Do Flow and Pulsatility Index within the Accepted Ranges Predict Long-Term Outcomes after Coronary Artery Bypass Grafting?

BACKGROUND: Transit-time flow measurement (TTFM) is the gold standard for intraoperative detection of graft failure. Several reports show that TTFM and distal coronary bed quality (DCBQ) may also be useful for midterm detection of graft failure. Nonetheless, there are no data regarding their predictive role on long-term outcomes. METHODS: Patients with three-vessel disease who underwent isolated coronary artery bypass grafting (CABG) in 2006 and received at least one graft to the left anterior descending artery (LAD) or to the first obtuse marginal (OM1) or posterior descending artery (PDA) were included. Baseline characteristics, mean graft flow, pulsatility index, and subjective impression of DCBQ for each coronary territory were collected. Long-term cardiovascular (CV) and overall survival, operative mortality, and new percutaneous coronary intervention (PCI) were evaluated. RESULTS: A total of 177 patients underwent isolated CABG. The OM1 was grafted in 131 patients, the LAD in 169 patients, and the PDA in 100 patients. Neither DQCB nor TTFM were predictors for new PCI. Independent predictors for overall survival were age, previous acute myocardial infarction (AMI), and DQCB of OM1 (odds ratio [OR] = 2.97; 95% confidence interval [CI]: 1.15-7.71). Age, previous AMI, and DCBQ of OM1 (OR = 2.5; 95% CI: 1.39-4.81) were independent predictors for CV survival. CONCLUSIONS: TTFM on patients with functioning grafts does not predict long-term survival or performance of new PCI. Subjective evaluation of distal coronary bed, especially of the OM1, has a strong impact on long-term outcomes.

Early anticoagulation after aortic valve replacement with porcine bioprosthesis randomized control trial (ANTIPRO).

OBJECTIVES: Most evidence for anticoagulation (AC) in aortic bioprosthesis is centred on embolic events, bleeding and reintervention risk. The effect of AC on haemodynamics has not been previously assessed. Our hypothesis was that patients with early AC after aortic valve replacement (AVR) with porcine bioprosthesis have better haemodynamics at 1 year of follow-up. METHODS: Prospective, randomized, open-label trial conducted at 2 cardiac surgery centres. All patients undergoing AVR with porcine bioprosthesis were consecutively recruited. The anticoagulated group received warfarin + aspirin and the non-anticoagulated (control) only aspirin. The primary outcome was mean gradient after 1 year of AVR and change in New York Heart Association class. Secondary outcomes were major and minor bleeding, embolic events and prosthetic leak. RESULTS: Of 140 participants in the study, 71 were assigned to the anticoagulated group and 69 to the control group. The mean age of the overall population was 72.4 (SD: 7.1) years. Global EuroSCORE was 7.65 (SD: 5.73). At 1 year, the mean gradient was similar between both groups [18.6 (SD: 1.1 mmHg) and 18.1 (SD: 1.0 mmHg) in the control and anticoagulated groups, respectively, P = 0.701]. No differences in functional class at 3 months or 1 year were found among groups. No differences were found among groups in the secondary outcomes. CONCLUSIONS: The addition of 3 months of oral AC to anti-aggregation treatment was not detected to affect bioprosthetic haemodynamics nor functional class at 1 year after AVR. Likewise, AC does not lead to the higher incidence of complications.

Global Longitudinal Strain Predicts Survival and Left Ventricular Function After Mitral Valve Surgery: A Meta-analysis.

The timing for surgical treatment in patients with primary organic severe mitral valve regurgitation and preserved left ventricular ejection fraction (LVEF) systolic is a challenge since it depends upon LV end systolic dimension and LVEF which may be late markers of LV dysfunction. Echocardiography is the most important tool in the diagnosis of mechanisms, etiology, severity, and hemodynamic consequences of mitral regurgitation. The global longitudinal strain (GLS), a new and sensitive method for the detection of LV dysfunction, might be a useful method for the evaluation of preclinical systolic dysfunction. Nevertheless, its role for predicting postoperative outcomes is not well established. A meta-analysis was performed to address the role of GLS in patients with severe mitral regurgitation and preserved LVEF who underwent mitral surgery. We included studies that compared outcomes according to preoperative GLS in regard to survival and postoperative LV function. We included 2358 patients enrolled in 8 studies. Patients with reduced GLS% had worse long term survival after mitral valve surgery (hazard ratio = 1.13, 95% confidence interval [CI]: 1.02-1.26). Patients with preoperatively reduced GLS% had lower LVEF after surgery (mean difference [MD] = -5.06%, 95% CI: -8.97-1.16%) and additionally, patients who presented postoperative LVEF dysfunction had worse preoperative GLS (MD = 4.33, 95% CI: 3.89-4.76). In patients with primary mitral regurgitation, preoperative GLS is a predictor for long term survival and postoperative LVEF. It is a useful parameter to be included when considering early surgery in patients with severe mitral regurgitation and normal LVEF.

Predictive Factors of Mortality in Acute Aortic Dissection and Validity of the EuroSCORE Algorithm in a Small-Sized Cardiac Surgery Institution.

