High Residual Gradient Following a Self-Expandable Transcatheter Aortic Valve-in-Valve Implantation — Risk Factor Analysis, Outcomes, and Survival

Abstract Introduction: Transcatheter aortic valve-in-valve implantation (TAVI-ViV) can be associated with unfavorable hemodynamic outcomes. This study aimed to estimate the prevalence, identify the risk factors, and evaluate the outcomes and survival of patients with high residual gradients after TAVI-ViV. Methods: A total of 85 patients were included in the study. The cohort was divided into group A, with postprocedural mean pressure gradient (PG) ≥ 20 mmHg, and group B, with mean PG < 20 mmHg. Results: Postprocedural PG ≥ 20 mmHg was observed in 24.7% of the patients. In a univariate analysis, preoperative gradient, pre-existing patient-prosthesis mismatch (PPM), deep valve implantation, small degenerated valves, and an older generation of transcatheter aortic valves were found to be risk factors for high residual gradient. Multivariate analysis showed that preexisting maxPG > 60 mmHg, implantation level of 4 mm below neo-annulus, and degenerated valve size ≤ 23 mm were independent predictors of high residual gradient. There were no differences in early morbidity (myocardial infarction, pacemaker implantation, stroke, acute renal insufficiency) between groups. Kaplan-Meier estimated that the survival rate was comparable at one and five years regardless of postoperative gradient. Survivors with high residual mean gradient were significantly affected by a high New York Heart Association (NYHA) class. Conclusion: High residual transvalvular gradient after TAVI-ViV is not rare, but it does not significantly affect mortality. High residual mean gradient has a negative impact on NYHA functional class improvement after the procedure. High preoperative gradient, implantation level, and small failed bioprosthesis may predispose to increased residual gradient.

Risk Factors for Deep Sternal Wound Infection after Off-Pump Coronary Artery Bypass Grafting: a Case-Control Study

Abstract Introduction: The objective of this study was to identify risk factors for deep sternal wound infection (DSWI) after off-pump coronary artery bypass (OPCAB) grafting surgery. Methods: A total of 8,442 patients undergoing OPCAB from April 1, 2009 to December 31, 2018 were retrospectively analyzed. A total of 956 were eventually enrolled on this study based on our exclusion criteria. All subjects were divided into two groups: group 1 (n=63) - DSWI; group 2 (n=893) - without DSWI. Patients were excluded if they had one of the following: acute coronary syndrome, conversion to OPCAB grafting surgery, redo procedure, concomitant cardiac surgery procedures. Results: The prevalence of body mass index (BMI) ≥40 kg/m2 (7.9% vs. 1.9%, respectively; P=0.01), lower extremity atherosclerotic artery disease (23.8% vs. 7.2%, respectively; P=0.001) and use of bilateral internal thoracic artery (19.5% vs. 2.5%, respectively; P=0.008) was significantly higher in patients with DSWI. The incidence of morbidities, including reoperation for bleeding (26.4% vs. 2.1%, respectively; P<0.001), stroke (4.8% vs. 0.8%, respectively; P=0.02), acute renal failure (7.9% vs. 0.8%, respectively; P=0.001), delirium (7.9% vs. 1.7%, respectively; P=0.008) and blood transfusion (30.6% vs. 9.8%, respectively; P<0.001) was significantly higher in patients with DSWI. Conclusions: A BMI of >40 kg/m2, lower extremity artery disease, use of bilateral internal thoracic artery (BITA) graft, postoperative stroke, sepsis, reoperation due to postoperative complications and blood product requirement significantly increased the risk of sternal infection after OPCAB.

High Residual Gradient Following a Self-Expandable Transcatheter Aortic Valve-in-Valve Implantation - Risk Factor Analysis, Outcomes, and Survival.

