Cardiac Surgery – ABC CARDIOL

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Research Letter

Infective Endocarditis: A Never-Ending Ordeal?

Catarina Gregório et al. Ana Beatriz Garcia Susana Gonçalves Nuno Guerra … Fausto J. Pinto Catarina Sousa

Introduction

Prosthetic valve endocarditis (PVE) is an uncommon but life-threatening condition. This report describes a challenging case of recurrent PVE with paravalvular complications requiring multiple surgical interventions.

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IJCS

Editorial

Risk Stratification in Patients Hospitalized With Infective Endocarditis Undergoing Cardiac Surgery: How Sharp Are We?

Ana Margarida Martins et al. Catarina Sousa

Infective endocarditis (IE) is an infrequent yet life-threatening and disabling condition, with an estimated incidence between 3 and 12 cases per 100,000 subjects per year.^, Recent epidemiological studies have suggested a rising trend in the incidence of IE, potentially attributable to factors such as an aging population and a growing group of susceptible patients with congenital heart disease, intracardiac prosthesis or devices, and chronic renal failure on dialysis. Limited information is available concerning Brazil’s temporal trends on IE incidence and clinical outcomes. The primary source of evidence regarding the IE scenario in Brazil stems from single or multicenter observational studies.^– Analyzing available data, it appears that IE predominantly affects younger male patients in Brazil. The most prevalent microbial culprits are Staphylococcus, followed by Enterococcus and Streptococcus species; rheumatic heart disease is an important underlying heart condition as well.

The diverse clinical spectrum of IE, coupled with the substantial risk of complications and the limited availability of randomized clinical trials on IE, justify that it continues to be a prognostic challenge. Despite the unquestionable diagnostic and therapeutic advances in the management of IE in recent decades, its prognosis is still marked by high rates of complications and significant in-hospital mortality. In developed countries, IE is associated with mortality rates of approximately 20%,^,, whereas in low- and middle-income countries, the mortality of IE ranges from 15% to 30%. The predominant focus in studies on IE has been the evaluation of clinical factors that may influence the course of the disease. In one of these studies, a machine learning-based analysis identified peripheral stigmata, nosocomial IE, the absence of vegetation, and surgery in the presence of neurologic complications as characteristics associated with higher in-hospital mortality.

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ABCHF

Viewpoint

Surgical Treatment of Cardiomyopathy

Lucas F. Cardoso et al. Samuel P. Steffen Fabio A. Gaiotto

Ischemic Cardiomyopathy

Ischemic heart disease is the most common cause, and at the same time, it is the main isolated risk factor that favors the increased incidence of heart failure in the world.

Several improvements incorporated in coronary artery bypass graft surgery have made the procedure safer and more effective, so patients who were previously candidates for heart transplants are now frequently revascularized. Hausmann et al. showed that, with the more comprehensive indication of myocardial revascularization in this scenario, patients with advanced heart failure due to ischemic cardiomyopathy now represent 29.3% of recipients who are candidates for transplantation in the studied center, in comparison with data from the same period by the International Society of Heart and Lung Transplantation, which indicated that 47.2% of recipients had an ischemic etiology.

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ABC

Editorial

Infective Endocarditis: New Spectra, Same Severity

Tiago Bignoto

Infective endocarditis is a rare disease with a high rate of serious complications and can often be seen as a syndrome. A cold assessment of data published internationally shows us that despite all the technological advances and an early trend towards surgical intervention, there was no great reduction in clinical outcomes, especially mortality, but a more detailed search for information may bring us other points of view.

The article by Jorge MS et al. corroborates the idea of early diagnoses and interventions in this broad spectrum of patients, and observing the epidemiological change of patients over the years is a fundamental key to a broad reading of the management of contemporary infective endocarditis.

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ABC

Editorial

From Volume to Value Creation in Cardiac Surgery: What is Needed to Get off the Ground in Brazil?