INTRODUCTION: Acute aortic dissection (AAD) is a devastating surgical emergency, with high operative mortality. Several scoring algorithms have been used to establish the expected mortality in these patients. Our objective was to define the predictive factors for mortality in our center and to validate the EuroSCORE and Penn classification system. METHODS: Patients who underwent surgery for AAD from 2006 to 2016 were retrieved from the institution's database. Preoperative, operative and postoperative variables were collected. Observed and expected mortality was calculated by EuroSCORE. Logistic regression analysis and Cox regression analysis were performed to find predictors of operative mortality and survival, respectively. The receiver operating characteristic (ROC) curves were plotted for logistic EuroSCORE, and the area under the ROC curve (AUC) was calculated. RESULTS: 87 patients (27.6% female) underwent surgery for AAD. The mean age was 58.6±9.7 years. Expected and observed operative mortality was 25.8±15.1% and 20.7%, respectively. Penn Aa, Ab and Abc shared similar observed/expected (O/E) mortality ratio. The only independent predictor of operative mortality (OR: 3.63; 95% CI: 1.19-11.09) and survival (HR: 2.6; 95% CI: 1.5-4.8) was female gender. EuroSCORE showed a very poor prediction capacity, with an AUC=0.566. CONCLUSION: Female gender was the only independent predictor of operative mortality and survival in our institution. EuroSCORE is a poor scoring algorithm to predict mortality in AAD, but with consistent results for Penn Aa, Ab and Abc.

The Beneficial Effect of Anticoagulation in Aortic Bioprosthesis is Associated with its Size.

OBJECTIVE: To evaluate the clinical and echocardiographic outcomes in aortic valve replacement (AVR) patients with aortic bioprosthesis under oral anticoagulation (OA). METHODS: Patients who underwent AVR with bioprosthesiswere prospectively enrolled. They were classified based on postoperative use of OA. Clinical and operative variables were collected. Echocardiographic and clinical follow-ups were performed two years after surgery. The primary outcome evaluated was change in transprosthetic gradient. Secondary outcomes analyzed were change in New York Heart Association (NYHA) class, major bleeding episodes, hospitalization, stroke, and transient ischemic attack. RESULTS: We included 103 patients (61 without OA and 42 with OA). Clinical characteristics were similar among groups, except for younger age (76±6.3 vs. 72.4±8.1 years, P=0.016) and higher prevalence of atrial fibrillation (0% vs. 23.8%, P<0.001) in the OA group. Mean (21.4±10 mmHg vs. 16.8±7.7 mmHg, P=0.037) and maximum (33.4±13.7 mmHg vs. 28.4±10.2 mmHg, P=0.05) transprosthetic gradients were higher in patients without OA. Improvement in NYHA class was more frequent in patients with OA (73% vs. 45.3%, P=0.032). Major bleeding, stroke, and hospitalization were similar among groups. OA was the only independent predictor for improvement of NYHA class after multivariate logistic regression analysis (odds ratio [OR]: 5.9, 95% confidence interval [CI]: 1.2-29.4; P=0.028). Stratification by prosthesis size showed that patients with ≤ 21 mm prosthesis benefited from OA. CONCLUSION: Early anticoagulation after AVR with bioprosthesis was associated with significant decrease of transprosthesis gradient and improvement in NYHA class. These associations were seen mainly in patients with ≤ 21 mm prosthesis.

CABG and Preoperative use of Beta-Blockers in Patients with Stable Angina are Associated with Better Cardiovascular Survival.

OBJECTIVE: In contrast to unstable angina, optimal therapy in patients with stable angina is debated. Our aim was to evaluate the outcomes of patients with stable angina scheduled for isolated coronary artery bypass grafts and the effect of preoperative use of beta-blockers. Overall and cardiovascular survivals were our primary outcome. Operative mortality and postoperative complications along with subgroup analysis of diabetic patients were our secondary outcomes. METHODS: Retrospective evaluation of patients with stable angina scheduled for isolated coronary artery bypass grafts was included. Pre- and postoperative variables were extracted from the institution database. Survival was obtained from the National Registry. RESULTS: We included 282 patients with stable angina, with a mean age of 65.6±9.5 years. 26.6% were female and 38.7% had diabetes. Three-vessel disease was present in 76.6% of patients. Previous beta-blocker treatment was evident in 69.9% of patients. 10-year overall survival in the whole population was 60.5% (95% confidence interval [CI]: 50.3-70.7%). Operative mortality during the study period was 3.5%. Patients with preoperative use of beta-blocker therapy had better overall survival (9.0 years, 95%CI: 8.6-9.5) than those without treatment (7.9 years, 95%CI: 7.1-8.8 years; P=0.048). Predictors for overall survival were: hypertension, diabetes, and age. Predictors for cardiovascular survival in diabetic patients were: beta-blocker use, gender, and age. CONCLUSION: Coronary artery bypass grafts surgery in patients with stable angina carries low operative mortality, postoperative complications, and excellent long-term cardiovascular survival. The preoperative use of beta-blockers in diabetic patients is associated with better cardiovascular survival after coronary artery bypass grafts.

Early surgery after angiography in patients scheduled for valve replacement.

Background There are limited data regarding the risks of cardiac surgery early after coronary angiography in patients scheduled for isolated aortic and/or mitral valve replacement. Our aim was to evaluate the risk of early surgery after coronary angiography in these patients. Methods We retrospectively analyzed data of 1044 patients who underwent isolated aortic and/or mitral valve replacement from 2006 to 2014. Baseline, operative, and postoperative variables were collected. The patients were divided into 3 groups based on the interval between coronary angiography and surgery: ≤3 days ( n = 216), 4-7 days ( n = 109), and ≥8 days ( n = 719). We evaluated hospital mortality and postoperative acute kidney injury. Subgroup analysis was performed according to preoperative creatinine clearance. Results Postoperative creatinine clearance was lower in patients who underwent surgery ≤3 days after coronary angiography (63.57 ± 38.52 mL min-1) compared to ≥8 days after coronary angiography (74.56 ± 54.25 mL min-1, p = 0.015). Patients who underwent surgery ≤3 days after coronary angiography had higher hospital mortality when preoperative creatinine clearance was ≤60 mL min-1 (12% vs. 4% for creatinine clearance ≤and >60 mL min-1, respectively; p = 0.039). Predictors of hospital mortality were New York Heart Association class and postoperative creatinine clearance. Conclusion Hospital mortality was higher in patients with decreased preoperative renal function who underwent surgery within the first 3 days after coronary angiography. Delaying surgery in this subgroup of patients could be a good strategy.