INTRODUCTION: Transcatheter aortic valve-in-valve implantation (TAVI-ViV) can be associated with unfavorable hemodynamic outcomes. This study aimed to estimate the prevalence, identify the risk factors, and evaluate the outcomes and survival of patients with high residual gradients after TAVI-ViV. METHODS: A total of 85 patients were included in the study. The cohort was divided into group A, with postprocedural mean pressure gradient (PG) ≥ 20 mmHg, and group B, with mean PG < 20 mmHg. RESULTS: Postprocedural PG ≥ 20 mmHg was observed in 24.7% of the patients. In a univariate analysis, preoperative gradient, pre-existing patient-prosthesis mismatch (PPM), deep valve implantation, small degenerated valves, and an older generation of transcatheter aortic valves were found to be risk factors for high residual gradient. Multivariate analysis showed that preexisting maxPG > 60 mmHg, implantation level of 4 mm below neo-annulus, and degenerated valve size ≤ 23 mm were independent predictors of high residual gradient. There were no differences in early morbidity (myocardial infarction, pacemaker implantation, stroke, acute renal insufficiency) between groups. Kaplan-Meier estimated that the survival rate was comparable at one and five years regardless of postoperative gradient. Survivors with high residual mean gradient were significantly affected by a high New York Heart Association (NYHA) class. CONCLUSION: High residual transvalvular gradient after TAVI-ViV is not rare, but it does not significantly affect mortality. High residual mean gradient has a negative impact on NYHA functional class improvement after the procedure. High preoperative gradient, implantation level, and small failed bioprosthesis may predispose to increased residual gradient.

Risk Factors for Deep Sternal Wound Infection after Off-Pump Coronary Artery Bypass Grafting: a Case-Control Study.

INTRODUCTION: The objective of this study was to identify risk factors for deep sternal wound infection (DSWI) after off-pump coronary artery bypass (OPCAB) grafting surgery. METHODS: A total of 8,442 patients undergoing OPCAB from April 1, 2009 to December 31, 2018 were retrospectively analyzed. A total of 956 were eventually enrolled on this study based on our exclusion criteria. All subjects were divided into two groups: group 1 (n=63) - DSWI; group 2 (n=893) - without DSWI. Patients were excluded if they had one of the following: acute coronary syndrome, conversion to OPCAB grafting surgery, redo procedure, concomitant cardiac surgery procedures. RESULTS: The prevalence of body mass index (BMI) ≥40 kg/m2 (7.9% vs. 1.9%, respectively; P=0.01), lower extremity atherosclerotic artery disease (23.8% vs. 7.2%, respectively; P=0.001) and use of bilateral internal thoracic artery (19.5% vs. 2.5%, respectively; P=0.008) was significantly higher in patients with DSWI. The incidence of morbidities, including reoperation for bleeding (26.4% vs. 2.1%, respectively; P<0.001), stroke (4.8% vs. 0.8%, respectively; P=0.02), acute renal failure (7.9% vs. 0.8%, respectively; P=0.001), delirium (7.9% vs. 1.7%, respectively; P=0.008) and blood transfusion (30.6% vs. 9.8%, respectively; P<0.001) was significantly higher in patients with DSWI. CONCLUSIONS: A BMI of >40 kg/m2, lower extremity artery disease, use of bilateral internal thoracic artery (BITA) graft, postoperative stroke, sepsis, reoperation due to postoperative complications and blood product requirement significantly increased the risk of sternal infection after OPCAB.

Outcomes and hemodynamics of Enable bioprosthesis in 432 patients: an afterword.

AIMS: To report the largest single-center experience in surgical aortic valve replacement (SAVR) using the Enable sutureless bioprosthesis concerning the clinical outcome and hemodynamic behavior. MATERIAL AND METHODS: From April 2010 to May 2017, a total of 432 patients (36.3% of them women) received the Enable sutureless prosthesis for aortic valve stenosis, regurgitation, and/or endocarditis. The endpoints were overall survival after operation for 30 days and adverse events. RESULTS: No intraoperative complications occurred; intraoperative mortality was 0%. The 30-day mortality rate was 3.5% overall and 0.9% for isolated procedure. No valve-related deaths were observed. There was a need for prosthesis replacement during the early postoperative period in eight patients (1.9%): seven patients (1.6%) had a significant paravalvular leak and one patient (0.2%) developed early postoperative endocarditis. The maximum and mean pressure gradients across the prosthesis were 19.2 ± 7.1 mmHg and 11.1 ± 4.6 mmHg, respectively. A permanent pacemaker was necessary in 6.5% of the patients. CONCLUSIONS: The Enable sutureless prosthesis showed a reliable clinical outcome with low perioperative mortality and morbidity. The hemodynamic performance was satisfactory. Our data confirmed the safety of SAVR using the Enable bioprosthesis. However, a higher rate of pacemaker implantation (6.5%) has to be mentioned.

