Cirurgia de Endocardite Infecciosa. Análise de 328 Pacientes Operados em um Hospital Universitário Terciário / Infective Endocarditis Surgery. Insights from 328 Patients Operated in a University Tertiary Hospital

Resumo Fundamento A endocardite infecciosa (EI) refere-se à infecção da superfície endocárdica do coração e geralmente ocorre em valvas nativas ou protéticas. Objetivo Este estudo teve como objetivo levantar dados de EI refletindo a terapêutica cirúrgica, em um Hospital Universitário do interior do estado de São Paulo - Brasil. Método Abordagem retrospectiva e observacional de 328 pacientes com EI operados entre 1982 e 2020 Resultados Os principais dados (n=121/37%), insuficiência cardíaca congestiva (n=114/35%), valvopatia (n=92/28%), diabetes mellitus (n=85/26%), doença renal crônica (n=59/18%) e febre reumática (49/15%). A insuficiência renal é um dos principais e mais relevantes fatores de risco pré-cirúrgicos para um mau prognóstico. Conclusão Para um melhor resultado clínico e cirúrgico é necessário o diagnóstico sindrômico e etiológico precoce da EI, principalmente em pacientes com múltiplas comorbidades.

Abstract Background Infectious endocarditis (IE) refers to infection of the endocardial surface of the heart and usually occurs in native or prosthetic valves. Objective This study aimed to raise IE data reflecting the surgical therapy in a University Hospital in the interior of the State of Sao Paulo-Brazil. Method Retrospective and observational approach of 328 patients with IE who underwent surgery between 1982 and 2020 Results The main data (n=121/37%), congestive heart failure (n=114/35%), valve disease (n=92/28%), diabetes mellitus (n=85/26%), chronic kidney disease (n=59/18%), and rheumatic fever (49/15%). Renal failure is one of the main and most relevant pre-surgical risk factors for a poor prognosis. Conclusion For a better clinical and surgical outcome, an early syndromic and etiological diagnosis of IE is necessary, especially in patients with multiple comorbidities.

Dialysis-related constrictive pericarditis: old enemies may sometimes come back / Pericardite Constritiva relacionada a diálise: velhos inimigos podem, às vezes, voltar

ABSTRACT Cardiovascular disease is the main cause of death in patients with chronic kidney disease (CKD). Several heart conditions have been associated with CKD, including myocardial and pericardial diseases. This paper describes a case of Dialysis-related constrictive pericarditis in a patient diagnosed with sudden hypotension during a hemodialysis session. A 65-year-old man diagnosed with hypertension, diabetes, obesity, and cirrhosis on hemodialysis for two years complained of symptoms during one of his sessions described as malaise, lipothymia, and confusion. The patient had a record of poor compliance with the prescribed diet and missed dialysis sessions. He was sluggish during the physical examination, and presented hypophonetic heart sounds, a blood pressure of 50/30mmHg, and a prolonged capillary refill time. The patient was referred to the intensive care unit and was started on antibiotics and vasoactive drugs. His workup did not show signs of infection, while electrocardiography showed low QRS-wave voltage. His echocardiogram showed signs consistent with a thickened pericardium without pericardial effusion. Cardiac catheterization showed equalization of diastolic pressures in all heart chambers indicative of constrictive pericarditis. The patient underwent a pericardiectomy. Examination of surgical specimens indicated he had marked fibrosis and areas of dystrophic calcification without evidence of infection, consistent with Dialysis-related constrictive pericarditis. Hypotension for unknown causes must be considered in the differential diagnosis of dialysis patients.

RESUMO A doença cardiovascular é a principal causa de morte em pacientes com doença renal crônica (DRC). Várias formas de acometimento cardíaco têm sido associadas. à DRC, incluindo doenças miocárdicas e pericárdicas. Este artigo descreve um caso de pericardite constritiva relacionada a em um paciente diagnosticado com hipotensão súbita durante uma sessão de hemodiálise. Um homem de 65 anos com diagnósticos prévios de hipertensão, diabetes, obesidade e cirrose em hemodiálise por dois anos queixou-se de sintomas durante uma de suas sessões, descritos como mal-estar, lipotímia e confusão mental. Apresentava histórico de baixa adesão à dieta prescrita e faltas frequentes às sessões de diálise. Ele estava fraco durante o exame físico e apresentava bulhas cardíacas hipofonéticas, pressão arterial de 50/30mmHg e tempo de enchimento capilar prolongado. O paciente foi encaminhado para a unidade de terapia intensiva e iniciou o tratamento com antibióticos e drogas vasoativas. Investigação laboratorial não mostrou sinais de infecção, enquanto o eletrocardiograma mostrou baixa voltagem de complexo QRS. Seu ecocardiograma evidenciou sinais consistentes com um pericárdio espessado, sem derrame pericárdico. O cateterismo cardíaco mostrou equalização das pressões diastólicas em todas as câmaras cardíacas, indicativo de pericardite constritiva. O paciente foi submetido a uma pericardiectomia. O exame anatomopatológico mostrou sinais de acentuada fibrose acentuada fibrose e áreas de calcificação distrófica sem evidência de infecção, consistente com pericardite constritiva relacionada a por diálise. A hipotensão por causas desconhecidas deve ser considerada no diagnóstico diferencial de pacientes em diálise.

