: The risk ratio (RR) for stroke in the "device closure" group compared with the "medical therapy" showed a statistically significant difference between the groups, favouring the "device closure" group (RR 0.400; 95% CI 0.183-0.873, P=0.021). There was no statistically significant difference between the groups regarding the safety outcomes death and major bleeding, but we observed an increase in the risk of atrial fibrillation in the "device closure group (RR 4.000; 95% CI 2.262-7.092, P<0.001). We also observed that the larger the proportion of effective closure, the lower the risk of stroke. Conclusion: This meta-analysis found that stroke rates are lower with percutaneously implanted device closure than with medical therapy alone, being these rates modulated by the rates of effective closure.

CABG Surgery Remains the best Option for Patients with Left Main Coronary Disease in Comparison with PCI-DES: Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: To compare the safety and efficacy of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. METHODS: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at 1-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Five studies fulfilled our eligibility criteria and they included a total of 4.595 patients (2.298 for CABG and 2.297 for PCI with DES). RESULTS: At 1-year follow-up, there was no significant difference between CABG and DES groups concerning the risk for death (risk ratio [RR] 0.973, P=0.830), myocardial infarction (RR 0.694, P=0.148), stroke (RR 1.224, P=0.598), and major adverse cerebrovascular and cardiovascular events (RR 0.948, P=0.680). The risk for target vessel revascularization (TVR) was significantly lower in the CABG group compared to the DES group (RR 0.583, P<0.001). It was observed no publication bias regarding the outcomes, but only the outcome TVR was free from substantial statistical heterogeneity of the effects. In the meta-regression, there was evidence that the factor "female gender" modulated the effect regarding myocardial infarction rates, favoring the CABG strategy. CONCLUSION: CABG surgery remains the best option of treatment for patients with ULMCA disease, with lower TVR rates.

CABG surgery remains the best option for patients with left main coronary disease in comparison with pci-des: meta-analysis of randomized controlled trials

Abstract Objective: To compare the safety and efficacy of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. Methods: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at 1-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Five studies fulfilled our eligibility criteria and they included a total of 4.595 patients (2.298 for CABG and 2.297 for PCI with DES). Results: At 1-year follow-up, there was no significant difference between CABG and DES groups concerning the risk for death (risk ratio [RR] 0.973, P=0.830), myocardial infarction (RR 0.694, P=0.148), stroke (RR 1.224, P=0.598), and major adverse cerebrovascular and cardiovascular events (RR 0.948, P=0.680). The risk for target vessel revascularization (TVR) was significantly lower in the CABG group compared to the DES group (RR 0.583, P<0.001). It was observed no publication bias regarding the outcomes, but only the outcome TVR was free from substantial statistical heterogeneity of the effects. In the meta-regression, there was evidence that the factor "female gender" modulated the effect regarding myocardial infarction rates, favoring the CABG strategy. Conclusion: CABG surgery remains the best option of treatment for patients with ULMCA disease, with lower TVR rates.

Stopping versus continuing acetylsalicylic acid before coronary artery bypass surgery: A systematic review and meta-analysis of 14 randomized controlled trials with 4499 patients.

This study aimed to evaluate the efficacy and safety of continuing versus stopping aspirin [acetylsalicylic acid (ASA)] preoperatively in patients undergoing coronary artery bypass graft surgery. MEDLINE, EMBASE, CENTRAL/Cochrane Controlled Trials Register (CCTR), ClinicalTrials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino Americana em Ciências da Saúde (LILACS), Google Scholar and reference lists of relevant articles were searched for randomized controlled trials that reported efficacy outcomes of myocardial infarction and mortality, and safety outcomes of blood loss, packed red blood cell transfusion and surgical re-exploration were compared between groups. Fourteen studies fulfilled our eligibility criteria and included a total of 4499 patients (2329 for 'continuing ASA' and 2170 for 'stopping ASA'). In the pooled analysis, continuing aspirin therapy did not reduce the risk of myocardial infarction [risk ratio 0.834, 95% confidence interval (CI) 0.688-1.010; P = 0.063] or operative mortality (risk ratio 1.384, 95% CI 0.727-2.636; P = 0.323). Preoperative ASA increased postoperative chest tube drainage (mean difference 143 ml, 95% CI 39-248 ml; P = 0.007) and packed red blood cell transfusion (mean difference 142 ml, 95% CI 55-228; P = 0.001) but did not increase the risk of surgical re-exploration (risk ratio 1.316, 95% CI 0.910-1.905; P = 0.145). This meta-analysis found no statistically significant difference regarding the risk of operative mortality and myocardial infarction between the 'continuing ASA' and 'stopping ASA' strategies. On the other hand, the mean volume of blood loss and packed red blood cell transfusion was higher in the 'continuing ASA' group, but this finding did not translate into higher risk of reoperation for bleeding.