Aortic Valve Neocuspidization Using Xenologous Pericardium Versus Bioprosthetic Valve Replacement.

BACKGROUND: Surgical aortic valve replacement (SAVR) for patients with aortic valve stenosis (AS) with small aortic root is associated with a higher rate of prosthesis-patient mismatch and suboptimal clinical outcomes. Aortic valve neocuspidization using xenologous pericardium (xAVNeo) has shown a favorable hemodynamic performance. The aim was to compare 6-year clinical outcomes of xAVNeo with SAVR. METHODS: Between 2003 and 2018, 412 patients with severe AS and small aortic root received either xAVNeo (n = 114) or bioprosthesis (n = 298). After propensity matching the cohort included 222 patients. The primary endpoints were early mortality, 6-year mortality, and freedom from reoperation. Mean follow-up averaged 3.4 ± 3.1 years and was 95% complete. RESULTS: Early mortality was 8.1% for the SAVR group versus 9.9% for the xAVNeo group (odds ratio, 1.25; 95% confidence interval, 0.51-2.89). The estimated survival probabilities at 6 years for the SAVR and xAVNeo cohorts were 89.9% and 88.8%, respectively (odds ratio, 1.07; 95% confidence interval, 0.49-2.34). Progressive degeneration of the neocusps resulted in a mean gradient increase from 6.1 ± 2.3 mm Hg to 22.7 ± 11.5 mm Hg (P < .0001); cusp sclerosis was the most common indication for reoperation in the xAVNeo group with a linearized rate of 1.92% versus 0.26% per patient-year (rate ratio, 7.41; 95% confidence interval, 0.95-333.7). The freedom from reoperation was 84.8% at 6 years, inferior to that of the SAVR group (100%). CONCLUSIONS: Early clinical outcomes and 6-year survival rates after xAVNeo and SAVR were comparable. However xAVNeo using bovine pericardium was associated with a higher rate of structural valve deterioration and inferior freedom from reoperation when compared with SAVR.

Pulmonary Valve Replacement in Tetralogy of Fallot: An Updated Meta-Analysis.

BACKGROUND: The benefits of pulmonary valve replacement (PVR) for pulmonary insufficiency in patients with repaired tetralogy of Fallot are still incompletely understood, and optimal timing remains challenging. METHODS: We systematically reviewed databases (PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials /Cochrane Controlled Trials Register, ClinicalTrials.gov, Scientific Electronic Library Online, Literatura Latino Americana em Ciências da Saúde, and Google Scholar) and reference lists of relevant articles for studies about PVR in repaired tetralogy of Fallot patients that reported any of the following outcomes: mortality and redo PVR rates, right ventricular (RV) and left ventricular measures, QRS duration, cardiopulmonary exercise test results, or brain natriuretic peptide. In addition to calculating the pooled treatment effects using a random-effects meta-analysis, we evaluated the effect of preoperative measures on PVR outcomes using meta-regressions. RESULTS: Eighty-four studies involving 7544 patients met the eligibility criteria. Pooled mortality at 30 days, 5 years, and 10 years after PVR was 0.87% (63 of 7253 patients, 80 studies), 2.7% (132 of 4952 patients, 37 studies), and 6.2% (510 of 2765 patients, 15 studies), respectively. Pooled 5- and 10-year redo PVR rates were 3.7% (141 of 3755 patients, 23 studies) and 16.8% (172 of 3035 patients, 16 studies), respectively. The results of the previous meta-analysis could be confirmed. In addition, we demonstrated that after PVR (1) QRS duration, cardiopulmonary exercise test results, and RV and left ventricular measures longitudinal strain do not significantly change; (2) brain natriuretic peptide decreases; and (3) greater indexed RV end-diastolic and end-systolic volumes are associated with lower chances of RV volume normalization after PVR. CONCLUSIONS: This updated meta-analysis provides evidence about the benefits of PVR.

Extended, virtual and augmented reality in thoracic surgery: a systematic review.