Delirium: prevalência e fatores associados ao pós-operatório de cirurgia cardiovascular em idosos / Delirium: prevalencia y factores asociados con el período postoperatorio de la cirugía cardiovascular en los ancianos / Delirium: prevalence and factors associated with the postoperative period of cardiovascular surgery in the elderly

Objetivo identificar a prevalência de delirium em idosos internados em Unidade de Terapia Intensiva que estejam em pós-operatório de cirurgia cardiovascular e verificar associação entre o delirium e as variáveis sociodemográficas e clínicas. Método estudo transversal, analítico, realizado em um centro cardiológico do Distrito Federal, Brasília, Brasil. Foram analisados idosos internados entre junho e outubro de 2018. A triagem para delirium foi realizada utilizando o Confusion Assessment Method for Intensive Care Unit. Resultados o sexo masculino teve incidência de 65% e a hipertensão arterial sistêmica (75%) foi a doença crônica mais relatada; 30% apresentaram Infarto Agudo do Miocárdio e maior tempo em circulação extracorpórea, além de terem permanecido mais tempo internados; e 30% dos delirantes evoluíram a óbito. Conclusão a prevalência encontrada foi de 40% e estava associada ao mais idoso, ao sexo masculino, ao nível significativo de escolaridade, ao uso de tabaco, à apresentação de comorbidades prévias; estes, permaneceram mais tempo internados e morreram mais quando comparados ao outro grupo.

Objetivo identificar la prevalencia del delirium en ancianos hospitalizados en una Unidad de Cuidados Intensivos en el periodo postoperatorio de la cirugía cardiovascular y verificar una asociación entre el delirium y las variables sociodemográficas y clínicas. Método transversal, estudio analítico, realizado en un centro de cardiología. Se analizaron los ancianos hospitalizados entre junio y octubre de 2018. La detección del delirium se realizó utilizando el Confusion Assessment Method for Intensive Care Unit. Resultados los hombres tenían una incidencia del 65% y la hipertensión arterial sistémica (75%) fue la enfermedad crónica más notificada; El 30% tenía infarto agudo de miocardio y más tiempo en circulación extracorpórea, además de haber permanecido hospitalizado más tiempo; y el 30% de los delirantes murieron. Conclusión la prevalencia encontrada fue del 40% y se asoció con los ancianos, con el sexo masculino, con el nivel significativo de educación, con el uso del tabaco, con la presentación de comorbilidades anteriores; estos permanecieron hospitalizados más tiempo y murieron más en comparación con el otro grupo.

Objective to identify the prevalence of delirium in elderly inpatients from an Intensive Care Unit in the postoperative period of cardiovascular surgery and to verify an association between delirium and sociodemographic and clinical variables. Method cross-sectional, analytical study, carried out in a cardiology center. Elderly inpatients between June and October 2018 were analyzed. Screening for delirium was performed using the Confusion Assessment Method for Intensive Care Unit. Results males had an incidence of 65% and systemic arterial hypertension (75%) was the most reported chronic disease; 30% had acute myocardial infarction and longer time in cardiopulmonary bypass, in addition to having remained hospitalized longer; and 30% of the delusional ones died. Conclusion the prevalence found was 40% and was associated with the elderly, with the male sex, with the significant level of education, use of tobacco, previous comorbidities; these remained hospitalized longer and died more when compared to the other group.

Does type 2 diabetes mellitus increase postoperative complications in patients submitted to cardiovascular surgeries?

Abstract Objective: To compare the incidence of postoperative complications (PC) between diabetic and nondiabetic patients undergoing cardiovascular surgeries (CS). Methods: This is a retrospective cross-sectional study, based on the analysis of 288 medical records. Patients aged ≥ 18 years, admitted to the intensive care unit (ICU) between January 2012 and January 2013, and undergoing coronary artery bypass grafting (CABG) or vascular surgeries were included. The population was divided into those with and without type 2 diabetes mellitus (T2DM), and then it was evaluated the incidence of PC between the groups. Results: The sample included 288 patients, most of them being elderly (67 [60-75] years old) male (64%) subjects. Regarding to surgical procedures, 60.4% of them were undergoing vascular surgeries and 39.6% were in the postoperative period of CABG. The incidence of T2DM in this population was 40% (115), just behind hypertension, with 72% (208). Other risk factors were also observed, such as smoking in 95 (33%) patients, dyslipidemias in 54 (19%) patients, and previous myocardial infarction in 55 (19%) patients. No significant difference in relation to PC (bleeding, atrial fibrillation, cardiorespiratory arrest, and respiratory complications) between the groups was observed (P>0.05). Conclusion: T2DM has a high incidence rate in the population of critically ill patients submitted to CS, especially in the elderly. However, in this small retrospectively analyzed study, there was no significant increase in PC related to diabetes for patients undergoing CS.

Avaliação do tempo de permanência hospitalar em cirurgia cardíaca em um hospital universitário / Evaluation of hospital permanence time in heart surgery in a university hospital / Evaluación del tiempo permanencia en el hospital en la cirugía del corazón en un hospital universitario

Objetivos: verificar a associação entre o tempo de internação hospitalar de pacientes submetidos à cirurgia cardíaca com as variáveis sociodemográficas e clínicas. Método: estudo transversal, retrospectivo a partir da análise de dados secundários de indivíduos que realizaram cirurgias cardíacas em um hospital universitário, na região Sudeste do Brasil. Resultados: foi identificada mediana de tempo de internação hospitalar maior nos pacientes com idade de 60 anos ou mais, sexo masculino, com comorbidades prévias. Além disso, a internação foi mais prolongada nos indivíduos que apresentaram complicações no pós-operatório como eventos neurológicos, arritmias cardíacas, insuficiência renal aguda, complicações pulmonares e infecção hospitalar. Conclusão: a associação das características e a identificação do perfil de pacientes que em geral permanecem mais tempo no leito poderão ser úteis na elaboração de protocolos e fluxos institucionais