EuroSCORE e mortalidade em cirurgia de revascularização miocárdica no Pronto Socorro Cardiológico de Pernambuco / EuroSCORE and mortality in coronary artery bypass graft surgery at Pernambuco Cardiologic Emergency Medical Services [Pronto Socorro Cardiológico de Pernambuco]

OBJETIVOS: O objetivo desse estudo foi avaliar a aplicabilidade do EuroSCORE em pacientes submetidos à cirurgia de revascularização miocárdica na Divisão de Cirurgia Cardiovascular do Pronto Socorro Cardiológico de Pernambuco - PROCAPE. MÉTODOS: Estudo retrospectivo envolvendo 500 pacientes operados entre maio de 2007 a abril de 2010. Os registros continham todas as informações utilizadas para calcular o EuroSCORE. O desfecho de interesse foi óbito. Análises univariada e multivariada por regressão logística backward foram aplicadas para verificar associação entre cada variável do EuroSCORE e ocorrência de óbito. Foram calculadas medidas de sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo. O poder de concordância do EuroSCORE entre mortalidade prevista e observada foi mensurado por meio do índice Kappa. A acurácia do modelo foi avaliada por meio da curva ROC (receiver operating characteristic). RESULTADOS: A ocorrência de morte foi de 13 por cento (n=65). Na análise multivariada, nove fatores permaneceram como preditores independentes de morte: doença pulmonar obstrutiva crônica, creatinina >2,3mg/dL, endocardite ativa, estado crítico no pré-operatório, angina instável, fração de ejeção de 30 por cento-50 por cento, infarto agudo do miocárdio <90 dias, cirurgia de emergência e cirurgia adicional. O escore obteve sensibilidade de 88,4 por cento, especificidade de 79,3 por cento, valor preditivo positivo de 40,7 por cento, valor preditivo negativo de 97,7 por cento e 80,6 por cento de concordância. A acurácia mensurada pela área sob a curva ROC foi de 0,892 (IC 95 por cento 0,862-0,922). CONCLUSÕES: O EuroSCORE mostrou-se um índice simples e objetivo, revelando-se um discriminador satisfatório de evolução pós-operatória em pacientes submetidos à cirurgia de revascularização miocárdica em nossa instituição.

OBJECTIVE: The aim of this study is to evaluate the applicability of EuroSCORE in patients undergoing coronary artery bypass graft (CABG) surgery at the Division of Cardiovascular Surgery of Pernambuco Cardiologic Emergency Medical Services - PROCAPE. METHODS: A retrospective study involving 500 patients operated between May 2007 and April 2010. The registers contained all the information used to calculate the EuroSCORE. The outcome of interest was death. Univariate analysis and multivariate analysis by backward logistic regression were applied to assess the association between each variable in the EuroSCORE and deaths. The following parameters were calculated: sensitivity, specificity, positive predictive value, and negative predictive value. The power of concordance between the predicted mortality by the EuroSCORE and the observed mortality was measured using the Kappa coefficient. The accuracy of the model was evaluated by the ROC (receiver operating characteristic) curve. RESULTS: The incidence of death was 13 percent. In multivariate analysis, nine variables remained independent predictors of death: chronic obstructive pulmonary disease, creatinine >2,3mg/dL, active endocarditis, preoperative critical state, unstable angina, ejection fraction 30 percent to 50 percent, acute myocardial infarction < 90 days, emergency surgery and additional surgery. The score had a sensitivity of 88.4 percent, specificity of 79.3 percent, positive predictive value of 40.7 percent, negative predictive value of 97.7 percent and 80.6 percent concordance. The accuracy measured by the area under the ROC curve was 0.892 (95 percent CI 0.862-0.922). CONCLUSIONS: The EuroSCORE proved to be a simple and objective index, revealing a satisfactory discriminator of postoperative evolution in patients undergoing CABG surgery at our institution.