Omar Asdrúbal Vilca Mejia et al. Fabio Biscegli Jatene

Some characteristics favored the great development of cardiovascular surgery; among them, creativity for developing techniques and devices and, mainly, much courage. Thus, cardiovascular surgery had a fantastic evolution, driven by its impact on the patient’s quality of life, quickly becoming one of the most performed procedures in the world. Maybe this would not have happened if not for two factors: on the one hand, the improvement of technical skills as a result of the increased surgical volume, and, on the other hand, the information from the databases analyzes.^, This has led to continuous improvement in perioperative techniques, devices, and outcomes.

This may explain the outcome improvement, even when procedures have become more complex and performed in increasingly severe patients. From the analysis of these records, some issues emerged to be resolved. This was when mortality risk scores were introduced to adjust and better understand the results. From that moment, and to achieve continuous improvement, implementing quality programs has become a necessity. Another important step was the hospitals’ public reporting initiatives, introducing the concept of transparency.

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IJCS

Original Article

Is Frailty Syndrome a Predictor of Morbimortality in Postoperative Cardiac Surgery? – A Retrospective Cohort Study

Daniela Meirelles do Nascimento et al. Cíntia Ehlers Botton Felipe Vargas Santos Márcia Cristina Rover … Marília Santos Moura Bruna Müller Leão Beatriz D. Schaan

Abstract

Background

Frailty is a biological syndrome suggested as a better predictor of morbimortality than chronological age.

Objective

To assess associations between frailty and morbimortality outcomes in postoperative cardiac surgery.

Methods

A retrospective cohort study was conducted with cardiac surgery patients. Frailty and maximal inspiratory pressure (MIP) were assessed before surgery. Postoperative outcomes were: extracorporeal circulation time; use of vasopressor; mean arterial pressure (MAP); red blood cell (RBC) transfusion; cardiac arrhythmia and/or heart arrest; presence of intra-aortic balloon pump; antibiotic use; extubation time; length of stay in the intensive care unit (ICU); length of postoperative stay; mortality. One-way ANOVA was used to compare postoperative variables between frailty categories; Spearman was used to evaluate the correlations between frailty and postoperative variables. Age, sex, and MIP were introduced into multiple regression models to find the independent association between postoperative variables and frailty. A significance level of p < 0.05 was adopted.

Results

The medical records of 200 patients were analyzed (65.7±7.2 years; 68.5% men; 63.5% non-frail, 22.5% pre-frail, 14% frail). Frailty was not a predictor of postoperative outcomes. Age was an independent predictor for alterations in MAP (PR: 1.028, 95% CI: 1.003-1.053, p=0.025), need for RBC transfusion (PR: 1.034, 95% CI: 1.007-1.062, p=0.014), longer extubation time (PR: 1.052, 95% CI: 1.023-1.083, p<0.001), length of stay in the ICU (ß: 0.031, 95% CI: 0.010-0.053, p=0.005), length of postoperative stay (ß: 0.017, 95% CI: 0.003-0.031, p=0.015).

Conclusions

Frailty was not a predictor of morbimortality following cardiac surgery in middle-aged and older adults; however, age did predict morbidities in this setting.

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IJCS

Original Article

Gender Based Analysis of a Population Series of Patients Hospitalized with Infective Endocarditis in Portugal – How do Women and Men Compare?

Catarina Sousa et al. Paulo Jorge Nogueira Fausto J. Pinto

Abstract

Background:

The impact of gender on the outcome of patients hospitalized with infective endocarditis (IE) is not fully understood.

Objective:

To verify the association between gender and the clinical profile of patients hospitalized with IE, treatment strategies, and clinical outcomes.

Methods:

This is a retrospective nationwide study of patients hospitalized with IE, based on hospital admissions between 2010 and 2018 in Portugal. Descriptive statistics were used to present variables. An inferential analysis was performed using multiple logistic regression. A 95% confidence interval and a 5% significance level were considered.