Objectives: to verify the association between the length of hospital stay of patients undergoing cardiac surgery and the sociodemographic and clinical variables. Method: cross-sectional, retrospective study based on secondary data analysis of individuals who underwent cardiac surgery at a university hospital in the Southeast region of Brazil. Results: median length of hospital stay was identified higher in patients aged 60 years or older, male, with previous comorbidities. In addition, hospitalization was longer in individuals with postoperative complications such as neurological events, cardiac arrhythmias, acute renal failure, pulmonary complications, and nosocomial infection. Conclusion: the association of the characteristics and the identification of the profile of patients who usually stay longer in bed may be useful in the elaboration of protocols and institutional flows

Objetivos: verificar la asociación entre la duración de la estancia hospitalaria de los pacientes sometidos a cirugía cardíaca y las variables sociodemográficas y clínicas. Método: estudio transversal retrospectivo basado en el análisis de datos secundarios de individuos que se sometieron a una cirugía cardíaca en un hospital universitario en la región sudeste de Brasil. Resultados: la mediana de la duración de la estancia hospitalaria se identificó más alta en pacientes de 60 años o más, hombres, con comorbilidades previas. Además, la hospitalización fue más prolongada en individuos con complicaciones postoperatorias como eventos neurológicos, arritmias cardíacas, insuficiencia renal aguda, complicaciones pulmonares e infección nosocomial. Conclusión: la asociación de las características y la identificación del perfil de los pacientes que suelen permanecer más tiempo en la cama puede ser útil en la elaboración de protocolos y flujos institucionales

Associação do estado nutricional e os desfechos clínicos em cirurgia cardíaca pediátrica / Relación del estado nutricional y los resultados clínicos en cirugía cardíaca pediátrica / Association of nutritional status and clinical outcomes in pediatric cardiac surgery

Resumo Objetivo Verificar a associação do fator pessoal biológico estado nutricional, das crianças submetidas à cirurgia cardíaca, com os seguintes comportamentos: mortalidade/alta hospitalar, tempo de internação na Unidade de Terapia Intensiva (UTI) e tempo de ventilação mecânica (VM). Métodos Estudo transversal, retrospectivo realizado com 786 prontuários de crianças menores de cinco anos, submetidas à cirurgia cardíaca. O modelo de Nola J. Pender foi usado para analisar os dados. Aplicou-se o teste Qui-Quadrado de Pearson para verificar associação entre o fator pessoal biológico e o comportamento mortalidade/alta hospitalar. O teste Kruskal-Wallis foi utilizado para verificar a diferença entre medianas do fator pessoal biológico e os comportamentos tempo de VM e de UTI. Resultados A associação entre os fatores pessoais biológicos (pobre estado nutricional, desnutrição aguda e desnutrição crônica) com o comportamento mortalidade foi de OR 2,18 (1,42 - 3,34), p=0,003, OR 0,75 (0,46 - 1,2), p=0,24 e OR 2,7 (1,77 - 4,12), p<0,0001, respectivamente. A mediana de tempo em dias de uso de VM e tempo em dias de UTI foi, respectivamente de 3 (p<0,0001) e 8 (p<0,0001) para o pobre estado nutricional, 2 (p=0,041) e 6,5 (p=0,006) para a desnutrição aguda, 3 (p<0,0001) e 8 (p<0,0001) para a desnutrição crônica. Conclusão Os fatores pessoais biológicos que tiveram associação significativa com o comportamento mortalidade foram o pobre estado nutricional e desnutrição aguda. Foi verificado que as crianças com déficits nutricionais analisados tiveram uma superior mediana de tempo de VM e tempo de UTI quando comparadas com as crianças sem déficits nutricionais.

Resumen Objetivo Verificar la relación del factor personal biológico estado nutricional de niños sometidos a cirugía cardíaca, con los siguientes comportamientos: mortalidad/alta hospitalaria, tiempo de internación en Unidad de Cuidados Intensivos (UCI) y tiempo de ventilación mecánica (VM). Métodos Estudio transversal, retrospectivo realizado con 786 historias clínicas de niños menores de cinco años sometidos a cirugía cardíaca. Para analizar los datos se utilizó el modelo de Nola J. Pender. Se aplicó la prueba χ2 de Pearson para verificar la relación entre el factor personal biológico y el comportamiento mortalidad/alta hospitalaria. La prueba de Kruskal-Wallis fue utilizada para verificar la diferencia entre medianas del factor personal biológico y los comportamientos tiempo de VM y de UCI. Resultados La relación entre los factores personales biológicos (mal estado nutricional, desnutrición aguda y desnutrición crónica) y el comportamiento mortalidad fue de OR 2,18 (1,42 - 3,34), p=0,003, OR 0,75 (0,46 - 1,2), p=0,24 y OR 2,7 (1,77 - 4,12), p<0,0001, respectivamente. La mediana del tiempo en días de uso de VM y tiempo en días de UCI fue de 3 (p<0,0001) y 8 (p<0,0001) respectivamente para el mal estado nutricional, 2 (p=0,041) y 6,5 (p=0,006) para la desnutrición aguda, 3 (p<0,0001) y 8 (p<0,0001) para la desnutrición crónica. Conclusión Los factores personales biológicos que tuvieron relación significativa con el comportamiento mortalidad fueron el mal estado nutricional y la desnutrición aguda. Se verificó que los niños con deficiencias nutricionales estudiados tuvieron una mediana mayor de tiempo de VM y tiempo de UCI en comparación con niños sin deficiencias nutricionales.