Aortic assessment of bicuspid aortic valve patients and their first-degree relatives.

Background Bicuspid aortic valve patients have an increased risk of aortic dilatation. A deficit of nitric oxide synthase has been proposed as the causative factor. No correlation between flow-mediated dilation and aortic diameter has been performed in patients with bicuspid aortic valves and normal aortic diameters. Being a hereditary disease, we compared echocardiographic features and endothelial function in these patients and their first-degree relatives. Methods Comprehensive physical examinations, routine laboratory tests, transthoracic echocardiography, and measurements of endothelium-dependent and non-dependent flow-mediated vasodilatation were performed in 18 bicuspid aortic valve patients (14 type 1 and 4 type 2) and 19 of their first-degree relatives. Results The first-degree relatives were younger (36.7 ± 18.8 vs. 50.5 ± 13.9 years, p = 0.019) with higher ejection fractions (64.6% ± 1.7% vs. 58.4% ± 9.5%, p = 0.015). Aortic diameters indexed to body surface area were similar in both groups, the except the tubular aorta which was larger in bicuspid aortic valve patients (19.3 ± 2.7 vs. 17.4 ± 2.2 mm·m-2, p = 0.033). Flow-dependent vasodilation was similar in both groups. A significant inverse correlation was found between non-flow-dependent vasodilation and aortic root diameter in patients with bicuspid aortic valve ( R = -0.57, p = 0.05). Conclusions Bicuspid aortic valve patients without aortopathy have larger ascending aortic diameters than their first-degree relatives. Endothelial function is similar in both groups, and there is no correlation with ascending aorta diameter. Nonetheless, an inverse correlation exists between non-endothelial-dependent dilation and aortic root diameter in bicuspid aortic valve patients.

Mitral valve replacement in the elderly is associated with low mortality and similar survival to the general population.

BACKGROUND: With the increase of elderly population, cardiologists and surgeons are faced with an increased incidence of mitral regurgitation. Most of these patients are denied surgery due to a misconceived perception of ominous surgical results. Our objective was to analyze early and late survival in elderly patients after mitral valve surgery in a center in which replacement is the procedure of choice. METHODS: We obtained clinical follow-up of patients older than 70 years who underwent first-time isolated replacement from January 2000 to January 2012. Observed survival was compared with expected survival in the general population of Uruguay. Independent predictors of operative mortality and survival were determined. RESULTS: A total of 127 patients were included. Global operative mortality was 9.4% (1.8% after year 2006 vs. 15.3% before 2006; P<0.05). Surgery performed before 2006, preoperative hematocrit and creatinine were independent predictors for operative mortality after multivariate analysis. 6-year survival was 70.2% for females (72.4% expected survival, P=ns) and 40.1% in males (63.5% expected survival, P<0.05). Independent predictors of survival were surgery performed before 2006 (HR=3.2) and female sex (HR=0.4). CONCLUSION: Mitral valve replacement is a feasible option for elderly patients with mitral valve disease in centers with lack expertise in valve repair. Actual surgical results provide low operative mortality and similar survival to general the population (mainly in females).

Predictors and Outcomes of Prosthesis-Patient Mismatch After Aortic Valve Replacement.

OBJECTIVES: This study sought to evaluate predictors of prosthesis-patient mismatch (PPM) and its association with the risk of perioperative and overall mortality. BACKGROUND: PPM is associated with increased mid- and long-term mortality after surgical aortic valve replacement. Conflicting results have been reported with regard to its association with perioperative mortality. METHODS: Databases were searched for studies published between 1965 and 2014. Main outcomes of interest were perioperative mortality and overall mortality. RESULTS: The search yielded 382 studies for inclusion. Of these, 58 articles were analyzed and their data extracted. The total number of patients included was 40,381 (39,568 surgical aortic valve replacement and 813 transcatheter aortic valve replacement). Perioperative (odds ratio: 1.54; 95% confidence interval: 1.25 to 1.91) and overall (i.e., perioperative and post-operative) mortality (hazard ratio: 1.26; 95% confidence interval: 1.16 to 1.36) was increased in patients with PPM. The impact of PPM on mortality was higher in those studies in which the mean age of the patients was <70 years of age (and/or AVR with associated coronary artery bypass graft was included). Severe PPM was associated with increased risk of both perioperative and overall mortality, whereas moderate PPM was associated with increased risk of perioperative mortality but not of overall mortality. The impact of PPM was less pronounced in patients with larger body mass index (>28 kg/m(2)) compared with those with lower index. Predictors of PPM were older age, female sex, hypertension, diabetes, renal failure, larger body surface area, larger body mass index, and the utilization of a bioprosthesis. CONCLUSIONS: PPM increases perioperative and overall mortality proportionally to its severity. The identification of predictors for PPM may be useful to identify patients who are at higher risk for PPM. The findings of this study support the implementation of strategies to prevent PPM especially in patients <70 years of age and/or with concomitant coronary artery bypass graft.

Is patient-prosthesis mismatch a predictor of survival or a surrogate marker of co-morbidities in cardiac surgery?