Treatment of atrial fibrillation using ultrasonic cardiac ablation, during valvular heart surgery.

OBJECTIVE: This study aims to evaluate the surgical treatment of atrial fibrillation with ultrasound ablation concomitant to mitral surgery in PROCAPE's patients with permanent atrial fibrillation. METHODS: From March 2008 through January 2009 a prospective study was performed at the Pernambuco Cardiology Emergency Facility on 44 consecutive patients with a permanent atrial fibrillation and concomitant cardiac valvular surgery indication, from March 2008 through January 2009 at Pernambuco Cardiology Emergency Facility Twenty two patients underwent epicardial ultrasonic ablation on the right atrium and had ultrasonic ablation performed in the left atrium endocardial concomitant with the valve procedure. The other 22 patients, the concurrent controls were submitted to valve procedure without ultrasonic ablation. Patients with serious diseases such as coronary and others were excluded of the research. RESULTS: It was observed 90% restoration to sinus rhythm immediately after surgery in patients submitted to treatment of atrial fibrillation with ultrasound ablation simultaneous a mitral surgery. The evolution in late post operation showed that the maintenance of sinus rhythm drops although it was still 27% higher in the group which received ablation compared with the control group. 86.40% of the patients who received ablation had improved in functional class; they also have fewer complications than patients in the control group. CONCLUSION: The results showed that the patients who received treatment for atrial fibrillation simultaneously with valvar surgery had advantages related to the control group.

Clinical and surgical profile of patients operated for postinfarction interventricular septal rupture.

OBJECTIVES: To study clinical features, complications and in-hospital outcomes of patients operated for postinfarction ventricular septal rupture. METHODS: A retrospective study involving 21 patients between January/1996 and June/2009. All operations were performed at the Division of Cardiovascular Surgery of Complexo Hospitalar HUOC/PROCAPE. RESULTS: Mean age of patients was 62.81 years (± 8.21), 61.9% (n = 13) were male. Rupture occurred on average 4.8 days after infarction. Cardiogenic shock was observed in 57.1% (n = 12), being risk factor for death (100% with shock vs. 22.2% without shock; P<0.001). Survivors had a higher mean ejection fraction compared to deaths (66.29% ± 4.61% versus 42.71% ± 4.79%, P <0.001). All were classified as high risk by the EuroSCORE, and the survivors had lower average score compared to deaths (6.57 ± 0.53 versus 10.93 ± 2.23; P <0.001). The majority (76.2%, n = 16) of the patients needed to use vasoactive drugs and 57.1% (n = 12) considered hemodynamically unstable. Need for vasoactive drugs was a risk factor for death (81.3% with vasoactive drugs versus 20% without vasoactive drugs, P = 0.025). Hemodynamic instability was also a risk factor for death (100% in the unstable group versus 22.2% in the stable group; P <0.001). The rate of in-hospital mortality was 66.7% (n = 14). CONCLUSIONS: The need for vasoactive drugs, hemodynamic instability and cardiogenic shock were associated with higher rates of mortality. Patients who had adverse outcomes had less ventricular function and higher score in the EuroSCORE. Mortality remains high.

Tratamento da fibrilação atrial com ablação por ultrassom, durante correção cirúrgica de doença valvar cardíaca / Treatment of atrial fibrillation using ultrasonic cardiac ablation, during valvular heart surgery