Results:

In total, 3266 (43.1%) women and 4308 (56.9%) men were hospitalized with IE. The women were older (76 vs 69 years old, p<0.001), more frequently presented arterial hypertension (39.8% vs 35.4%, p<0.001) and atrial fibrillation (29.5% vs 21.2%, p<0.001), and had less cardiovascular comorbidities. Acute heart failure was more common in women (32.9 vs 26.9%, p<0.001) and acute renal failure (13.6% vs 11.7%, p<0.001) and sepsis (12.1% vs 9.1%, p<0.001), in men. Women were less likely to undergo cardiac surgery (OR 0.48 – 95%CI 0.40–0.57, p<0.001) and had a higher postoperative mortality (OR 1.84, 95% CI 1.19–2.84, p=0.006). In-hospital mortality rates were comparable between genders (20.3% vs 19.6%, p=0.45).

Conclusions:

Women were less likely to undergo cardiac surgery when hospitalized with IE, and the female gender was a predictor factor for postoperative mortality. Overall, in-hospital mortality was not influenced by gender. Further research is necessary to fully clarify the impact of gender on IE management and outcomes.

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IJCS

Original Article

Prevalence of Frailty in Patients Undergoing Cardiac Valve Surgery: Comparison of Frailty Tools

Gabriela Harada et al. Monique Carvalho Andrade Julia Nobrega Brito Caio de Assis Moura Tavares … Flávio Tarasoutchi Pablo Maria Alberto Pomerantzeff Luiz Bortolotto Maria Ignez Zanetti Feltrim

Abstract

Background

There is no consensus among tools for assessing frailty.

Objective

To evaluate the prevalence of frailty according to different tools in patients referred for elective valve cardiac surgery.

Methods

This is a cross-sectional study. All patients were ≥ 18 years of age, clinically stable. The following patients were excluded: those unable to perform the tests because of physical, cognitive, or neurological limitations; those requiring non elective/emergency procedures or hemodynamic instability. During the preoperative cardiology visit, frailty was assessed by the Short Physical Performance Battery (SPPB), the Frailty Deficit Index (FDI), handgrip strength, and gait speed 3m. For the entire analysis, the statistical significance was set at 5%.

Results

Our cohort consisted of 258 subjects. From the total cohort, 201 were ≤ 70 years of age (77.9%), the predominant etiology according to rheumatic disease (50.7% vs 8.8%; p=0.000) with double mitral lesion (24.9% vs 0%; p=0.000). Frailty was present in 32.9% according SPPB, 29.1% with reduced muscular strength. and 8.9% with FDI. Handgrip strength was weaker in elderly patients (26.7 vs 23.6; p=0.051) and gait speed was lower in the younger group, in which 36% were considered frail (36% vs 14%; p=0.002). Variables associated with frailty were age ≥ 70 years, female gender, aortic stenosis, and regurgitation.

Conclusion

Frailty in adult patients who will have elective heart valve surgery is present even in the younger groups, although the older group with comorbidities are more frail. Frailty was more clearly shown by the SPPB than by the FDI and handgrip tests.

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IJCS

Original Article

Transfusion of Blood Products in the Postoperative of Cardiac Surgery

Antonieta Moraes et al. Juliana Neves Giordani Cristiane Tavares Borges Pauline Eloise Mariani … Laura Maggi da Costa Leonardo Hennig Bridi Ari Tadeu Lirio dos Santos Renato Kalil

Abstract

Background:

The indiscriminate use of blood transfusion in surgery has been associated with increased risk of infection and increased length of hospital stay.

Objective:

To identify the average amount of bleeding and rates of transfusion of blood products in the postoperative period of patients undergoing cardiac surgery in a cardiology center.

Methods:

Medical records of patients who underwent myocardial revascularization surgery and/or heart valve replacement with use of cardiopulmonary bypass (CPB) were analyzed. Perioperative data such as CPB time, hematocrit and hemoglobin values were collected after surgery. The amount of bleeding (mL), blood transfusion (IU), clinical complications and time of hospitalization were also recorded. The correlation between bleeding in the postoperative period and blood transfusion was performed using the Spearman correlation. A p < 0.05 was considered statistically significant.