BACKGROUND: Patient-prosthesis mismatch (PPM) has ignited much debate and no definite conclusions have been drawn on the outcome of these patients. Therefore, additional large studies with long-term follow-up are required to help the cardiologist and surgeon outline the best therapeutic strategy for patients with high risk for PPM. METHODS: Patients who underwent aortic valve replacement (AVR) from 2000 to 2013 were identified. Baseline and operative data was extracted and indexed effective orifice area calculated for each patient. The presence of PPM was defined in those patients with an iEOA ≤ 0.85 cm(2)/m(2). Regression analyses were performed to determine the association of PPM with operative mortality, post-operative complications and survival. Predictors for PPM were evaluated based on clinical and operative data. RESULTS: From 2023 patients who underwent AVR, PPM was present in 64.6%. These patients had increased age, more coronary artery bypass procedures, increased risk of diabetes, hypertension, higher creatinine values and higher Euroscore. Age, body surface area, prosthesis type and size were found to be predictors of mismatch. Operative mortality (8.1% vs 5.7%, p = 0.05), stroke (3.9% vs 2.4, p = 0.02) and acute kidney injury (47.6% vs 35.1%, p =< 0 .001) were more frequent in patients with PPM and mean 10-year survival was reduced (6.6 years, 95% CI: 6.3-6.8 vs 7.3, 95% CI: 6.9-7.2, p < 0.001). After adjusting for confounders, PPM was not found to be associated to either adverse outcome or survival. CONCLUSIONS: Patients with PPM have worse operative mortality, post-operative complications and survival mainly due to the fact that they represent a higher risk population based on age and co-morbidities.

Lo mejor del Congreso Uruguayo de Cardiología 2019 / The best of the 2019 Uruguayan Congress of Cardiology / O melhor do Congresso Uruguaio de Cardiologia 2019

Resumen: El 35° Congreso Uruguayo de Cardiología tuvo lugar en Punta del Este, del 7 al 9 de noviembre. Como cada año, constituyó una oportunidad de actualización en diferentes áreas de la cardiología, contando con la participación de invitados nacionales e internacionales. Asimismo, se dio a conocer la actividad científica desarrollada por diferentes autores mediante la exposición de temas libres. A continuación, comentamos los siete artículos premiados por el Comité Científico. - Prevención de muerte súbita (PREMUDE) en jugadores de fútbol: 10 años de valoración precompetitiva. - Perfil clínico de la fibrilación auricular en el posoperatorio de cirugía cardíaca. - Protocolo de cardio-oncología para el seguimiento de pacientes con riesgo de disfunción ventricular por quimioterapia. - Implicancia del uso del score de calcio coronario en la re-estratificación del riesgo cardiovascular en prevención primaria. - Análisis de la morbimortalidad asociada a implante percutáneo de válvula aórtica: valor de variables clínicas y scores de riesgo a mediano plazo. - Anticoagulación en bioprótesis valvular aórtica. Ensayo clínico randomizado multicéntrico. - Strain global longitudinal del ventrículo izquierdo permite predecir mejoría funcional y sobrevida en pacientes con insuficiencia mitral severa asintomática y función normal. Metaanálisis.

Summary: The 35th Uruguayan Congress of Cardiology was held in Punta del Este in November 7th to 9th. As every year, it was an opportunity to update in different cardiovascular areas with participation of national and international guests. Scientific activity of different authors was also announced, through exposition of several articles. We will comment the seven awarded abstracts. - Sudden death prevention (PREMUDE) in soccer players: 10 years of pre-competitive assessment. - Clinical profile of atrial fibrillation in the postoperative period of cardiac surgery. - Cardio-oncology protocol for the follow-up of patients at risk of ventricular dysfunction due to chemotherapy. - Implication of the use of coronary calcium score in the re-stratification of cardiovascular risk in primary prevention. - Analysis of morbidity and mortality associated with percutaneous aortic valve implantation: value of clinical variables and medium-term risk scores. - Anticoagulation in aortic valve bioprosthesis. Multicenter randomized clinical trial. - Longitudinal global left ventricular strain allows prediction of functional improvement and survival in patients with severe asymptomatic mitral regurgitation and normal function. Meta-analysis.

Resumo: O 35º Congresso Uruguaio de Cardiologia, aconteceu em Punta del Este, de 7 a 9 de novembro. Como todos os anos, foi uma oportunidade de atualização em diferentes áreas cardiológicas, graças à experiência de convidados nacionais e internacionais. Também foi anunciada a atividade científica de diferentes serviços, através da exposição de vários artigos. Propomos comentar os sete artigos premiados. - Prevenção de morte súbita (PREMUDE) em jogadores de futebol: 10 anos de avaliação pré-competitiva. - Perfil clínico da fibrilação atrial no pós-operatório de cirurgia cardíaca. - Protocolo cardio-oncológico para acompanhamento de pacientes com risco de disfunção ventricular devido à quimioterapia. - Implicação do uso do escore de cálcio coronariano na ré estratificação do risco cardiovascular na prevenção primária. - Análise da morbimortalidade associada ao implante valvar aórtico percutâneo: valor de variáveis clínicas e escores de risco a médio prazo. - Anticoagulação na bioprótese valvar aórtica. Ensaio clínico randomizado multicêntrico. - O strain global longitudinal do ventrículo esquerdo permite predizer melhora funcional e sobrevida em pacientes com insuficiência mitral assintomática grave e função normal. Meta-análise.