Abstract Objective To find the association of the biological personal factor 'nutritional status' of children undergoing cardiac surgery with the following behaviors: mortality/hospital discharge, length of stay in the Intensive Care Unit (ICU) and time in mechanical ventilation (MV). Methods Cross-sectional, retrospective study of 786 medical records of children under five years of age who underwent cardiac surgery. Nola J. Pender's model was used for data analysis. The Pearson's Chi-Square test was applied to find the association between the biological personal factor and the mortality/hospital discharge behavior. The Kruskal-Wallis test was used to assess the difference between medians of the biological personal factor and the behaviors of time in MV and ICU length of stay. Results The association between personal biological factors (poor nutritional status, acute malnutrition and chronic malnutrition) with mortality behavior was OR 2.18 (1.42 - 3.34), p=0.003, OR 0.75 (0.46 - 1.2), p=0.24 and OR 2.7 (1.77 - 4.12), p<0.0001, respectively. The median time in days of MV use and ICU length of stay in days was, respectively, 3 (p<0.0001) and 8 (p<0.0001) for poor nutritional status, two (p=0.041) and 6.5 (p=0.006) for acute malnutrition, 3 (p<0.0001) and 8 (p<0.0001) for chronic malnutrition. Conclusion The personal biological factors with a significant association with mortality behavior were poor nutritional status and acute malnutrition. Children with analyzed nutritional deficits had a higher median time of MV and time of ICU compared with children without nutritional deficits.

Acute response to aerobic exercise on autonomic cardiac control of patients in phase iii of a cardiovascular rehabilitation program following coronary artery bypass grafting

Abstract Objective: The aim of the present study was to investigate the acute response to aerobic exercise on autonomic cardiac control of patients undergoing coronary artery bypass grafting (CABG). Methods: The study sample consisted of eight patients (age: 58.6±7.7 years; body mass index: 26.7±3.5 kg.m2) who underwent a successful CABG (no complications during surgery and/or in the following weeks). To assess heart rate variability (HRV), participants remained in a supine position with a 30-degree head elevation for 20 minutes. Electrocardiographic signal (protocol with three derivations) was collected from 600 Hz sample rate to obtain beat-to-beat intervals (R-R interval). This assessment was performed before, after one hour and after 24 hours of the exercise session. All patients underwent a 35 minutes aerobic exercise session (AES) (low-moderate intensity) on the cycle ergometer. Results: Significant differences were found in the time domain, with positive changes in root mean square of successive RR interval differences (rMSSD) (ms) (parasympathetic component) (one [P=0.017] and 24 hours [P=0.007] post-session). In the frequency domain, we found a significant difference in high frequency (HF) (ms2) (parasympathetic component) (one hour [P=0.048] post-session). The low frequency (LF)/HF ratio (sympathetic and parasympathetic components with a predominance of the sympathetic component) reached statistical significance only 24 hours (P=0.018) post-session. Additionally, the largest effect size was observed only for the LF/HF ratio at one (d=-0.8) and 24 hours (d=-1.3) after one AES. Conclusion: The practice of (acute) aerobic exercise improved autonomic cardiac control in patients undergoing CABG.

Resultados a 5 años de la revascularización exclusiva con dos arterias mamarias en pacientes con enfermedad coronaria multivaso / Exclusive coronary revascularization with both mammary arteries: analysis of 73 patients

Background: Exclusive coronary revascularization with both mammary arteries could result in lower rates of adverse events in the long term. Aim: To describe the five-year evolution of a cohort of patients operated on with this technique. Material and Methods: Follow up analyzing survival of 73 patients aged 59 ± 9 years (82% men) who underwent exclusive coronary surgery with two mammary arteries between December 1,2010 and April 12,2017. We studied their clinical characteristics, surgical results, operative morbidity and mortality and adverse events up to June 30, 2018. Results: Six patients had two-vessel lesions and 67 three-vessel lesions. The operative risk calculated by additive and logistic EuroSCORE was 2.5 and 2.3%, respectively. A mean of 3.75 anastomoses /patient were performed, 116 with left mammary artery (73 to the anterior descending artery, 38 to a diagonal artery and 5 for other objectives) and 158 with right mammary artery (69 to a first marginal artery, 23 to a second marginal artery and 64 to posterior descending artery). There was one case of mediastinitis and one (1.5%) patient died. The mean follow-up was 64.6 ± 23.7 months. The 5-year survival was 90.4%. Conclusions: Coronary revascularization with two exclusive mammary arteries allowed a complete revascularization of the heart with a low rate of complications and adverse effects at five years.

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.

Potentially modifiable predictors for renal replacement therapy in patients with cardiac surgery associated-acute kidney injury: a propensity score-matched case-control study

Abstract Objective: To discover potentially modifiable perioperative predictors for renal replacement therapy (RRT) in patients with cardiac surgery-associated acute kidney injury (CSA-AKI). Methods: A cohort of 1773 consecutive cardiac surgery patients with postoperative acute kidney injury (AKI) from January 2013 to December 2015 were included retrospectively. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The primary outcome was CSA-AKI requiring renal replacement therapy (AKI-RRT). The initiation of RRT was based on clinical judgment regarding severe volume overload, metabolic abnormality (e.g., acidosis, hyperkalemia), and oliguria. Patients with AKI-RRT were matched 1:1 with patients without AKI-RRT by a propensity score, to exclude the influence of patients' demographics, comorbidities, and baseline renal function. Multivariable regression was performed to identify the predictors in the matched sample. Results: AKI-RRT occurred in 4.4% of the entire cohort (n=78/1773), with 28.2% of in-hospital mortality (n=22/78). With the propensity score, 78 pairs of patients were matched 1:1 and the variables found to be predictors of AKI-RRT included the contrast exposure within 3 days before surgery (odds ratio [OR]=2.932), central venous pressure (CVP) >10 mmHg on intensive care unit (ICU) admission (OR=1.646 per mmHg increase), and erythrocyte transfusions on the 1st day of surgery (OR=1.742 per unit increase). Conclusion: AKI-RRT is associated with high mortality. The potentially modifiable predictors found in this study require concern and interventions to prevent CSA-AKI patients from worsening prognosis.