Results:

A total of 423 patients undergoing coronary artery bypass grafting (51.5%) or heart valve replacement (33.6%) were included. During the first 24 hours, the average bleeding volume was 353.3 ± 268.3 mL. Transfusion of blood products was required in 40.1% of cases, most frequently (70.6%) in the immediate postoperative period. Red blood cell concentrate was the most frequently used product (22.9% and 60%).

Conclusion:

The occurrence of bleeding in the cases was low, and when transfusion of blood components was indicated, red blood cell concentrates were the most widely used component. (Int J Cardiovasc Sci. 2021; [online].ahead print, PP.0-0)

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IJCS

Original Article

A Retrospective Study on Unfractionated Bovine Heparin Safety in On-Pump Cardiac Surgery

Fernando Antonio de Lima Torres et al. Andressa C. B Torres Allinson Ribeiro Cauê O Maia … Fernanda P Almeida João Roceto Jorge A Matkovski Matheus G Kovalski Vanessa A Pizato Tatiana M. G Cordeiro

Abstract

Background:

Heparin decreases the risks of thrombotic phenomena in extracorporeal circulation. However, it must present a robust safety profile itself, especially for bleeding. Contamination of porcine heparin demands an alternative source and consequent assessment of safety.

Objective:

To evaluate the safety of unfractionated bovine heparin during on-pump cardiac surgery.

Methods:

Descriptive, retrospective study, evaluating medical records from all patients who had on-pump cardiac surgery over four years. We observed the occurrence of bleeding, thrombocytopenia, postoperative vasoplegia, activated clotting time values and any other coagulation phenomena as safety profile parameters.

Results:

We evaluated 204 medical records reporting the use of unfractionated bovine heparin. 66.18% of the patients presented thrombocytopenia, 1.04% presented bleeding of more than 2000 mL in the first 24 hours of the postoperative period. One patient presented clots in the surgical field. Median activated clotting time was 137 seconds at baseline, 803 seconds after the first dose of heparin and, after protamine, it returns to similar baseline values, that is, 149.5 seconds.

Conclusion:

Unfractionated bovine heparin did not present unusual adverse effects and can be considered safe for on-pump cardiac surgery.

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ABC

Original Article

Risk Factors for In-Hospital Mortality in Infective Endocarditis

Ana Marques et al. Inês Cruz Daniel Caldeira Sofia Alegria … Ana Catarina Gomes Ana Luísa Broa Isabel João Hélder Pereira

Abstract

Background:

Infective endocarditis (IE) is associated with severe complications and high mortality. The assessment of mortality rates and predictors for fatal events is important to identify modifiable factors related to the pattern of treatment, in order to improve outcomes.

Objectives:

We sought to evaluate clinical outcomes of patients with IE and to determine predictors of in-hospital mortality.

Methods:

Retrospective single-center study including patients with IE admitted during a 10-year period (2006-2015). Data on comorbidities, clinical presentation, microbiology and clinical outcomes during hospitalization were evaluated. Risk factors of in-hospital death were analyzed. A p-value < 0.05 was considered significant.

Results:

A total of 134 cases were included (73% males, mean age of 61 ± 16 years-old). Half of them had previous valvular heart disease. Healthcare-associated IE and negative blood-cultures occurred in 22% and prosthetic IE in 25%. The aortic valve was the one most often affected by infection. Staphylococcus aureus was the most commonly isolated microorganism. Forty-four (32.8%) patients underwent cardiac surgery. The in-hospital mortality rate was 31.3% (42 patients). The identified risk factors for in-hospital mortality were Staphylococcus aureus etiology (OR 6.47; 95% CI: 1.07-39.01; p = 0.042), negative blood-cultures (OR 9.14; 95% CI: 1.42-58.77; p = 0.02), evidence of valve obstruction in echocardiography (OR 8.57; 95% CI: 1.11-66.25; p = 0.039), clinical evolution with heart failure (OR 4.98; 95%CI: 1.31-18.92; p = 0.018) or septic shock (OR 20.26; 95% CI: 4.04-101.74; p < 0.001). Cardiac surgery was a protective factor of mortality (OR 0.14; 95% CI 0.03-0.65; p = 0.012).