Predictive factors of mortality in acute aortic dissection and validity of the euroscore algorithm in a small-sized cardiac surgery institution

Abstract Introduction: Acute aortic dissection (AAD) is a devastating surgical emergency, with high operative mortality. Several scoring algorithms have been used to establish the expected mortality in these patients. Our objective was to define the predictive factors for mortality in our center and to validate the EuroSCORE and Penn classification system. Methods: Patients who underwent surgery for AAD from 2006 to 2016 were retrieved from the institution's database. Preoperative, operative and postoperative variables were collected. Observed and expected mortality was calculated by EuroSCORE. Logistic regression analysis and Cox regression analysis were performed to find predictors of operative mortality and survival, respectively. The receiver operating characteristic (ROC) curves were plotted for logistic EuroSCORE, and the area under the ROC curve (AUC) was calculated. Results: 87 patients (27.6% female) underwent surgery for AAD. The mean age was 58.6±9.7 years. Expected and observed operative mortality was 25.8±15.1% and 20.7%, respectively. Penn Aa, Ab and Abc shared similar observed/expected (O/E) mortality ratio. The only independent predictor of operative mortality (OR: 3.63; 95% CI: 1.19-11.09) and survival (HR: 2.6; 95% CI: 1.5-4.8) was female gender. EuroSCORE showed a very poor prediction capacity, with an AUC=0.566. Conclusion: Female gender was the only independent predictor of operative mortality and survival in our institution. EuroSCORE is a poor scoring algorithm to predict mortality in AAD, but with consistent results for Penn Aa, Ab and Abc.

The beneficial effect of anticoagulation in aortic bioprosthesis is associated with its size

Abstract Objective: To evaluate the clinical and echocardiographic outcomes in aortic valve replacement (AVR) patients with aortic bioprosthesis under oral anticoagulation (OA). Methods: Patients who underwent AVR with bioprosthesiswere prospectively enrolled. They were classified based on postoperative use of OA. Clinical and operative variables were collected. Echocardiographic and clinical follow-ups were performed two years after surgery. The primary outcome evaluated was change in transprosthetic gradient. Secondary outcomes analyzed were change in New York Heart Association (NYHA) class, major bleeding episodes, hospitalization, stroke, and transient ischemic attack. Results: We included 103 patients (61 without OA and 42 with OA). Clinical characteristics were similar among groups, except for younger age (76±6.3 vs. 72.4±8.1 years, P=0.016) and higher prevalence of atrial fibrillation (0% vs. 23.8%, P<0.001) in the OA group. Mean (21.4±10 mmHg vs. 16.8±7.7 mmHg, P=0.037) and maximum (33.4±13.7 mmHg vs. 28.4±10.2 mmHg, P=0.05) transprosthetic gradients were higher in patients without OA. Improvement in NYHA class was more frequent in patients with OA (73% vs. 45.3%, P=0.032). Major bleeding, stroke, and hospitalization were similar among groups. OA was the only independent predictor for improvement of NYHA class after multivariate logistic regression analysis (odds ratio [OR]: 5.9, 95% confidence interval [CI]: 1.2-29.4; P=0.028). Stratification by prosthesis size showed that patients with ≤ 21 mm prosthesis benefited from OA. Conclusion: Early anticoagulation after AVR with bioprosthesis was associated with significant decrease of transprosthesis gradient and improvement in NYHA class. These associations were seen mainly in patients with ≤ 21 mm prosthesis.

Perfil clínico y etiológico de pacientes operados con endocarditis activa. Seguimiento a diez años / Clinical and etiological profile of patients operated on with active endocarditis. Follow-up at 10 years / Perfil clínico e etiológico dos pacientes operados com endocardite ativa. Acompanhamento aos 10 anos

Resumen: Antecedentes: la endocarditis infecciosa es una enfermedad con elevada morbimortalidad, la cual se encuentra en torno al 25%. Aproximadamente el 50% de los casos requiere tratamiento quirúrgico. En nuestro medio se desconocen las características clínicas y evolutivas de pacientes operados por endocarditis infecciosa activa. Objetivos: primario, determinar mortalidad operatoria (MO) y sobrevida a largo plazo; secundario, definir predictores de embolias, complicaciones locales (CL), MO y endocarditis protésica (EP) en la evolución. Métodos: trabajo retrospectivo y analítico. Se identificaron pacientes que recibieron cirugía cardíaca por endocarditis activa entre enero de 2006 y diciembre de 2017. Mediante regresión logística multivariada se identificaron predictores para los objetivos enunciados. Resultados: se incluyeron 101 pacientes. El microorganismo más frecuentemente encontrado fue Staphylococcus aureus (SA) (15,8%). La topografía fue protésica en 20,8%, aórtica en 46,5%, mitral en 23,8% y mitro-aórtica en 13,9%. La MO fue 11,3% y 29,5% (p=0,025), según ausencia o presencia de CL, único predictor independiente de mortalidad (OR=3,38). El 47,5% presentó CL, siendo la más frecuente el absceso (25,7%). Fueron predictores independientes: EP (OR=5,8), endocarditis valvular aórtica (OR=2,9) y sexo masculino (OR=3,5). La incidencia de EP precoz fue 3% y tardía 4%. El 30% de los pacientes adquirió la EI como consecuencia de un procedimiento médico invasivo en los 6 meses previos. De los siete pacientes con EP en la evolución, seis tenían CL (p<0,05). El 31,7% presentaba embolias, resultando predictores independientes: Staphylococcus aureus (OR=4,6), vegetación en el velo mitral posterior (OR=3,2) y antecedente de hipertensión arterial (OR=3,32). La sobrevida a cinco y diez años fue de 88,20%±0,04 y 81,50%±0,05 respectivamente. Conclusiones: la MO de la endocarditis activa en nuestro medio es similar a la reportada internacionalmente. La presencia de CL se asocia a EP en la evolución y resultó ser un predictor independiente de sobrevida a largo plazo, y de MO. La sobrevida a largo plazo es similar a la reportada internacionalmente. Se observó una alta incidencia de agentes intrahospitalarios y procedimientos invasivos como causas probables.