OBJECTIVES: Extended reality (XR), encompassing both virtual reality (VR) and augmented reality, allows the user to interact with a computer-generated environment based on reality. In essence, the immersive nature of VR and augmented reality technology has been warmly welcomed in all aspects of medicine, gradually becoming increasingly feasible to incorporate into everyday practice. In recent years, XR has become increasingly adopted in thoracic surgery, although the extent of its applications is unclear. Here, we aim to review the current applications of XR in thoracic surgery. METHODS: A systematic database search was conducted of original articles that explored the use of VR and/or augmented reality in thoracic surgery in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to December 2020. RESULTS: Our search yielded 1494 citations, of which 21 studies published from 2007 to 2019 were included in this review. Three main areas were identified: (i) the application of XR in thoracic surgery training; (ii) preoperative planning of thoracic procedures; and (iii) intraoperative assistance. Overall, XR could produce progression along the learning curve, enabling trainees to reach acceptable standards before performing in the operating theatre. Preoperatively, through the generation of 3D-renderings of the thoracic cavity and lung anatomy, VR increases procedural accuracy and surgical confidence through familiarization of the patient's anatomy. XR-assisted surgery may have therapeutic use particularly for complex cases, where conventional methods would yield inadequate outcomes due to inferior accuracy. CONCLUSION: XR represents a salient step towards improving thoracic surgical training, as well as enhancing preoperative planning and intraoperative guidance.

Strategies to Prevent Acute Kidney Injury after Pediatric Cardiac Surgery: A Network Meta-Analysis.

BACKGROUND AND OBJECTIVES: AKI is a common complication after pediatric cardiac surgery and has been associated with higher morbidity and mortality. We aimed to compare the efficacy of available pharmacologic and nonpharmacologic strategies to prevent AKI after pediatric cardiac surgery. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: PubMed/MEDLINE, Embase, Cochrane Controlled Trials Register, and reference lists of relevant articles were searched for randomized controlled trials from inception until August 2020. Random effects traditional pairwise, Bayesian network meta-analyses, and trial sequential analyses were performed. RESULTS: Twenty randomized controlled trials including 2339 patients and 11 preventive strategies met the eligibility criteria. No overall significant differences were observed compared with control for corticosteroids, fenoldopam, hydroxyethyl starch, or remote ischemic preconditioning in traditional pairwise meta-analysis. In contrast, trial sequential analysis suggested a 80% relative risk reduction with dexmedetomidine and evidence of <57% relative risk reduction with remote ischemic preconditioning. Nonetheless, the network meta-analysis was unable to demonstrate any significant differences among the examined treatments, including also acetaminophen, aminophylline, levosimendan, milrinone, and normothermic cardiopulmonary bypass. Surface under the cumulative ranking curve probabilities showed that milrinone (76%) was most likely to result in the lowest risk of AKI, followed by dexmedetomidine (70%), levosimendan (70%), aminophylline (59%), normothermic cardiopulmonary bypass (57%), and remote ischemic preconditioning (55%), although all showing important overlap. CONCLUSIONS: Current evidence from randomized controlled trials does not support the efficacy of most strategies to prevent AKI in the pediatric population, apart from limited evidence for dexmedetomidine and remote ischemic preconditioning.

Open Access and Article Processing Charges in Cardiology and Cardiac Surgery Journals: a Cross-Sectional Analysis.