Conclusion:

The risk factors for in-hospital mortality were clinical (heart failure, septic shock), evidence of valve obstruction in echocardiography, Staphylococcus aureus etiology or negative blood cultures. Invasive treatment by surgery significantly decreased the mortality risk.

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IJCS

Case Report

Fourteen Years’ Survival After Batista Operation: The Short History of a Long Journey

Gustavo Luiz Gouvêa de Almeida Junior et al. Waldir Jazbik Juliana Visconti Morgado Gustavo Luiz Gouvêa de Almeida

Rogério Gomes da Silva et al. Gustavo Glotz de Lima Andréia Laranjeira Altamiro Reis da Costa … Edemar Pereira Rubem Rodrigues

OBJECTIVE: To determine the incidence of atrial fibrillation in the postoperative period of cardiac surgery, its impact on morbidity, mortality, and hospital stay, and to analyze the risk factors in the pre, trans, and postoperative periods. METHOD: Contemporary cohort study with 158 adult patients undergoing cardiac surgery, of whom those with atrial fibrillation in the preoperative period were excluded. The patients were assessed with continuous cardiac monitoring and daily electrocardiograms. Any episode of irregular rhythm with the presence of f waves of variable morphology and amplitude was considered atrial fibrillation. RESULTS: The general incidence of atrial fibrillation was 28.5%, being 21.6% for revascularized patients and 44.3% for those undergoing valvular repair. Factors independently associated with atrial fibrillation were left heart failure in the preoperative period (p=0.05; RC=2.2), total fluid balance (p=0.01; RC=1.0), duration of surgery (p=0.03; RC=1.01) [and other associated factors, age > 70 years, aortic valvular disease, psychomotor agitation, length of installation of the drains, pulmonary congestion and respiratory insufficiency in the postoperative period]. The use of beta-blockers (p=0.01; RC=0.3) was a protective factor. Atrial fibrillation in the postoperative period was associated with an increase in the length of hospital stay (16.9±12.3 days versus 9.2±4.0 days, p<0.001) and a greater incidence of stroke or postoperative death (p=0.02). CONCLUSION: The incidence of atrial fibrillation in the postoperative period of cardiac surgery was high and caused a significant increase in morbidity, mortality, and the length of hospital stay. Among the independent risk factors, excessive fluid balance is significant. The use of beta-blockers was identified as a protective factor.

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ABC

Artigo Original

Acute renal failure after coronary artery bypass surgery with extracorporeal circulation: incidence, risk factors, and mortality

Fernando Oliveira Santos et al. Marco Antonio Silveira Roberto Barreto Maia Marcelo Dantas Cerqueira Monteiro Reinaldo Martinelli