Criação e implementação de um banco de dados cirúrgico totalmente informatizado baseado nas ferramentas Google: experiência inicial em cirurgia cardiovascular / Design and implementation of a fully electronic surgery database based on Google tools: an initial experience in cardiovascular surgery

RESUMO Objetivo: descrever de maneira prática e detalhada a criação de uma plataforma totalmente informatizada para coleta, armazenamento e análise de dados, inicialmente proposta para cirurgia cardiovascular, com interfaces reprodutíveis e aplicáveis a outras especialidades cirúrgicas, bem como, apresentar a experiência inicial de trabalho com esta ferramenta e os resultados preliminares obtidos após sua implementação em um hospital universitário terciário brasileiro. Métodos: a plataforma foi desenvolvida com base nas ferramentas Google, gratuitas, de fácil utilização e amplamente acessíveis. Desde o início desta iniciativa, em maio de 2015, até a análise preliminar, em fevereiro de 2017, dados de 271 pacientes, consecutivos, submetidos à cirurgia cardiovascular foram prospectivamente recordados e analisados. Resultados: a iniciativa foi implementada com pleno sucesso, com 100% dos pacientes incluídos e sem perda de qualquer variável em um banco de dados composto por mais de 500 variáveis. As complicações pós-operatórias imediatas mais frequentes foram: fibrilação atrial (22,5%), broncopneumonia (10,7%), delirium (10,3%), insuficiência renal aguda (10%), acidente vascular encefálico (5%) e morte (7%). Comparando-se as taxas de mortalidade no primeiro e segundo anos da iniciativa, uma redução de 10,8% para 4% (p=0,042), respectivamente, foi evidenciada. Conclusão: a nova proposta de coleta e armazenamento de dados apresentada neste trabalho mostrou-se plenamente factível e efetiva. Por serem gratuitas, de fácil manuseio e universalmente acessíveis, estas ferramentas podem ser úteis a outras especialidades cirúrgicas que desejem desenvolver métodos de avaliação de sucesso e complicações pós-operatórios, bem como, programas de melhoria de qualidade.

ABSTRACT Objective: to describe, in a practical and step-by-step manner, the construction of a fully electronic platform for data collection, storage, and analysis, initially proposed for cardiovascular surgery, with interfaces that are reproducible and applicable to other surgical specialties, as well as to present the initial work experience with this instrument in cardiac surgery and the preliminary results obtained after its implementation in a Brazilian tertiary university hospital. Methods: the platform was developed based on Google tools, which are free, easy to use, and widely accessible. From the beginning of this initiative, in May 2015, to the preliminary analysis, in February 2017, data from 271 consecutive patients submitted to cardiovascular surgery were prospectively recorded and preliminarily analyzed. Results: the initiative was implemented with full success, with 100% of patients included and without loss of any variable, in a database composed of more than 500 variables. The most frequent immediate postoperative complications were: atrial fibrillation (22.5%), bronchopneumonia (10.7%), delirium (10.3%), acute renal failure (10%), stroke (5%), and death (7%). Comparing mortality rates in the first and second years of the initiative, a reduction from 10.8% to 4% (p=0.042), respectively, was evidenced. Conclusion: the new proposal of data collection and storage presented in this work was fully feasible and effective. It may be useful to other surgical specialties that wish to develop methods to evaluate success and postoperative complication rates, as well as quality improvement programs.

Outcomes after surgical resection of primary non-myxoma cardiac tumors

Abstract Objective: Primary cardiac tumors are rare lesions with different histological type. We reviewed our 17 years of experience in the surgical treatment and clinical results of primary non-myxoma cardiac tumors. Methods: Between July 2000 and February 2017, 21 patients with primary cardiac tumor were surgically treated in our institution. The tumors were categorized as benign non-myxomas and malignants. Data including the demographic characteristics, details of the tumor histology and grading, cardiac medical and surgical history, surgical procedure of the patients were obtained from the hospital database. Results: Eleven patients were diagnosed with benign non-myxoma tumor (male/female:7/4), ranging in age from 10 days to 74 years (mean age 30.9±26.5 years). Papillary fibroelastoma was the most frequent type (63.6%). There were two early deaths in benign group (all were rhabdomyoma), and mortality rate was 18%. The mean follow-up period was 69.3±58.7 months (range, 3 to 178 months). All survivals in benign group were free of tumor-related symptoms and tumor relapses. Ten patients were diagnosed with malignant tumor (sarcoma/lymphoma:8/2, male/female:3/7), ranging in age from 14 years to 73 years (mean age 44.7±18.9 years). Total resection could be done in only three (30%) patients. The mean follow-up period was 18.7±24.8 months (range, 0-78 months). Six patients died in the first 10 months. Conclusion: Complete resection of the cardiac tumors, whenever possible, is the main goal of surgery. Surgical resection of benign cardiac tumors is safe, usually curative and provides excellent long-term prognosis. On the contrary, malignant cardiac tumors still remain highly lethal.

Oral health status, health behaviour and treatment needs of patients undergoing cardiovascular surgery

Abstract Objective: The aim of the present study was to assess the oral health status and treatment needs of cardiovascular surgery patients. Second, the awareness of cardiovascular surgery patients regarding the association between oral health and heart disease was considered. Methods: Assessment of oral health status, oral hygiene practices and treatment needs of 106 hospitalized patients in preparation for cardiovascular surgery. Patients were interviewed using a structured questionnaire designed for this study and oral examination was carried out by a dentist. Results: The oral hygiene practices of the study cohort were not up to the standard. Patients' awareness of infective endocarditis was poor. Approximately 68% patients experienced dental caries as decayed teeth or missing teeth due to caries and filled teeth. The mean plaque index in the study group was 1.25. In this study cohort, the mean probing depth of periodontal pockets was 5.7±1.3, whereas the mean number of teeth with periodontal pockets > 6 mm was 0.5±0.9. A total of 84 (74.2%) of the patients required dental treatment. Conclusion: The principal finding in this study was that patients with heart disease had poor oral health. This study also highlights the importance of better interaction among all healthcare professionals to integrate oral health as part of comprehensive inpatient healthcare.