INTRODUCTION: Open access (OA) publishing often requires article processing charges (APCs). While OA provides opportunities for broader readership, authors able to afford APCs are more commonly associated with well-funded, high-income country institutions, skewing knowledge dissemination. Here, we evaluate publishing models, OA practices, and APCs in cardiology and cardiac surgery. METHODS: The InCites Journal Citation Reports 2019 directory by Clarivate Analytics was searched for "Cardiac and Cardiovascular Systems" journals. Sister journals of included journals were identified. All journals were categorized as predominantly cardiology or cardiac surgery. Publishing models, APCs, and APC waivers were defined for all journals. RESULTS: One hundred sixty-one journals were identified (139 cardiology, 22 cardiac surgery). APCs ranged from $244 to $5,000 ($244-5,000 cardiology; $383-3,300 cardiac surgery), with mean $2,911±891 and median $3,000 (interquartile range [IQR]: $2,500-3,425) across 139 journals with non-zero available APCs ($2,970±890, median $3,000, IQR: $2,573-3,450, cardiology; $2,491±799, median $2,740, IQR: $2,300-3,000, cardiac surgery). Average APCs were $3,307±566 and median $3,250 (IQR: $3,000-3,500) for hybrid journals ($3,344±583, median $3,260, IQR: $3,000-3,690, cardiology; $2,983±221, median $2,975, IQR: $2,780-3,149, cardiac surgery) and $1,997±832 and median $2,100 (IQR: $1,404-2,538) for fully OA journals ($2,039±843, median $2,100, IQR: $1,419-2,604, cardiology; $1,788±805, median $2,000, IQR: $1,475-2,345, cardiac surgery). Waivers were available for 51 (86.4%) fully OA and 37 (37.4%) hybrid journals. Seventeen journals were fully OA without APCs, one journal did not yet release APCs, and four journals were subscription-only. CONCLUSION: OA publishing is common in cardiology and cardiac surgery with substantial APCs. Waivers remain limited, posing barriers for unfunded and lesser-funded researchers.

Aortic Root Replacement for Destructive Endocarditis - Clinic and Microbiology

Abstract Introduction: Destructive aortic root endocarditis is associated with high mortality rates. The objective of this article was to characterize the clinical and microbiological profiles of these patients, especially concerning an already implanted aortic valve prosthesis. We also focused on prognostic factors. Methods: Eighty patients underwent aortic root replacement due to destructive endocarditis from 1999 to 2018 in our institution. We analyzed their pre, intra, and postoperative data, outcomes, and predictors of mortality. Results: Thirty-one patients had native valve endocarditis (NVE), eight patients had early-onset prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE. Streptococcus was found in 19.4% of NVE cases and no PVE case. Coagulase-negative Staphylococcus was responsible for 62.5% of the cases of early-onset PVE. Thirty-four (42.5%) patients had received inappropriate antibiotics before admission. No microorganism was associated with higher risk of mortality. Aortoventricular dehiscence was identified as an independent risk factor of mortality along with PVE, concomitant bypass surgery, and delayed diagnosis. The incidence of postoperative complications was similar in all three groups. Rates of long-term survival (P=0.044) and freedom from the composite endpoint (P=0.024) defined as death, stroke, aortic valve reinfection, and aortic valve reoperation were the lowest within the NVE group and the highest among the PVE patients. Conclusion: In endocarditis, prolonged diagnostics, inadequate antimicrobial treatment, and late surgery led to destructive local complications and worsened the prognosis. PVE is associated with higher mortality than NVE.

Oral Use of Phenytoin to Reduce Calcification in Bovine Pericardium and Porcine Aortic Leaflets Implants in Rats.

INTRODUCTION: This study aims to test the effect of phenytoin as an inhibitor of the process of dystrophic calcification in bovine pericardium and porcine leaflets implanted in the subcutaneous tissue of rats. METHODS: Isolated segments of biomaterials were implanted subcutaneously in young rats. The study groups received 500 mg phenytoin per kilogram of diet per day. After 90 days, samples were collected and quantitative calcification assessment by optical microscopy, radiological studies with mammography, and atomic emission spectrometry were performed. RESULTS: Inflammatory reaction was a frequent finding in all groups when analyzed by optical microscopy. The calcium level assessed by atomic absorption spectrophotometry was significantly lower in the study groups using phenytoin compared to the control groups (control bovine pericardium group X=0.254±0.280 µg/mg; study bovine pericardium group X=0.063±0.025 µg/mg; control porcine aortic leaflets group X=0.640±0.226 µg/mg; study porcine aortic leaflets group X=0.056±0.021 µg/mg; P<0.05). Radiologic studies revealed a statistically significant difference between the groups treated with and without phenytoin (not only regarding the bovine pericardium but also the porcine leaflets). CONCLUSION: The results obtained suggest that phenytoin reduces the calcification process of bovine pericardium segments and porcine aortic leaflets in subdermal implants in rats; also, the incidence of calcification in bovine pericardium grafts was similar to that of porcine aortic leaflets.