OBJETIVO: Este estudo visa avaliar a eficácia do tratamento cirúrgico da fibrilação atrial com ablação por ultrassom, concomitante à cirurgia valvar mitral, em pacientes do Pronto Socorro Cardiológico de Pernambuco (PROCAPE) portadores de fibrilação atrial permanente. MÉTODOS: De março 2008 até janeiro 2009, foi realizado no PROCAPE um estudo prospectivo com 44 pacientes consecutivos, portadores de fibrilação atrial permanente e indicação de cirurgia valvar mitral. Vinte e dois pacientes foram submetidos à ablação com ultrassom no epicárdio do átrio direito (AD) e no endocárdio do átrio esquerdo (AE) concomitantemente ao reparo valvar. Os outros 22 pacientes foram submetidos ao procedimento valvar sem ablação por ultrassom. Pacientes com doença coronária diagnosticada e outras enfermidades graves foram excluídos da pesquisa. RESULTADOS: Foi observada 90 por cento de reversão da FA a ritmo sinusal no pós-operatório imediato dos pacientes que receberam ablação por ultrassom concomitante ao reparo mitral. A evolução no pós-operatório tardio mostrou queda na permanência da reversão a sinusal, porém o grupo que recebeu intervenção ainda apresentou percentual superior a 27 por cento em relação ao grupo controle. Dos 22 pacientes submetidos à ablação com ultrassom, 86,40 por cento apresentaram melhora da classe funcional e não foi constatado neste grupo maior ocorrência de complicações do que no grupo que foi submetido à correção valvar sem ablação. CONCLUSÃO: Os resultados apresentados pelo estudo demonstraram que os pacientes submetidos a tratamento cirúrgico da FA, com aplicação de ultrassom concomitante à correção valvar, apresentaram vantagens em relação ao grupo controle.

OBJECTIVE: This study aims to evaluate the surgical treatment of atrial fibrillation with ultrasound ablation concomitant to mitral surgery in PROCAPE's patients with permanent atrial fibrillation. METHODS: From March 2008 through January 2009 a prospective study was performed at the Pernambuco Cardiology Emergency Facility on 44 consecutive patients with a permanent atrial fibrillation and concomitant cardiac valvular surgery indication, from March 2008 through January 2009 at Pernambuco Cardiology Emergency Facility Twenty two patients underwent epicardial ultrasonic ablation on the right atrium and had ultrasonic ablation performed in the left atrium endocardial concomitant with the valve procedure. The other 22 patients, the concurrent controls were submitted to valve procedure without ultrasonic ablation. Patients with serious diseases such as coronary and others were excluded of the research. RESULTS: It was observed 90 percent restoration to sinus rhythm immediately after surgery in patients submitted to treatment of atrial fibrillation with ultrasound ablation simultaneous a mitral surgery. The evolution in late post operation showed that the maintenance of sinus rhythm drops although it was still 27 percent higher in the group which received ablation compared with the control group. 86.40 percent of the patients who received ablation had improved in functional class; they also have fewer complications than patients in the control group. CONCLUSION: The results showed that the patients who received treatment for atrial fibrillation simultaneously with valvar surgery had advantages related to the control group.

Perfil clínico-cirúrgico de pacientes operados por ruptura do septo interventricular pós-infarto do miocárdio / Clinical and surgical profile of patients operated for postinfarction interventricular septal rupture

OBJETIVOS: Estudar características clínicas, complicações e desfechos intra-hospitalares de pacientes operados por ruptura do septo interventricular pós-infarto. MÉTODOS: Estudo retrospectivo envolvendo 21 pacientes entre janeiro/1996 e junho/2009. Todas as operações foram realizadas na Divisão de Cirurgia Cardiovascular do Complexo Hospitalar HUOC/PROCAPE. RESULTADOS: Idade média dos pacientes foi de 62,81 anos (± 8,21), sendo 61,9 por cento (n=13) do sexo masculino. Ruptura ocorreu, em média, 4,8 dias após o infarto. Foi observado choque cardiogênico em 57,1 por cento (n=12) dos casos, sendo este fator de risco para óbito (100 por cento com choque vs. 22,2 por cento sem choque; P<0,001). Sobreviventes apresentaram média de fração de ejeção maior em comparação aos óbitos (66,29 por cento ± 4,61 por cento versus 42,71 por cento ± 4,79 por cento; P<0,001). Todos pacientes foram classificados em alto risco pelo EuroSCORE, tendo os sobreviventes média de pontuação menor em comparação aos óbitos (6,57 ± 0,53 versus 10,93 ± 2,23; P<0,001). A maioria (76,2 por cento; n=16) dos pacientes teve necessidade de uso de drogas vasoativas e 57,1 por cento (n=12) foram considerados instáveis hemodinamicamente. Necessidade de drogas vasoativas foi fator de risco para óbito (81,3 por cento no grupo com drogas vasoativas versus 20 por cento no grupo sem drogas vasoativas, P=0,025). Instabilidade hemodinâmica também foi fator de risco para óbito (100 por cento no grupo instável versus 22,2 por cento no grupo estável; P<0,001). A taxa de mortalidade intra-hospitalar foi de 66,7 por cento (n=14). CONCLUSÕES: Necessidade de drogas vasoativas, instabilidade hemodinâmica e choque cardiogênico se associaram com maiores taxas de mortalidade. Pacientes que evoluem com desfecho adverso apresentam menor função ventricular e maior pontuação no EuroSCORE. A taxa de mortalidade permanece alta.