OBJECTIVE: To identify the incidence, risk factors, and mortality of acute renal failure (ARF) in patients undergoing myocardial coronary artery bypass surgery with extracorporeal circulation. METHODS: All patients undergoing myocardial coronary artery bypass surgery were prospectively studied, and their clinical and laboratory variables were assessed using uni- and multivariate analysis (logistic regression). RESULTS: Acute renal failure occurred in 16.1% of the 223 patients studied; 4.9% of patients required dialysis. Risk factors associated with ARF in the univariate analysis were age > 63 years, OR 3.6 (95% CI=1.6 to 8.3); preoperative serum creatinine > 1.2 mg/dL, OR 5.9 (95% CI=2.4 to 14.6); duration of extracorporeal circulation > 90 min, OR 2.1 (95% CI=1.0 to 4.4); use of intraaortic balloon, OR 2.6 (95% CI=1.2 to 5.5); need for inotropic drugs, OR 4.4 (95% CI=1.9 to 10.2). In the multivariate analysis, independent factors associated with ARF were: age > 63 years, OR 3.0 (95% CI=1.3 to 7.2); preoperative serum creatinine > 1.2 mg/dL, OR 4.3 (95% CI=1.6 to 11.4); need for inotropic drugs, OR 3.2 (95% CI=1.3 to 8.0). Mortality in the patients with ARF was 25.0% compared with 1.1% in those without ARF and 63.6% in those who required dialysis. CONCLUSION: Acute renal failure after myocardial coronary artery bypass surgery is a frequent complication associated with a high mortality rate. The independent risk factors are age, previous renal failure, and the need for inotropic drugs.

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ABC

Original Article

Behavior of inflammatory markers of myocardial injury in cardiac surgery: laboratory correlation with the clinical picture of postpericardiotomy syndrome

Ilmar Köhler et al. Paulo J. Saraiva Orlando B. Wender Alcides J. Zago

OBJECTIVE: To verify the association of serum markers of myocardial injury, such as troponin I, creatinine kinase, and creatinine kinase isoenzyme MB, and inflammatory markers, such as tumor necrosis factor alpha (TNF-alpha), C-reactive protein, and the erythrocyte sedimentation rate in the perioperative period of cardiac surgery, with the occurrence of possible postpericardiotomy syndrome. METHODS: This was a cohort study with 96 patients undergoing cardiac surgery assessed at the following 4 different time periods: the day before surgery (D0); the 3rd postoperative day (D3); between the 7th and 10th postoperative days (D7-10); and the 30th postoperative day (D30). During each period, we evaluated demographic variables (sex and age), surgical variables (type and duration , extracorporeal circulation), and serum dosages of the markers of myocardial injury and inflammatory response. RESULTS: Of all patients, 12 (12.5%) met the clinical criteria for a diagnosis of postpericardiotomy syndrome, and their mean age was 10.3 years lower than the age of the others (P=0.02). The results of the serum markers for tissue injury and inflammatory response were not significantly different between the 2 assessed groups. No significant difference existed regarding either surgery duration or extracorporeal circulation. CONCLUSION: The patients who met the clinical criteria for postpericardiotomy syndrome were significantly younger than the others were. Serum markers for tissue injury and inflammatory response were not different in the clinically affected group, and did not correlate with the different types and duration of surgery or with extracorporeal circulation.

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Original Article

Infective endocarditis: surgical therapy

Luís Sérgio de Moura Fragomeni et al. Fabiano Fernandes Vieira Júlio Cesar de Mello Bajerski Roque Paulo Falleiro … Gustavo Hoppen Iselso Sartori

OBJECTIVE: To assess the major causes of surgical morbidity and mortality in patients with infective endocarditis operated upon in a regional cardiology center. METHODS: Thirty-four patients underwent surgical treatment for infective endocarditis. Their ages ranged from 20 to 68 years (mean of 40.6) and 79% were males. Their NYHA functional classes were as follows: IV – 19 (55.8%) patients; III – 12 (35.2%) patients; II – 3 (8.8%) patients. Blood cultures were positive in only 32% of the cases. Eight patients had already undergone previous cardiac surgery, whose major indication (82.3%) was heart failure refractory to clinical treatment. RESULTS: Four (11.7%) patients died at the hospital. Follow-up was complete in 26 (86%) patients. Five (14.7%) patients died later, 12, 36, 48, 60, and 89 months after hospital discharge. Of the 21 patients being currently followed up, 1 is in NYHA functional class III, and 5 in NYHA functional class II. CONCLUSION: A high degree of clinical suspicion, at an early diagnosis, and indication of surgical treatment prior to deterioration of left ventricular function and installation of generalized sepsis may improve prognosis.

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