Summary: Introduction: infective endocarditis is a high morbidity and mortality disease, which is about 25%. About fifty percent of patients require heart surgery. In our environment, clinical and evolutionary characteristics of patients operated with active endocarditis are unknown. Objective: primary, determine operative mortality and long-term survival; secondary, define predictors of embolisms, local complications, operative mortality and prosthetic endocarditis in evolution. Methods: retrospective, analytical study. Patients who received cardiac surgery for active endocarditis between January 2006 and December 2017 were identified. Through multivariate logistic regression, predictors were identified for the stated objectives. Results: one hundred and one patients were included. The most frequently found microorganism was Staphylococcus aureus (15.8%). The topography was prosthetic in 20.8%, aortic 46.5%, mitral 23.8% and mitro-aortic 13.9%. The operative mortality was 11.3% and 29.5% (p = 0.025) according to the absence or presence of local complications , the only independent predictor of mortality (OR = 3.32). Local complications were present in 47.5%, the most frequent were abscess (25.7%), independent predictors were: prosthetic endocarditis (OR=5.8), aortic endocarditis (OR=2.9) and male sex (OR=3.5). The incidence of early prosthetic endocarditis was 3% and late 4%. Thirty percent of patients acquired infective endocarditis as a result of an invasive medical procedure in the previous 6 months. Of the seven patients with prosthetic endocarditis in evolution, six had local complications (p <0.05). Embolic events were present in 31.7% of patients, were independent predictors: Staphylococcus aureus (OR=4.6), presence of vegetation in the posterior mitral leaflet (OR=3.2) and history of hypertension (OR=3.32). Survival at 5 and 10 years was 88.20% ± 0.04 and 81.50% ± 0.05 respectively. Conclusions: operative mortality of active endocarditis in our environment is high and similar to that reported internationally. The presence of local complications is associated with prosthetic endocarditis in evolution and proved to be an independent predictor of long-term survival, and operative mortality. Long-term survival is similar to that reported internationally. A high incidence of in-hospital agents was observed and invasive procedures as probable causes.

Resumo: Antecedentes: a endocardite infecciosa é uma doença com alta morbimortalidade. Requerem tratamento cirúrgico o 50%. Em nosso meio, as características clínicas e evolutivas dos pacientes operados com endocardite ativa são desconhecidas. Objetivos: primário, determinar a mortalidade operatória e a sobrevida a longo prazo; secundário: Definir preditores de embolias, complicações locais, mortalidade operatória e endocardite protética na evolução. Métodos: trabalho retrospectivo, analítico. Foram identificados no banco de dados pacientes submetidos à cirurgia de endocardite ativa entre janeiro de 2006 e dezembro de 2017. Através de regressão logística multivariada, os preditores foram identificados para os objetivos estabelecidos. Resultados: cento e um pacientes foram incluídos. Staphylococcus aureus foi o microrganismo mais frequente (15,8%). A topografia foi protética em 20,8%, aórtica 46,5%, mitral 23,8% e mitroaórtica 13,9%. A mortalidade operatória foi de 11,3% e 29,5% (p = 0,025), de acordo com a ausência ou presença de complicações locais, o único preditor independente de mortalidade (OR). Um 47,5% apresentaram complicações locais, sendo o mais frequente o abscesso (25,7%). Os preditores independentes foram: endocardite protética (OR = 5,8), endocardite valvar aórtica (OR=2,9)) e sexo masculino (OR = 3,5). A incidência de endocardite protética precoce foi de 3% e tardia de 4%. Trinta por cento dos pacientes adquiriram endocardite infecciosa como resultado de um procedimento médico invasivo nos 6 meses anteriores. Dos pacientes com endocardite protética na evolução, 85,7% apresentava complicações locais (p <0,05). O 31,7% apresentava embolia, resultando em preditores independentes: Staphylococcus aureus (OR = 4,6), vegetação no véu mitral posterior (OR = 3,2) e história de hipertensão arterial (OR = 3,32). A sobrevida em 5 e 10 anos foi de 88,20% ± 0,04 e 81,50% ± 0,05, respectivamente. Conclusões: a mortalidade operatória da endocardite ativa em nosso ambiente é alto e semelhante ao relatado internacionalmente. A presença de complicações locais está associada à endocardite protética na evolução e provou ser um preditor independente de sobrevida a longo prazo e mortalidade operatória. A sobrevivência a longo prazo é semelhante à relatada internacionalmente. Foi observada alta incidência de agentes hospitalares e procedimentos invasivos como causas prováveis.

Endocarditis infecciosa a Staphylococcus caprae con múltiples embolias preoperatorias graves y vegetación mitral gigante residual / Infectious endocarditis to Staphylococcus caprae with multiple severe preoperative embolisms and residual giant mitral vegetation / Endocardite infecciosa para Staphylococcus caprae com múltiplos embolismos pré-operatórios severos e vegetação mitral gigante residual

Resumen: La endocarditis infecciosa (EI) es una enfermedad infrecuente, heterogénea en su presentación, con una alta mortalidad global y frecuente indicación de cirugía cardíaca. Presentamos el caso de una joven con EI a S. caprae y múltiples embolias preoperatorias graves. Dado que se presenta al ingreso con infección en curso, absceso esplénico y vegetación remanente de muy alto riesgo embólico, plantea un dilema terapéutico en cuanto a oportunidad quirúrgica y orden en que deben resolverse las complicaciones de su enfermedad infecciosa. En este caso se procedió a cirugía vascular, posteriormente esplenectomía y por último cirugía valvular, todas en breve plazo, logrando resolver la patología integralmente y sin complicaciones.

