General Surgery – ABC CARDIOL

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Editorial

Predictors of Hospital Readmission After Coronary Artery Bypass Grafting – Reflections and Perspectives

Aspects such as the high cost of health care, the overload of health professionals, and the aging population with the consequent increase in chronic diseases highlight the need for attention to quality in highly complex cardiovascular care, especially in cardiac surgery. In this scenario, quality indicators are an extremely important instrument in the evaluation of care.

There are several quality indicators currently available, and one of them is the hospital readmission rate, which can be seen as an outcome often used as secondary and, despite being quite promising, depends on the methodology used to collect the data.

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A Prosthetic Dysfunction Earlier Than Expected

Mariana Laranjeira et al. Maria Inês Bertão Rodolfo Pereira Olga Sousa

Prosthetic Heart Valves, despite their improvements over the last few decades, can be subject to complications and dysfunction. Mechanical prosthetic valves have an expected lifespan of approximately 10 to 20 years, with many lasting longer. For biological valves, the lifespan is generally shorter (5 to 15 years). However, the durability varies according to individual factors, valve type, and patient health. Although their greater durability, Mechanical Heart Valves are more pro-thrombotic than biological valves, and their dysfunction may be associated, for example, with thrombotic events and the formation of pannus. Pannus is an inflammatory tissue composed of inflammatory cells, fibroblasts, and blood vessels, and its presence can lead to dysfunction or other complications such as valve obstruction or endocarditis. The prevalence of pannus in cardiac valve prostheses varies depending on several factors, such as the type of prosthesis (biological or mechanical) and the patients’ clinical conditions. It is estimated that the formation of pannus occurs in about 1% to 5% of patients with valve prostheses, although it may be more common in biological ones. The annual rate of thrombus formation can reach 5.7-8%, being higher in tricuspid and mitral valve prostheses.^, A multimodality-based approach can provide useful data for differential diagnosis, complementing clinical assessment and offering an appropriate and optimized therapeutic approach. Valve dysfunction, in case of delayed diagnosis, can progress to cardiogenic shock. Valvular dysfunctions can be structural (valve dysfunction due to changes related to the valve itself) or non-structural (dysfunctions not related to the valve resulting in stenosis or regurgitation, which include the formation of pannus), which arises from the accumulation of fibrous tissue in the valve, causing its dysfunction. It forms less frequently than thrombi and its risk is higher in the mitral position compared to the tricuspid.

The authors present a case of mechanical mitral valve prosthesis dysfunction due to pannus. A Caucasian 43 years-old woman, with dyslipidaemia and hypertension with a history of infectious endocarditis of the mitral valve in 04/2022, presented with signs of infectious infiltration of both leaflets and severe mitral regurgitation. At this point, a cycle of antibiotic therapy was performed with ampicillin and flucloxacillin, with no agent being isolated (neither in blood cultures nor microbiological examination of the explanted valve). A double-disc mechanical valve prosthesis was implanted in the mitral position. The patients were hypocoagulated with a vitamin K antagonist (warfarin, with target INR levels of 2.5-3.5) and discharged from the hospital for outpatient follow-up.

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Original Article

Prognostic Value of Preoperative Electrocardiogram in Low-Risk Patients Undergoing Surgical Intervention and General Anesthesia

Lafayete Ramos et al. Alexandre Chataubriand Coutinho José Rebelato Marcos Vinicius Ramos … Eliane Elly Pedro Amoedo Gustavo Viel Valdir Ambrósio Moises

Abstract

Background

Patients aged over 50 years require four times more surgical interventions than younger groups. Many guidelines recommend the performance of preoperative electrocardiogram (ECG) in this population.

Objectives

To determine the value of preoperative ECG in patients aged over 50 years and classified as ASA I–II (surgical risk).

Methods

Patients older than 50 years, without comorbidities, who underwent surgical intervention and general anesthesia were included in the study. Patients were randomized to undergo ECG (group A, n=214) or not (group B, n=213) in the preoperative period. The following variables were analyzed: sex, age, ECG, chest x-ray and laboratory tests results, surgical risk, surgery duration, adverse events and in-hospital mortality. The level of significance was set at 5%.

Results

Adverse outcomes were reported in 23 (5.4%) patients, with a significant number of adverse events in male patients (OR=7.91 95%CI 3.3-18.90, p<0.001) and in those undergoing major surgeries (OR=30.02 95%CI 4.01-224.92, p<0.001). No differences were observed between patients who underwent ECG and those who did not (OR=1.59, 95%CI, 0.67-3.75, p=0.289). No significant differences were found in the other variables. In multivariate logistic regression, male sex (OR = 6.49; 95%CI 2.42-17.42, p<0.001) and major surgery (OR=22.62; 95%CI 2.95-173.41, p=0.002) were independent predictors of adverse outcomes, whereas undergoing (or not) ECG (OR=1.09; IC95% 0.41-2.90, p=0.867) remained without statistical significance.

Conclusion

Our findings suggest that preoperative ECG could not predict an increased risk of adverse outcomes in our study population during the hospital phase.

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Predictors of Hospital Readmission After Coronary Artery Bypass Grafting – Reflections and Perspectives

A Prosthetic Dysfunction Earlier Than Expected

Prognostic Value of Preoperative Electrocardiogram in Low-Risk Patients Undergoing Surgical Intervention and General Anesthesia

Abstract

Background

Objectives

Methods

Results

Conclusion

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