Evolução pós-operatória mediata e tardia de pacientes submetidos a cirurgias cardíacas eletivas / Postoperative medium and long-term evolution of patients who underwent elective cardiac surgery

Introdução. O estudo procurou investigar a evolução pós-operatória (PO) mediata e tardia de pacientes que participaram de um estudo anterior, sendo submetidos à primeira cirurgia de revascularização do miocárdio (CRM), correção de valvopatias e cirurgias combinadas, entre agosto/2013 e fevereiro/2015. Objetivo. Identificar as principais complicações e a ocorrência de óbito no PO mediato e investigar a evolução tardia desses pacientes, dentro de dois anos, quanto aos locais de retorno, necessidade de novas internações e de procedimentos relacionados ao aparelho circulatório, presença de infecção de sítio cirúrgico (ISC) e desfecho ao término deste período. Método. Estudo observacional, tipo coorte retrospectiva. Coletouse os dados mediante consulta aos prontuários dos pacientes e ao sistema de intranet do hospital, de março/2016 a outubro/2017. No PO mediato investigou-se a presença de complicações por sistema e o desfecho da internação; no PO tardio investigou-se o local dos retornos ambulatoriais; reinternações e suas causas; novos procedimentos/condutas relacionados ao aparelho circulatório; presença de ISC e desfecho clínico após dois anos. Realizamos uma análise descritiva das variáveis do estudo. Resultados. A amostra foi composta por 118 pacientes, 59 (50%) submetidos à CRM, 48 (40,6%) às cirurgias para correção de valvopatias e 11 (9,4%) às cirurgias combinadas. A hiperglicemia foi a complicação mais frequente entre pacientes que realizaram a CRM (64,4%) e entre aqueles submetidos às cirurgias combinadas (45,5%). No grupo de pacientes que realizaram cirurgias para correção de valvopatias, a complicação mais frequente foi o distúrbio de coagulação (20,8%). Todos os pacientes da amostra tiveram alta hospitalar. Quanto ao seguimento PO inicial, todos os pacientes, independentemente da cirurgia realizada, tiveram pelo menos um retorno no hospital do estudo. Ao longo de dois anos após a alta, 25,4% dos pacientes submetidos à CRM foram reinternados, assim como 33,3% dos submetidos às cirurgias para correção de valvopatias e 18,2% dos submetidos às cirurgias combinadas. Dois pacientes do grupo de CRM foram submetidos à intervenção coronária percutânea (ICP) e apenas um do grupo de válvula foi submetido a uma nova cirurgia cardíaca no período do estudo. Quanto à ISC, no grupo de CRM, cinco pacientes apresentaram infecção na safenectomia, um evoluiu com endocardite e um com mediastinite; no grupo de valva, apenas um evoluiu com endocardite, daqueles submetidos às cirurgias combinadas, um apresentou infecção da ferida esternal e um mediastinite. A maioria dos pacientes encontrava-se vivo após dois anos da alta hospitalar (CRM = 96,6%; cirurgia de valva = 83,3% e cirurgia combinada = 90,9%). Conclusão. A frequência de complicações dos pacientes no PO mediato foi baixa, e todos tiveram alta hospitalar. Quanto à evolução PO tardia, a maioria dos pacientes permanecia em acompanhamento ambulatorial no hospital do estudo após dois anos da alta hospitalar. Entre os pacientes estudados, apenas um do grupo de cirurgias corretivas de valvopatias foi submetido a nova cirurgia cardíaca, e dois do grupo de CRM à ICP. Quanto à ISC, poucos a desenvolveram, a maioria dos quais pertencia ao grupo de CRM. A maioria deles, independentemente da cirurgia realizada, encontrava-se vivo após dois anos da alta hospitalar

Introduction. This study aimed at investigating the medium and long-term postoperative (PO) evolution of patients who participated in a previous study, who were submitted to the first myocardium revascularization surgery (MRS), valvopathy correction and to combined surgeries, from August/2013 to February/2015. Objective. Identifying the main complications and cases of death among patients in the medium-term PO and investigate the late evolution of these patients, within two years, their return to the hospital, the need for other hospitalizations, the need for new procedures regarding their circulatory system, the presence of surgical site infections (SSI) and their outcome in this period. Method. Observational and retrospective cohort study. Data was collected from the records of patients and the intranet system of the hospital, from March/2016 to October/2017. In the medium-term PO, the complications in each system were investigated as was the outcome of the hospitalization; in the long-term PO, the site of outpatient returns; rehospitalizations and their motives; new procedures/conducts related to the circulatory system; the presence of SSI and the clinical outcome after two years. A descriptive analysis of the study variables was made. Results. The sample of the study included 118 patients, 59 (50%) had undergone MRS, 48 (40.6%) valvopathy correction surgeries and 11 (9.4%) combined surgeries. Hyperglycemia was the most common medium-term PO complication among patients who underwent the combined surgery (45.5%), while those who underwent valvopathy correction surgeries most commonly presented coagulation disorder (20.8%). All patients in the sample were discharged. Regarding the initial PO monitoring, all patients came back to the hospital at least once. Regarding the rehospitalizations in the first two years after the discharge from the first heart surgery, 25.4% of patients who underwent MRS were re-hospitalized, as were 33.3% of those who underwent valvopathy correction surgeries and 18.2% of those who underwent combined surgeries. Two patients from the MRS group were submitted to percutaneous coronary interventions (PCI) and only one in the group of corrective valvopathy was submitted to another surgery in the period of the study. Regarding the presence of SSI, in the SMR group, five patients had infections after saphenectomies, one had endocarditis and one, mediastinitis; considering valvopathy correction patients, one presented with endocarditis, while one of those who underwent combined surgeries had sternum injuries and another, mediastinitis. Most patients were alive two years after discharge (SMR=96.6%; valvopathy correction=83.3% and combined surgery=90.9%). Conclusion. The frequency of complications among patients in the medium-term PO was low, and all of them were discharged from the hospital. Regarding long-term PO evolution, most patients were undergoing outpatient monitoring in the hospital were the study was conducted two years after hospital discharge. Among all patients in the study, only one, in the group of valvopathy correction, underwent new cardiac surgeries, and two of the SMR group underwent PCI. Few patients presented SSI, and most were in the MRS group. Most patients were alive after two years