Summary: Infective endocarditis is an infrequent disease, heterogeneous presentation, with high mortality, and frequent indication of heart surgery. We introduce the case of a young woman, with S. caprae infective endocarditis, and multiple preoperative serious emboli. Since she presents at admission with infection in progress, splenic abscess and mitral vegetation with high embolic risk, it poses a therapeutic dilemma regarding surgical opportunity and the order in which the complications should be resolved. In this case we proceeded to vascular surgery, then splenectomy and finally valve surgery, all in a short time, to solve the pathology integrally and without complications.

Resumo: A endocardite infecciosa é uma doença infrequente, de apresentação heterogênea, com alta mortalidade e frequente indicação de cirurgia cardíaca. Apresentamos o caso de uma jovem mulher com endocardite infecciosa a S. caprae e múltiplos êmbolos pré-operatórios graves. Por se apresentar na admissão com infecção em curso, abscesso esplênico e vegetação mitral com alto risco embólico, apresenta um dilema terapêutico em relação à oportunidade cirúrgica e a ordem em que as complicações devem ser resolvidas. Neste caso precedeu à cirurgia vascular, depois à esplenectomia e finalmente à cirurgia valvar, tudo em um curto espaço de tempo, para resolver integralmente a patologia e sem complicações.

Similar survival after mitral valve replacement or repair for ischemic mitral regurgitation: a meta-analysis.

BACKGROUND: Ischemic mitral regurgitation (IMR) occurs in 20% of patients after myocardial infarction. There is no agreement as to the best surgical option. With no prospective randomized controlled trials available, our objective was to perform a meta-analysis comparing replacement and repair. METHODS: A literature search was performed in PubMed, EMBASE, Ovid, and Google Scholar. The following keywords were included: "ischemic mitral regurgitation" and "repair or replacement." Inclusion and exclusion criteria were used to reflect current surgical practice (subvalvular preservation, ring annuloplasty). Primary outcomes of interest were operative mortality and survival. Secondary outcomes analyzed were change in ejection fraction (EF), left ventricular (LV) dimensions, New York Heart Association (NYHA) class, reoperation rate, and 2+ or greater recurrence of mitral regurgitation. RESULTS: Of 280 articles, only 12 satisfied all inclusion and exclusion criteria. These articles included 2,508 patients, 64% of whom received valve replacement. Operative mortality was lower after repair (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.38-0.85; p = 0.001); no difference was found when only articles with patients operated on mainly after 1998 were included (OR, 0.70; 95% CI, 0.44 -1.12; p = 0.14). Survival was similar (hazard ratio [HR], 0.86; 95% CI, 0.66-1.13; p = 0.28). No differences in EF, ventricular dimensions, NYHA class, and reoperation were found. Regurgitation recurrence was higher in the repair group (OR, 7.51; 95% CI, 3.7-15.23; p < 0.001). CONCLUSIONS: Mitral valve repair is associated with lower operative mortality but higher recurrence of regurgitation in patients with ischemic mitral regurgitation. No differences were found regarding survival, NYHA class, and functional indicators.

Uso de NT-proBNP como predictor de evolución en el posoperatorio de cirugía cardíaca / Use of NT-proBNP to predict postoperative evolution in cardiac surgery / Uso do NT-proBNP como preditor de evolução no pós-operatório de cirurgia cardíaca

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Summary: Introduction: the amino-terminal pro brain-type natriuretic peptide (NT-proBNP) is a diagnostic and prognostic biomarker in heart failure. Its use as a prognosis predictor of postoperative evolution in cardiac surgery has not been established. Objective: to determine if the value of preoperative NT in cardiac surgery is associated with postoperative evolution parameters. Primary objective: to evaluate its association with the length of stay in intensive care unit. Secondary objectives: to evaluate its association with the time of mechanical ventilation and inotropic agents requirements. To determine the evolution of NT-proBNP concentration after cardiopulmonary bypass. Methods: multicentric retrospective study, endorsed by the Research Committee of the National Institute of Cardiac Surgery and the Ethic Research Committee of the Clinic Hospital. It included patients who underwent cardiac surgery between March and August 2018. NT-proBNP was measured during anesthesia induction and after cardiopulmonary bypass. A possible association of preoperative NT-proBNP with risk factors and type of procedure performed was studied. By analysing the ROC curve, the area under curve (AUC) was calculated and then, the best cut-off value of NT-proBNP to predict prolonged intensive care unit stay was determined. Intensive care unit stays, mechanical ventilation and inotropic requirements were defined as prolonged when they exceeded 2 days, 6 and 24 hours respectively. Through the use of multivaried logistics, the predicting value of NT-proBNP was determined for each one of the aforementioned variables. A value of alfa 0.05 was considered significant. Results: a total of 155 patients were included in the study. Age, creatininemia, and left ventricular ejection fraction were 65.8±11.4 years, 1.15±1.10 mg/dl and 52.8±11.9% respectively. Female prevalence was 30.3%, arterial hypertension 77.4%, diabetes mellitus 25.2% and dyslipidemia 50.3%. In 42.6% isolated myocardial revascularization was performed, in 12.9% myocardial revascularization plus one or more valve procedures, and in 44.5% isolated valve procedures. In all cases there was a significant reduction between preoperative (443 pg/ml, interquartile range 143-1.193) and postoperative NT-proBNP (362 pg/ml, interquartile range 138-939) (p<0.001). Age, creatininemia, left ventricular ejection fraction, functional classification IV of the New York Heart Association and dyslipidemia turned out to be predictors of preoperative NT-proBNP. Preoperative NT-proBNP was higher in patients with prolonged intensive care unit stay, mechanical ventilation and inotropic requirements. However, it turned out to be an independent predictor only for prolonged intensive care unit stay. (OR=1.62; IC95%:1.11-2.35. p=0.012). The best cut-off value for prolonged intensive care unit stay was 409 pg/ml (AUC=0.68). Conclusion: preoperative determination of NT-proBNP is an efficient tool to predict postoperative evolution. Cardiopulmonary bypass is associated to a significant drop in that marker.

