Database – ABC CARDIOL

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Original Article

Immediate Results after Multiple Arterial Grafts in Coronary Artery Bypass Graft Surgery in the São Paulo State: Cross Cohort Study

Raúl Armando Micalay Paredes et al. Gabrielle Barbosa Borgomoni Anny Kátia Puchalski Micalay José Carlos Arteaga Camacho … Luís Roberto Palma Dallan Luiz Augusto Ferreira Lisboa Luís Alberto de Oliveira Dallan Omar Asdrúbal Vilca Mejia Grupo de estudos REPLICCAR

Abstract

Background

The short-term results after using arterial grafts still raise questions and doubts for medical society.

Objective

To compare the immediate outcomes of patients undergoing single arterial graft versus multiple arterial grafts coronary artery bypass grafting surgery.

Methods

Cross-sectional cohort study in the São Paulo Registry of Cardiovascular Surgery II (REPLICCAR II). Perioperative data from 3122 patients were grouped by the number of arterial grafts used, and their outcomes were compared: reoperation, deep sternal wound infection (DSWI), stroke, acute kidney injury, prolonged intubation (>24 hours), short hospital stay (14 days), morbidity and mortality. Propensity Score Matching (PSM) matched 1062 patients, adjusted for the mortality risk.

Results

After PSM, the single arterial graft group showed patients with advanced age, more former smokers, hypertension, diabetes, stable angina, and previous myocardial infarction. In the multiple arterial grafts, there was a predominance of males, recent pneumonia, and urgent surgeries. After the procedure, there was a higher incidence of pleural effusion (p=0.042), pneumonia (p=0.01), reintubation (p=0.006), DSWI (p=0.007), and sternal debridement (p=0.015) in the multiple arterial grafts group, however, less need for blood transfusion (p=0.005), extremity infections (p=0.002) and shorter hospital stays (p=0.036). Bilateral use of the internal thoracic artery was not related to increased DSWI rate, but glycosylated hemoglobin >6.40% (p=0.048).

Conclusion

Patients undergoing the multiarterial technique had a higher incidence of pulmonary complications, and DSWI, where glycosylated hemoglobin ≥6.40%, had a greater influence on the infectious outcome than the choice of grafts.

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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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Original Article

Predictors of Hospital Mortality Based on Primary Angioplasty Treatment: A Multicenter Case-Control Study

Pedro Paulo Neves de Castro et al. Marco Antonio Nazaré Castro Guilherme Abreu Nascimento Isabel Moura José Luiz Barros Pena

Abstract

Background

Identification of high-risk patients undergoing primary angioplasty (PCI) is essential.

Objective

Identify factors related to the causes of death in PCI patients.

Methods

This work consisted of a multicenter case-control study using a Brazilian registry of cardiovascular interventions as the data source. The association between each variable and death was assessed using a binary logistic regression model, p <0.05 was considered significant.

Results

A total of 26,990 records were analyzed, of which 18,834 (69.8%) were male patients, with a median age of 61 (±17) years. In the multivariate analysis, the main variables related to the causes of death with their respective odds ratios and 95%confidence intervals (CI) were advanced age, 70-79 years (2.46; 1.64-3.79) and ≥ 80 years (3.69; 2.38-5.81), p<0.001; the classification of Killip II (2.71; 1.92-3.83), Killip III (8.14; 5.67-11.64), and Killip IV (19.83; 14.85-26.69), p<0.001; accentuated global dysfunction (3.63; 2,39-5.68), p<0.001; and the occurrence of infarction after intervention (5.01; 2.57-9.46), p<0.001. The main protective factor was the post-intervention thrombolysis in myocardial infarction (TIMI) III flow (0.18; 0.13-0.24), p<0.001, followed by TIMI II (0.59; 0.41 -0.86), p=0.005, and male (0.79; 0.64-0.98), p = 0.032; dyslipidemia (0.69; 0.59-0.85), p<0.001; and number of lesions treated (0.86; 0.9-0.94), p<0.001.

Conclusion

The predictors of mortality in patients undergoing PCI were Killip’s classification, reinfarction, advanced age, severe left ventricular dysfunction, female gender, and post-intervention TIMI 0 / I flow.

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Editorial

How Do We Know a Change is an Improvement? The (Not So) New Scientific Knowledge Every Physician Should Learn, Master and Lead

Alexandre Siciliano Colafranceschi

Cardiothoracic surgeons have a rich history of quality improvement and a strong ethos of transparency and innovation allowing for the rapid diffusion of standards, techniques, and benchmarks worldwide. Nationally, few medical specialties have contributed as much to the development of knowledge as the Brazilian cardiac surgery. From the hard work developed during decades by pioneering surgeons such as Euryclides Zerbini and Adib Jatene to the most contemporaneous leaders in the field, the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – InCor – is definitely at the heart of this journey. In this issue of Arquivos Brasileiros de Cardiologia the work by Mejia et al. has the merit of taking into account the evolution of the number of cardiovascular surgeries performed at InCor during a 35-year period. The total number is a remarkable one: over 100,000 open heart procedures were analyzed. After all, the mean number of procedures/year is 2,964, – or more than 11 procedures per workday. It is noteworthy the fact that the total number of procedures has been increasing, especially due to an increase in valvular operations and the correction of congenital cardiopathies. Also, of note, there is a 7% decrease in coronary artery bypass graft surgery volume in the most recent period studied.

Besides describing the volume of disease-specific open-heart surgical procedures throughout five different periods of time over the 35 years of data, another objective of the study by Mejia et al. was to evaluate the impact of the actions taken from a continuous quality improvement program on mortality from cardiovascular surgery. It is not clear, however, how the periods of time were selected for the analyses.