First results of the Brazilian Registry of Percutaneous Left Atrial Appendage Closure / Primeiros Resultados do Registro Brasileiro de Oclusão Percutânea do Apêndice Atrial Esquerdo

Abstract Background: Left atrial appendage closure (LAAC) is an effective alternative to oral anticoagulation (OA) for the prevention of stroke in patients with non-valvular atrial fibrillation (NVAF). Objective: To present the immediate results and late outcomes of patients submitted to LAAC and included in the Brazilian Registry of Percutaneous Left Atrial Appendage Closure. Methods: 91 patients with NVAF, high stroke risk (CHA2DS2VASc score = 4.5 ± 1.5) and restrictions to OAC (HAS-BLED score = 3.6 ± 1.0) underwent 92 LAAC procedures using either the Amplatzer cardiac plug or the Watchman device in 11 centers in Brazil, between late 2010 and mid 2016. Results: Ninety-six devices were used (1.04 device/procedure, including an additional non-dedicated device), with a procedural success rate of 97.8%. Associated procedures were performed in 8.7% of the patients. Complete LAAC was obtained in 93.3% of the successful cases. In cases of incomplete closure, no residual leak was larger than 2.5 mm. One patient needed simultaneous implantation of 2 devices. There were 7 periprocedural major (5 pericardial effusions requiring pericardiocentesis, 1 non-dedicated device embolization and 1 coronary air embolism without sequelae) and 4 minor complications. After 128.6 patient-years of follow-up there were 3 deaths unrelated to the procedure, 2 major bleedings (one of them in a patient with an unsuccessful LAAC), thrombus formation over the device in 2 cases (both resolved after resuming OAC for 3 months) and 2 strokes (2.2%). Conclusions: In this multicenter, real world registry, that included patients with NVAF and high thromboembolic and bleeding risks, LAAC effectively prevented stroke and bleeding when compared to the expected rates based on CHA2DS2VASc and HASBLED scores for this population. Complications rate of the procedure was acceptable considering the beginning of the learning curve of most of the involved operators.

Resumo Fundamento: A oclusão percutânea do apêndice atrial esquerdo (OAAE) é uma alternativa eficaz à anticoagulação oral (ACO) para a prevenção de acidente vascular cerebral (AVC) em pacientes com fibrilação atrial não-valvular (FANV). Objetivo: Apresentar os resultados imediatos e o seguimento tardio de pacientes submetidos a OAAE e incluídos no Registro Brasileiro de Oclusão Percutânea do Apêndice Atrial Esquerdo. Métodos: 91 pacientes com FANV, alto risco de AVC (escore CHA2DS2VASc = 4,5 ± 1,5) e restrição à AO (escore HAS-BLED = 3,6 ± 1,0) foram submetidos a 92 procedimentos de OAAE com as próteses Amplatzer Cardiac Plug e Watchman em 11 centros do Brasil, entre o final de 2010 e a metade de 2016. Resultados: Utilizaram-se 96 próteses no total (1,04 próteses/procedimento, incluindo-se o uso de 1 prótese não-dedicada adicional em um dos casos), obtendo-se sucesso em 97,8% dos procedimentos. Realizaram-se procedimentos associados à OAAE em 8,7% dos pacientes. Observou-se oclusão total do AAE em 93,3% dos casos com sucesso, e nos casos de oclusão incompleta, nenhum leak foi > 2,5 mm. Um paciente necessitou do implante simultâneo de 2 próteses. Houve 7 complicações maiores periprocedimento (5 derrames pericárdicos necessitando pericardiocentese, 1 embolização da prótese não-dedicada e 1 embolia aérea coronariana sem sequelas) e 4 menores. No seguimento de 128,6 pacientes-ano, houve 3 óbitos não relacionados ao procedimento, 2 sangramentos maiores (um deles em um dos casos de insucesso da OAAE), formação de trombo sobre a prótese em 2 casos (tratados com sucesso com reinstituição da ACO por 3 meses), e 2 AVCs (2,2%). Conclusões: Neste registro multicêntrico de mundo real, que incluiu pacientes com FANV e alto risco de sangramento e de eventos tromboembólicos, a OAAE foi eficaz na prevenção de AVC e sangramento quando comparada às taxas de AVC previstas pelos escores CHA2DS2VASc e HASBLED para esta população. O índice de complicações do procedimento foi aceitável, considerando se tratar do início da curva de aprendizado da maioria dos operadores envolvidos.