Resumo: Introdução: a porção terminal amino do peptído natriurético tipo B é um biomarcador diagnóstico e prognóstico na insuficiência cardíaca. Seu uso como preditor prognóstico no pós-operatório de cirurgia cardíaca não está estabelecido. Objetivo: determinar se o valor de NT-proBNP no período pré-operatório de cirurgia cardíaca está associado a parâmetros de evolução pós-operatória. Objetivo primário: avaliar sua associação com tempo prolongado de internação em unidade de terapia intensiva. Objetivos secundários: associação com tempo de ventilação mecânica e necessidade inotrópica. Determinar a evolução da concentração de NT-proBNP após circulação extracorpórea. Método: estudo multicêntrico retrospectivo endossado pelo Comitê de Pesquisa do Instituto Nacional de Cirurgia Cardíaco e pelo Comitê de Ética da Pesquisa do Hospital da Clínica. Foram incluídos pacientes operados de março a agosto de 2018. O NT-proBNP foi dosado durante a indução anestésica e após a circulação extracorpórea. O NT-proBNP foi comparado de acordo com os fatores de risco e procedimentos realizados. A área da curva (AUC) foi determinada pela análise da curva ROC e o melhor ponto de corte NT-proBNP foi estabelecido na previsão do tempo prolongado de internação em unidade de terapia intensiva. O tempo de internação em unidade de terapia intensiva, tempo de ventilação mecânica e necessidade inotrópica prolongada foram definidos como maiores que 2 dias, 6 e 24 horas, respectivamente. Um alfa de 0,05 foi considerado significativo. Resultados: 155 pacientes foram incluídos. Idade, creatininemia e fração de ejeção do ventrículo esquerdo foram 65,8± 11,4 anos, 1,15 ± 1,10 mg/dl e 52,8 ± 11,9 %, respectivamente. A prevalência do sexo feminino foi 30,3%, hipertensão arterial 77,4%, diabetes mellitus 25,2% e dislipidemia 50,3%. Em 42,6%, foi realizada revascularização do miocárdio isolada, em 12,9% revascularização do miocárdio associada a um ou mais procedimentos valvares, e em 44,5% procedimentos puros da válvula. Em todos os casos, houve uma diminuição significativa entre o pré-operatório (443 pg/ml, rango interquartílico 143-1.193) e o pós-operatório de NT-proBNP (362 pg/ml, rango interquartilico 138-939) (p <0,001). Idade, cretininemia, fração de ejeção do ventrículo esquerdo, classe funcional IV da New York Heart Association e dislipidemia foram preditores de NT-proBNP pré-operatório. NT-proBNP pré-operatório foi elevado em pacientes com tempo prolongado de internação em unidade de terapia intensiva, tempo de ventilação mecânica e necessidade inotrópica prolongada, mas apenas acabou por ser preditor independente em internação prolongada em unidade de terapia intensiva (OR=1,62; IC95%:1,11-2,35. p=0,012). O melhor valor de corte para internação prolongada foi de 409 pg/ml (AUC = 0,68). Conclusão: a determinação pré-operatória de NT-proBNP é útil como ferramenta na previsão da evolução pós-operatória. A circulação extracorpórea está associada a uma diminuição significativa desse marcador.

Does early coronary artery bypass surgery improve survival in non-ST acute myocardial infarction?

A best evidence topic was written according to a structured protocol. Lack of evidence exists regarding the optimal timing for coronary artery bypass graft (CABG) surgery after non-ST myocardial infarction (NSTEMI). While some authors address the importance of the timing of surgery alone, others take into account the extent of myocardial damage. The question addressed was whether early or late CABG surgery improves hospital mortality and cardiovascular events after NSTEMI in stable patients. Using a designated search strategy, 459 articles were found, of which seven represented the best available evidence. All of these studies were level 3 (retrospective cohort studies). Studies could be divided into those which assessed CABG outcome based on preoperative cardiac troponin I (cTnI) level as a measure of the extent of myocardial damage and those which considered only the timing after myocardial infarction. Outcome measures included short-term survival, hospital mortality, length of hospital stay and major adverse cardiovascular events (MACEs). The biggest retrospective study analysing postoperative outcomes based on the timing of surgery after NSTEMI concluded that operative mortality is higher when surgery is performed within 6 h of the event. After 6 h, mortality is similar at any timepoint after 6h of NSTEMI. While other smaller studies agree that there are fewer postoperative complications when surgery is performed after 48 h of the event, no consensus is found regarding mortality between early (less than 48 h) and late CABG surgery. Taking into account preoperative cTnI values, CABG has a higher incidence of MACEs and hospital mortality in patients with cTnI >0.15 ng/ml. When surgery is performed within 24 h of symptoms, preoperative cTnI >0.72 ng/ml is associated with worse outcomes. In view of the methodological limitations and level of evidence of the studies included, it appears that surgery may be safely performed in NSTEMI patients at any time after the first 6 h of the event in patients with cTnI <0.15 ng/ml, whereas in those patients with higher values of cTnI, waiting for cTnI to reduce before considering surgery seems to be a wise option in order to decrease the incidence of MACEs and hospital mortality.