[…]

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Original Article

Creation and Implementation of a Prospective and Multicentric Database of Patients with Acute Myocardial Infarction: RIAM

Jacqueline Vaz et al. Anibal Pereira Abelin Marcia Moura Schmidt Pedro Piccaro de Oliveira … Carlos A. M. Gottschall Clarissa Garcia Rodrigues Alexandre Schaan de Quadros

Abstract

Background

Multicenter registries representing the real world can be a significant source of information, but few studies exist describing the methodology to implement these tools.

Objective

To describe the process of implementing a database of ST-segment elevation acute myocardial infarction (STEMI) at a reference hospital, and the application of this process to other centers by means of an online platform.

Methods

In 2009, our institution implemented an Registry of Acute Myocardial Infarction (RIAM), with the prospective and consecutive inclusion of every patient admitted to the institution who received a diagnosis of STEMI. From March 2014 to April 2016, the registries were uploaded to a web-based system using the REDCap software and the registry was expanded to other centers. Upon subscription, the REDCap platform is a noncommercial software made available by Vanderbilt University to institutions interested in research.

Results

The following steps were taken to improve and expand the registry: 1. Standardization of variables; 2. Implementation of institutional REDCap (Research Electronic Data Capture); 3. Development of data collection forms (Case Report Form – CRF); 4. Expansion of registry to other reference centers using the REDCap software; 5. Training of teams and participating centers following an SOP (Standard Operating Procedure).

Conclusion

The description of the methodology used to implement and expand the RIAM may help other centers and researchers to conduct similar studies, share information between institutions, develop new health technologies, and assist public policies regarding cardiovascular diseases. (Arq Bras Cardiol. 2020; 114(3):446-455)

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Editorial

Short Editorial: “Creation and Implementation of a Prospective Multicenter Registry of Acute Myocardial Infarction: RIAM”

José Mariani Junior

Cardiovascular diseases, including acute myocardial infarction (AMI), represent a major public health issue in Brazil and worldwide, with elevated incidence and mortality rates. The rates of Brazilian mortality for this group of causes (183.3/100,000)^, are amongst the highest in the world and is similar to that of countries such as China and areas such as the east of Europe.^,

The implementation of health promotion policies, early diagnosis and effective treatment are some of the most important prevention and treatment strategies for these diseases, which remain the leading cause of mortality among adult patients globally. However, the recognition of these diseases, as well as their real and effective measurements, are among the strategies that must be optimized in our field.

[…]

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Editorial

Interaction among Cardiovascular Scientific Journals in Brazil: A Model that should be Better Explored

Carlos Eduardo Rochitte

In the environment of intense, and apparently unlimited competition among scientific journals for the best article, and the highest number of citations and impact factor (IF), the Arquivos Brasileiros de Cardiologia (ABC Cardiol) has taken actions to foster the growth of other journals with similar scope in the national scientific community. The main objective is to promote dissemination of our best science by journals of increasingly higher quality, so that it can attract deserving attention and make a stronger contribution to the world scientific community.

With the current IF of nearly 1.7 according to the Journal of Citation Reports (JCR), the ABC Cardiol has attracted more and more submissions from national and international authors.^, Our acceptance rate is no more than 15% and tends to decrease even more. In this scenario, many papers of significant quality cannot be accepted for publication in the ABC Cardiol, including articles from studies developed in our successful postgraduate programs. This has an undesirable effect – the reduced exposure of our best science in indexation sources such as PubMED, Scielo, among others.

[…]

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Original Article

Analysis of >100,000 Cardiovascular Surgeries Performed at the Heart Institute and a New Era of Outcomes

Omar A.V. Mejia et al. Luiz Augusto Ferreira Lisboa Luiz Fernando Caneo Elisandra Trevisan Arita … Carlos Manuel de Almeida Brandão Ricardo Ribeiro Dias Roberto Costa Marcelo Biscegli Jatene Pablo Maria Alberto Pomerantzeff Luís Alberto Oliveira Dallan Fabio Biscegli Jatene

Abstract

Background:

The current challenge of cardiovascular surgery (CVS) is to improve the outcomes in increasingly severe patients. In this respect, continuous quality improvement (CQI) programs have had an impact on outcomes.

Objective:

To assess the evolution of the incidence and mortality due to CVS, as well as the current outcomes of the Hospital das Clínicas Heart Institute of the University of São Paulo Medical School (InCor-HCFMUSP).

Methods:

An outcome analysis of CVSs performed at the InCor, between January 1984 and June 2019. We observed the surgical volume and mortality rates in 5 time periods: 1st (1984-1989), 2nd (1990-1999), 3rd (2000-2007), 4th (2008-2015) and 5th (2016-2019). The CQI program was implemented between 2015 and 2016. The analysis included the total number of surgeries and the evolution of the most frequent procedures.

Results:

A total of 105,599 CCVs were performed, with an annual mean of 2,964 procedures and mortality of 5,63%. When comparing the 4th and the 5th periods, the average global volume of surgeries was increased from 2,943 to 3,139 (p = 0.368), bypass graft (CABG), from 638 to 597 (p = 0.214), heart valve surgery, from 372 to 465 (p = 0.201), and congenital heart disease surgery, from 530 to 615 (p = 0.125). The average global mortality went from 7.8% to 5% (p < 0.0001); in CABG surgery, from 5.8% to 3.1% (p < 0.0001); in heart valve surgery, from 14% to 7.5% (p < 0.0001) and in congenital heart disease surgery, from 12.1% to 9.6% (p < 0.0001).

Conclusion:

In spite of a recent trend towards increased surgical volume, there was a significant decrease in operative mortality in the groups studied. After the implementation of the CQI program, the mortality rates were closer to international standards.

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