Hybrid treatment with complete transposition of supra-aortic trunks versus conventional surgery for the treatment of aortic arch aneurysm

Abstract Objective: The disease of the aortic arch is traditionally approached by open surgical repair requiring cardiopulmonary bypass and circulatory arrest. This study performed a retrospective analysis comparing outcomes through primary hybrid patients submitted to aortic arch surgery without cardiopulmonary bypass with patients submitted to conventional open surgery. Methods: 25 patients submitted to the aortic arch surgery were selected in the period 2003-2012 at the Madre Teresa Hospital in the city of Belo Horizonte, Brazil; 13 of these underwent hybrid technique without cardiopulmonary bypass and 12 underwent conventional open surgery. Results: The mortality rate for the hybrid group was 23% and for the conventional surgery group was 17% (P=0.248). The postoperative complication rate was also similar in both groups, with no significant difference. Conclusion: Both techniques proved to be similar in mortality and morbidity. However, due to the small sample, more analytical studies with larger samples and long-term follow-up are needed to clarify this issue.

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.

Chronic atrial fibrillation ablation with harmonic scalpel during mitral valve surgery

Abstract Objective To evaluate surgical treatment of chronic atrial fibrillation with ultrasound in patients with mitral valve disease, considering preoperative clinical characteristics of patients undergoing surgical procedure and follow-up in the immediate postoperative period, in hospital and up to 60 months after discharge. Methods: We studied 100 patients with chronic atrial fibrillation and mitral valve disease who underwent surgical treatment using ultrasound ablation. Patient data were reviewed by consulting the control reports, including signs and symptoms, underlying disease, functional class, hospital stay, surgical procedure time, ablation time, immediate complications, and complications at discharged and up to 60 months later. Actuarial curve (Kaplan-Meier) was used for the study of permanence without recurrence after 12, 24, 36, 48 and 60 months. Results: 86% of the patients had rheumatic mitral valve disease, 14% had degeneration of the mitral valve, 40% had mitral regurgitation, and 36% had mitral stenosis. Main symptoms included palpitations related to tachycardia by chronic atrial fibrillation (70%), congestive heart failure (70%), and previous episodes of acute pulmonary edema (27%). Early results showed that 94% of the patients undergoing ultrasound ablation reversed the rate of chronic atrial fibrillation, 86% being in sinus rhythm and 8% in atrioventricular block. At hospital discharge, maintenance of sinus rhythm was observed in 86% of patients and there was recurrence of chronic atrial fibrillation in 8% of patients. At follow-up after 60 months, 83.8% of patients maintained the sinus rhythm. Conclusion: Surgical treatment of chronic atrial fibrillation with ultrasound concomitant with mitral valve surgery is feasible and satisfactory, with maintenance of sinus rhythm in most patients (83.8%) after 60 months of follow-up.

Dacron graft intussusception technique for treatment of type a aortic dissections: technical notes and preliminary results

Abstract Introduction: Optimal surgical management for acute type A aortic dissection (AAAD) remains unclear. The in-hospital mortality rate is still high (15%), and the intraoperative bleeding is an independent risk factor for hospital mortality. Objective: The aim of our study was describe a new method for aortic anastomosis in the repair of AAAD and report the hospital mortality and bleeding complications. Methods: Between January 2008 and November 2014, 24 patients, 16 male, median age 62 years, underwent surgical treatment of AAAD. The surgical technique consisted of intussusception of a Dacron tube in the dissected aorta, which is anastomosed with a first line of 2-0 polyester everting mattress suture and a second line of 3-0 polypropylene running suture placed at the outermost side. Open distal anastomosis was performed with bilateral selective antegrade cerebral perfusion in 13 (54.1%) patients. Results: Cardiopulmonary bypass and aortic clamping time ranged from 75 to 135 min (mean=85 min) and 60 to 100 min (mean=67 min), respectively. The systemic circulatory arrest ranged from 29 to 60 min (mean=44.5 min). One (4.1%) patient required reoperation for bleeding, due to the use of preoperative clopidogrel. The postoperative bleeding was 382-1270 ml (mean=654 ml). We used an average of 4.2 units of red blood cells/patient. There were two (8.3%) hospital deaths, one due to intraoperative bleeding and another due to mesenteric ischemia. The average length of stay in the intensive care unit and hospital was 44 hours and 6.7 days, respectively. Conclusion: This new method for surgical correction of AAAD was reproducible and resulted in satisfactory clinical outcomes.

Impact of Cardiovascular Interventions on the Quality of Life in the Elderly

ABSTRACT INTRODUCTION: The elderly population is growing rapidly. Political and socio-economic changes led to the demographic transition in this population with the highest number of surgeries and as well as many comorbidities. OBJECTIVE: To evaluate the impact of cardiovascular intervention on quality of life of elderly patients after three and six months. METHODS: Analytical prospective cohort study with elderly between 60 and 80 years of age, of both sexes, with a diagnosis of coronary artery disease and underwent cardiovascular intervention during the period June 2010 to June 2011. Data were collected by individual interviews in the pre and postoperative periods (after three and six months) by telephone. We used the SF-36 to analyse quality of life in order to assess the physical and mental health of the study population. RESULTS: Of the 44 individuals evaluated, 59.1% were men, 75% in the range of 65 to 74 years, 38.6% were white and 38.6% were black, 31.8% were uneducated, 43.2% were married and 68.2% had less than a minimum wage. Prevailed patients: non-diabetics (68.2%), non-obese (81.8%), hypertensive (84.1%), non-alcoholic and non-smokers (68.2% and 61.4%, respectively). A significant increase in the average of the SF-36 scores between pre and post-surgical periods (three and six months) for the domains: functional capacity, pain, general health, vitality and emotional aspect. CONCLUSION: The elderly population undergoing intervention may have cardiovascular benefits and improvements of quality of life. Physical fitness improvement measures can be taken to resume that capability.