OBJECTIVES: To study clinical features, complications and in-hospital outcomes of patients operated for postinfarction ventricular septal rupture. METHODS: A retrospective study involving 21 patients between January/1996 and June/2009. All operations were performed at the Division of Cardiovascular Surgery of Complexo Hospitalar HUOC/PROCAPE. RESULTS: Mean age of patients was 62.81 years (± 8.21), 61.9 percent (n = 13) were male. Rupture occurred on average 4.8 days after infarction. Cardiogenic shock was observed in 57.1 percent (n = 12), being risk factor for death (100 percent with shock vs. 22.2 percent without shock; P<0.001). Survivors had a higher mean ejection fraction compared to deaths (66.29 percent ± 4.61 percent versus 42.71 percent ± 4.79 percent, P <0.001). All were classified as high risk by the EuroSCORE, and the survivors had lower average score compared to deaths (6.57 ± 0.53 versus 10.93 ± 2.23; P <0.001). The majority (76.2 percent, n = 16) of the patients needed to use vasoactive drugs and 57.1 percent (n = 12) considered hemodynamically unstable. Need for vasoactive drugs was a risk factor for death (81.3 percent with vasoactive drugs versus 20 percent without vasoactive drugs, P = 0.025). Hemodynamic instability was also a risk factor for death (100 percent in the unstable group versus 22.2 percent in the stable group; P <0.001). The rate of in-hospital mortality was 66.7 percent (n = 14). CONCLUSIONS: The need for vasoactive drugs, hemodynamic instability and cardiogenic shock were associated with higher rates of mortality. Patients who had adverse outcomes had less ventricular function and higher score in the EuroSCORE. Mortality remains high.

Postoperative mediastinitis in cardiovascular surgery postoperation. Analysis of 1038 consecutive surgeries.

OBJECTIVE: To report the incidence of mediastinitis in cardiovascular surgery postoperation. METHODS: The records of all 1038 patients who underwent cardiovascular surgical procedures between May/2007 and June/2009 were reviewed. All operations were performed in Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE. RESULTS: The complication occurred within, on average, 13 days after operation, in total of 25 (2.4%), eight (32%) deaths occurred. Several risk factors mediastinitis were identified: 56% diabetes, 56% smokers, 20% obeses, 16% with chronic obstructive pulmonary disease and 8% of chronic renal failure. Mediastinitis were reported in 21 (84%) cases of patients submitted to coronary artery bypass grafting, being associated to major risk of infection development (IC 3.448.30, P=0.0001). High rates of complications were observed: respiratory insufficiency (44%), stroke (16%), cardiogenic shock (12%), acute renal failure (28%), pulmonary infection (36%), multiple organs failure (16%) and esternal deiscence (48%). Bacterial cultures of exudates were positive in 84% of patients; Staphylococcus aureus was the most responsible pathogen (28.8%). CONCLUSION: Mediastinitis stays a serious surgical complication and difficult management in cardiovascular surgery postoperation. The disease stays with low incidence, but still with high lethality. Coronary bypass was associated to major risk of infection development.

Mediastinite no pós-operatório de cirurgia cardiovascular: análise de 1038 cirurgias consecutivas / Mediastinitis in cardiovascular surgery postoperation: analysis of 1038 consecutive surgeries