Open Access and Article Processing Charges in Cardiology and Cardiac Surgery Journals: a Cross-Sectional Analysis

Abstract Introduction: Open access (OA) publishing often requires article processing charges (APCs). While OA provides opportunities for broader readership, authors able to afford APCs are more commonly associated with well-funded, high-income country institutions, skewing knowledge dissemination. Here, we evaluate publishing models, OA practices, and APCs in cardiology and cardiac surgery. Methods: The InCites Journal Citation Reports 2019 directory by Clarivate Analytics was searched for "Cardiac and Cardiovascular Systems" journals. Sister journals of included journals were identified. All journals were categorized as predominantly cardiology or cardiac surgery. Publishing models, APCs, and APC waivers were defined for all journals. Results: One hundred sixty-one journals were identified (139 cardiology, 22 cardiac surgery). APCs ranged from $244 to $5,000 ($244-5,000 cardiology; $383-3,300 cardiac surgery), with mean $2,911±891 and median $3,000 (interquartile range [IQR]: $2,500-3,425) across 139 journals with non-zero available APCs ($2,970±890, median $3,000, IQR: $2,573-3,450, cardiology; $2,491±799, median $2,740, IQR: $2,300-3,000, cardiac surgery). Average APCs were $3,307±566 and median $3,250 (IQR: $3,000-3,500) for hybrid journals ($3,344±583, median $3,260, IQR: $3,000-3,690, cardiology; $2,983±221, median $2,975, IQR: $2,780-3,149, cardiac surgery) and $1,997±832 and median $2,100 (IQR: $1,404-2,538) for fully OA journals ($2,039±843, median $2,100, IQR: $1,419-2,604, cardiology; $1,788±805, median $2,000, IQR: $1,475-2,345, cardiac surgery). Waivers were available for 51 (86.4%) fully OA and 37 (37.4%) hybrid journals. Seventeen journals were fully OA without APCs, one journal did not yet release APCs, and four journals were subscription-only. Conclusion: OA publishing is common in cardiology and cardiac surgery with substantial APCs. Waivers remain limited, posing barriers for unfunded and lesser-funded researchers.

Aortic Root Replacement for Destructive Endocarditis - Clinic and Microbiology.

INTRODUCTION: Destructive aortic root endocarditis is associated with high mortality rates. The objective of this article was to characterize the clinical and microbiological profiles of these patients, especially concerning an already implanted aortic valve prosthesis. We also focused on prognostic factors. METHODS: Eighty patients underwent aortic root replacement due to destructive endocarditis from 1999 to 2018 in our institution. We analyzed their pre, intra, and postoperative data, outcomes, and predictors of mortality. RESULTS: Thirty-one patients had native valve endocarditis (NVE), eight patients had early-onset prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE. Streptococcus was found in 19.4% of NVE cases and no PVE case. Coagulase-negative Staphylococcus was responsible for 62.5% of the cases of early-onset PVE. Thirty-four (42.5%) patients had received inappropriate antibiotics before admission. No microorganism was associated with higher risk of mortality. Aortoventricular dehiscence was identified as an independent risk factor of mortality along with PVE, concomitant bypass surgery, and delayed diagnosis. The incidence of postoperative complications was similar in all three groups. Rates of long-term survival (P=0.044) and freedom from the composite endpoint (P=0.024) defined as death, stroke, aortic valve reinfection, and aortic valve reoperation were the lowest within the NVE group and the highest among the PVE patients. CONCLUSION: In endocarditis, prolonged diagnostics, inadequate antimicrobial treatment, and late surgery led to destructive local complications and worsened the prognosis. PVE is associated with higher mortality than NVE.

