Determinants of Aortic Prosthesis Mismatch in a Brazilian Public Health System Hospital: Big Patients or Small Prosthesis? / Determinantes da Desproporção de Prótese Aórtica em Hospital de Atendimento de Saúde Pública Brasileiro: Pacientes Grandes ou Próteses Pequenas?

Abstract Background: Prosthesis-patient mismatch (PPM) is associated with worse outcomes. Objective: Determine the frequency and evaluate preoperatory variables independently associated with severe PPM in a tertiary hospital focused on Public Health Care. Methods: A total of 316 patients submitted to aortic valve replacement, who had echocardiography performed within the first 30 days after surgery, were retrospectively analyzed. The indexed effective orifice area (iEOA) of the prosthesis was used to classify the patients into three groups, according to PPM, considering body mass index (BMI): severe PPM (iEOA) < 0.65 cm2/m2), mild to moderate PPM (iEOA, 0.65 cm2/m2 - 0.85 cm2/m2) and without PPM (iEOA > 0.85 cm2/m2) for a BMI < 30 kg/m2 and severe PPM (iEOA) < 0.55 cm2/m2), mild to moderate (iEOA, 0.55 cm2/m2- 0.70 cm2/m2) and without PPM (iEOA > 0.7 cm2/m2) for a BMI > 30 kg/m2. Statistical significance was considered when p < 0.05. Results: iEOA was obtained in 176 patients. The frequency of severe and moderate PPM was 33.4% and 36.2%, respectively. Severe PPM patients were younger and had larger BMI, but smaller left ventricular outflow tract diameter (LVOTD). The independent variables used to predict severe PPM were male gender, BMI > 25 kg/m2, age < 60 years, LVOTD < 21 mm, and rheumatic etiology with an area under the ROC curve of 0.82. Conclusion: The frequency of severe PPM is high in a Brazilian population representative of the Public Health System, and it is possible to predict PPM from preoperative variables such as rheumatic valvular disease, gender, BMI, age and LVOTD.

Resumo Fundamento: A desproporção entre o tamanho da prótese aórtica-paciente (DPP) está associada a maior mortalidade. Objetivo: Determinar a frequência e avaliar variáveis ​​pré-operatórias associadas à DPP acentuada no cenário da saúde pública em hospital terciário. Métodos: 316 pacientes submetidos à troca valvar aórtica (TVA), com ecocardiograma realizado nos primeiros 30 dias após cirurgia, foram analisados retrospectivamente. A área de orifício efetivo indexado (AOEi) da prótese foi utilizada para classificar os pacientes em três grupos de acordo com a DPP, considerando o índice de massa corporal (IMC): DPP acentuada (AOEi) < 0,65 cm2/m2, DPP discreta a moderada (AOEi, 0,65 cm2/m2 - 0,85 cm2/m2) e sem DPP (iEOA > 0,85 cm2/m2) para IMC < 30 kg/m2 e DPP acentuada (AOEi) < 0,55 cm2/m2), discreta a moderada (AOEi, 0,55 cm2/m2 - 0,70 cm2/m2) e sem DPP (AOEi > 0,7 cm2/m2) para IMC > 30 kg/m2. Significância estatística foi considerada com p < 0,05. Resultados: A AOEi foi obtida em 176 pacientes. A frequência de DPP acentuada foi de 33,4% e moderada de 36,2%. Pacientes com DPP acentuada foram mais jovens e com maior IMC, mas menor diâmetro da via de saída do ventrículo esquerdo (DVSVE). As variáveis independentes que podem predizer DPP acentuada são: gênero masculino, IMC > 25 kg/m2, idade < 60 anos, DVSVE < 21 mm e etiologia reumática com área sob a curva ROC de 0,82. Conclusão: A frequência de DPP acentuada é alta em uma população brasileira submetida à TVA no Sistema Público de Saúde. Os principais determinantes de DPP acentuada são: valvopatia reumática, gênero masculino, IMC alto, idade < 60 anos e menor DVSVE.

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

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

Off-pump versus on-pump coronary artery bypass grafting in frail patients: study protocol for the fragile multicenter randomized controlled trial

Abstract Introduction: Advances in modern medicine have led to people living longer and healthier lives. Frailty is an emerging concept in medicine yet to be explored as a risk factor in cardiac surgery. When it comes to CABG surgery, randomized controlled clinical trials have primarily focused on low-risk (ROOBY, CORONARY), elevated-risk (GOPCABE) or high-risk patients (BBS), but not on frail patients. Therefore, we believe that off-pump CABG could be an important technique in patients with limited functional capacity to respond to surgical stress. In this study, the authors introduce the new national, multicenter, randomized, controlled trial "FRAGILE", to be developed in the main cardiac surgery centers of Brazil, to clarify the potential benefit of off-pump CABG in frail patients. Methods: FRAGILE is a two-arm, parallel-group, multicentre, individually randomized (1:1) controlled trial which will enroll 630 patients with blinded outcome assessment (at 30 days, 6 months, 1 year, 2 years and 3 years), which aims to compare adverse cardiac and cerebrovascular events after off-pump versus on-pump CABG in pre-frail and frail patients. Primary outcomes will be all-cause mortality, acute myocardial infarction, cardiac arrest with successful resuscitation, low cardiac output syndrome/cardiogenic shock, stroke, and coronary reintervention. Secondary outcomes will be major adverse cardiac and cerebrovascular events, operative time, mechanical ventilation time, hyperdynamic shock, new onset of atrial fibrillation, renal replacement therapy, reoperation for bleeding, pneumonia, length of stay in intensive care unit, length of stay in hospital, number of units of blood transfused, graft patency, rate of complete revascularization, neurobehavioral outcomes after cardiac surgery, quality of life after cardiac surgery and costs. Discussion: FRAGILE trial will determine whether off-pump CABG is superior to conventional on-pump CABG in the surgical treatment of pre-frail and frail patients. Trial registration: ClinicalTrials.gov, ID: NCT02338947. Registered on August 29th 2014; last updated on March 21st 2016.

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

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

Revascularizaçäo do miocárdio com endarterectomia da artéria coronária: estratificaçäo dos fatores de risco de mortalidade imediata / Myocardial revascularization with coronary endarterectomy: stratification of risk factors for early mortality

OBJECTIVE: To determine the risk factors for mortality related to myocardial revascularization when performed in association with coronary endarterectomy. METHODS: We assessed retrospectively 353 patients who underwent 373 coronary endarterectomies between January '89 and November '98, representing 3.73 percent of the myocardial revascularizations in this period of time. The arteries involved were as follows: right coronary artery in 218 patients (58.45 percent); left anterior descending in 102 patients (27.35 percent); circumflex artery in 39 patients (10.46 percent); and diagonal artery in 14 patients (3.74 percent). We used 320 (85.79 percent) venous grafts and 53 (14.21 percent) arterial grafts. RESULTS: In-hospital mortality among our patients was 9.3 percent as compared with 5.7 percent in patients with myocardial revascularizations without endarterectomy (p=0.003). Cause of death was related to acute myocardial infarction in 18 (54.55 percent) patients. The most significant risk factors for mortality identified were as follows: diabetes mellitus (p=0.001; odds ratio =7.168), left main disease (<0.001; 9.283), female sex (0.01; 3.111), acute myocardial infarction (0.02; 3.546), ejection fraction <35 percent (<0.001; 5.89), and previous myocardial revascularization (<0.001; 4.295). CONCLUSION: Coronary endarterectomy is related to higher mortality, and the risk factors involved are important elements of a poor outcome