OBJETIVO: Relatar a incidência de mediastinite no pós-operatório de cirurgia cardiovascular. MÉTODOS: Foram analisados os prontuários de 1038 pacientes submetidos à cirurgia cardiovascular entre maio/ 2007 e junho/2009. Todas as operações foram realizadas na Divisão de Cirurgia Cardiovascular do Pronto Socorro Cardiológico de Pernambuco - PROCAPE. RESULTADOS: A mediastinite ocorreu, em média, 13 dias após a cirurgia, num total de 25 (2,4 por cento) casos, com taxa de letalidade 32,0 por cento (n=8). Vários fatores de risco foram identificados: 56 por cento diabéticos, 56 por cento tabagistas, 20 por cento obesos, 16 por cento portadores de doença pulmonar obstrutiva crônica e 8 por cento com insuficiência renal crônica. A maioria (n=21; 84,0 por cento) dos casos foi observada em pacientes submetidos à revascularização do miocárdio, sendo esta associada a maior risco de desenvolvimento da infecção (IC 3.44-8.30, P=0,0001). Observou-se alto índice de complicações: insuficiência respiratória (44 por cento), acidente vascular cerebral (16 por cento), choque cardiogênico (12 por cento), insuficiência renal aguda (28 por cento), infecção pulmonar (36 por cento), falência de múltiplos órgãos (16 por cento) e deiscência de esterno (48 por cento). A cultura do exsudato foi positiva em 84 por cento dos casos, sendo o Staphylococcus aureus o patógeno mais observado (28,8 por cento). CONCLUSÕES: A mediastinite continua como complicação cirúrgica bastante grave e de difícil manuseio no pós-operatório de cirurgia cardiovascular. A doença permanece como de baixa incidência, entretanto, ainda com alta letalidade. A cirurgia de revascularização está associada a maior risco de desenvolvimento da infecção.

OBJECTIVE: To report the incidence of mediastinitis in cardiovascular surgery postoperation. METHODS: The records of all 1038 patients who underwent cardiovascular surgical procedures between May/2007 and June/2009 were reviewed. All operations were performed in Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE. RESULTS: The complication occurred within, on average, 13 days after operation, in total of 25 (2.4 percent), eight (32 percent) deaths occurred. Several risk factors mediastinitis were identified: 56 percent diabetes, 56 percent smokers, 20 percent obeses, 16 percent with chronic obstructive pulmonary disease and 8 percent of chronic renal failure. Mediastinitis were reported in 21 (84 percent) cases of patients submitted to coronary artery bypass grafting, being associated to major risk of infection development (IC 3.448.30, P=0.0001). High rates of complications were observed: respiratory insufficiency (44 percent), stroke (16 percent), cardiogenic shock (12 percent), acute renal failure (28 percent), pulmonary infection (36 percent), multiple organs failure (16 percent) and esternal deiscence (48 percent). Bacterial cultures of exudates were positive in 84 percent of patients; Staphylococcus aureus was the most responsible pathogen (28.8 percent). CONCLUSION: Mediastinitis stays a serious surgical complication and difficult management in cardiovascular surgery postoperation. The disease stays with low incidence, but still with high lethality. Coronary bypass was associated to major risk of infection development.

EuroSCORE and mortality in coronary artery bypass graft surgery at Pernambuco Cardiologic Emergency Medical Services [Pronto Socorro Cardiológico de Pernambuco].

OBJECTIVE: The aim of this study is to evaluate the applicability of EuroSCORE in patients undergoing coronary artery bypass graft (CABG) surgery at the Division of Cardiovascular Surgery of Pernambuco Cardiologic Emergency Medical Services--PROCAPE. METHODS: A retrospective study involving 500 patients operated between May 2007 and April 2010. The registers contained all the information used to calculate the EuroSCORE. The outcome of interest was death. Univariate analysis and multivariate analysis by backward logistic regression were applied to assess the association between each variable in the EuroSCORE and deaths. The following parameters were calculated: sensitivity, specificity, positive predictive value, and negative predictive value. The power of concordance between the predicted mortality by the EuroSCORE and the observed mortality was measured using the Kappa coefficient. The accuracy of the model was evaluated by the ROC (receiver operating characteristic) curve. RESULTS: The incidence of death was 13%. In multivariate analysis, nine variables remained independent predictors of death: chronic obstructive pulmonary disease, creatinine >2,3mg/dL, active endocarditis, preoperative critical state, unstable angina, ejection fraction 30% to 50%, acute myocardial infarction < 90 days, emergency surgery and additional surgery. The score had a sensitivity of 88.4%, specificity of 79.3%, positive predictive value of 40.7%, negative predictive value of 97.7% and 80.6% concordance. The accuracy measured by the area under the ROC curve was 0.892 (95% CI 0.862-0.922). CONCLUSIONS: The EuroSCORE proved to be a simple and objective index, revealing a satisfactory discriminator of postoperative evolution in patients undergoing CABG surgery at our institution.