Impact of the COVID-19 pandemic on coronary artery bypass graft surgery in Brazil: A nationwide perspective.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has been a worldwide challenge, and efforts to "flatten the curve," including restrictions imposed by policymakers and medical societies, have forced a reduction in the number of procedures performed in the Brazilian Health Care System. The aim of this study is to evaluate the outcomes of coronary artery bypass graft (CABG) from 2008 to 2020 in the SUS and to assess the impacts of the COVID-19 pandemic in the number of procedures and death rate of CABG performed in 2020 through the database DATASUS. METHODS: This study is based on publicly available material obtained from DATASUS, the Brazilian Ministry of Health's data processing system, on numbers of surgical procedures and death rates. Only isolated CABG procedures were included in our study. We used the TabNet software from the DATASUS website to generate reports. RESULTS: We identified 281,760 CABG procedures performed from January 2008 to December 2020. The average number of procedures until the end of 2019 was of 22,104. During 2020 there was a 25% reduction CABG procedures, to 16,501. There was an increase in the national death rate caused by a statistical significant increase in death rates in Brazil's Southeast and Central-west regions. CONCLUSION: The COVID-19 pandemic remains a global challenge for Brazil's health care system. During the year of 2020 there was a reduction in access to CABG related to an increase in the number of COVID-19 cases. There was also an increase in the national CABG death rate.

Transcatheter valve-in-valve implantation for degenerated bioprosthetic aortic and mitral valves - an update on indications, techniques, and clinical results.

Introduction: Aortic and mitral bioprosthesis are the gold standard treatment to replace a pathological native valve. However, bioprostheses are prone to structural valve degeneration, resulting in limited long-term durability. During the past decade, the implantation of transcatheter stent-valves within degenerated aortic and mitral bioprostheses, (the so-called 'valve-in-valve' procedure), represents a valid alternative to redo surgery in patients with high-risk surgical profiles.Areas covered: We reviewed the clinical outcomes and the procedural details of transcatheter aortic and mitral valve-in-valve series according to current published literature and include a practical guide for valve sizing and stent-valve positioning and strategies to prevent complications.Expert opinion: In both aortic and mitral positions meticulous planning is fundamental in these procedures to avoid serious complications including patient prosthesis mismatch, coronary obstruction and left ventricular outflow tract obstruction.

Oral Use of Phenytoin to Reduce Calcification in Bovine Pericardium and Porcine Aortic Leaflets Implants in Rats

Abstract Introduction: This study aims to test the effect of phenytoin as an inhibitor of the process of dystrophic calcification in bovine pericardium and porcine leaflets implanted in the subcutaneous tissue of rats. Methods: Isolated segments of biomaterials were implanted subcutaneously in young rats. The study groups received 500 mg phenytoin per kilogram of diet per day. After 90 days, samples were collected and quantitative calcification assessment by optical microscopy, radiological studies with mammography, and atomic emission spectrometry were performed. Results: Inflammatory reaction was a frequent finding in all groups when analyzed by optical microscopy. The calcium level assessed by atomic absorption spectrophotometry was significantly lower in the study groups using phenytoin compared to the control groups (control bovine pericardium group X=0.254±0.280 µg/mg; study bovine pericardium group X=0.063±0.025 µg/mg; control porcine aortic leaflets group X=0.640±0.226 µg/mg; study porcine aortic leaflets group X=0.056±0.021 µg/mg; P<0.05). Radiologic studies revealed a statistically significant difference between the groups treated with and without phenytoin (not only regarding the bovine pericardium but also the porcine leaflets). Conclusion: The results obtained suggest that phenytoin reduces the calcification process of bovine pericardium segments and porcine aortic leaflets in subdermal implants in rats; also, the incidence of calcification in bovine pericardium grafts was similar to that of porcine aortic leaflets.

Association Between Epicardial Adipose Tissue and Stroke.

Epicardial adipose tissue (EAT) is correlated with endothelial dysfunction, metabolic syndrome, increased mortality and recent studies showed a possible association with the increased risk of stroke. We performed a systematic review of studies evaluating the association between EAT and stroke. Eighty studies met the inclusion criteria and were consequently analyzed. The review had Five main findings. First, the increased epicardial fat thickness (EFT) may be associated with the stroke episode. Second, regardless of the imaging method (echocardiography, MRI, and CT) this association remains. Third, the association of metabolic syndrome and atrial fibrillation seems to increase the risk of stroke. Fourth, this systematic review was considered as low risk of bias. Despite being unable to establish a clear association between EAT and stroke, we have organized and assessed all the research papers on this topic, analyzing their limitations, suggesting improvements in future pieces of research and pointing out gaps in the literature. Furthermore, the mechanistic links between increased EAT and stroke incidence remains unclear, thus, further research is warranted.