Myocardial Revascularization – ABC CARDIOL

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Editorial

Surgery is the Means, Not the End: Late Follow-Up of Coronary Artery Bypass Graft Surgery

João Carlos Ferreira Leal et al. Rafael Alessandro Ferreira Gomes Walter J. Gomes

Coronary artery bypass grafting (CABG) remains a leading treatment for coronary artery disease (CAD), particularly in high-risk patient subgroups such as those with multivessel disease, left ventricular dysfunction, diabetes mellitus, and high ischemic burden, as evidenced by decades of scientific evidence and its consistent long-term results.

Coronary artery disease (CAD) has a progressive, systemic, and chronic evolution, which makes long-term follow-up essential for interpreting the results in therapeutic strategies. Therefore, outcomes after coronary artery bypass grafting (CABG) cannot be limited solely to the technical success of the procedure or to in-hospital outcomes but must encompass a broader and more integrative long-term perspective.

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Original Article

Five-Year Mortality among Survivors of Coronary Artery Bypass Graft Surgery: A Retrospective Study from a Tertiary Center

Eduardo Martelli Moreira et al. Bernadette Cunha Waldvogel Eduardo Bello Martins Desiderio Favarato … Eduardo Gomes Lima Fabio Grunspun Pitta Fabiana Hanna Rached Henrique Trombini Pinesi Omar Asdrúbal Vilca Mejia Carlos Vicente Serrano Jr

Background

Long-term outcome data following Coronary Artery Bypass Graft (CABG) surgery in Brazil remain limited, yet are essential for informing public health policies and guiding clinical practice.

Objectives

To estimate five-year all-cause and cause-specific mortality rates in patients undergoing CABG and to identify associated risk factors.

Methods

A retrospective analysis of 6,933 patients who underwent CABG at the Heart Institute, Faculty of Medicine, University of São Paulo, between 2007 and 2018. Mortality data up to 2018 were retrieved from government databases. A significance level of 5% was adopted.

Results

The study cohort included 4,854 men (72%) with a median age of 63 years (IQR: 57–70). Diabetes mellitus was present in 2,984 patients (43%), and 1,918 (29%) had chronic kidney disease. During follow-up, 1,075 deaths occurred, of which 506 (47.1%) were attributed to cardiovascular causes. The 5-year all-cause mortality rate was 12.9% (95% CI: 11.9–13.9), and the cardiovascular mortality rate was 5.7% (95% CI: 5.1–6.4). The leading cause of cardiovascular death was ischemic heart disease (290 deaths, 57.3%), followed by cerebrovascular disease (84 deaths, 16.6%). Factors significantly associated with all-cause mortality included older age, diabetes mellitus, glomerular filtration rate, HDL-cholesterol, left ventricular ejection fraction, left atrial and left ventricular diastolic dimensions, urgent hospitalization, on-pump surgery, and length of hospital stay.

Conclusion

Patients undergoing CABG at a tertiary care center exhibited moderate 5-year all-cause and cardiovascular mortality rates. These findings highlight key prognostic factors that may support risk stratification and guide postoperative management strategies.

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Original Article

Comparison between Five Risk Scores in Patients with Acute Coronary Syndromes Undergoing Surgical Revascularization during the Index Hospitalization

José C. Nicolau et al. Roberto R. C. V. Giraldez Fabio B. Jatene Luís A. O. Dallan … Luiz A. Lisboa Omar A. V. Mejia Jorge L. M. Ribera Adriadne J. Bertolin Luciano M. Baracioli Felipe G. Lima Maria C. D. Andrade Santiago A. C. Vintimilla Leonardo Salis Fabiane L. de Freitas Maxim Goncharov Lucas C. Godoy Remo H. de M. Furtado Michael E. Farkouh

Abstract

Background

Risk scores (RS) for patients with acute coronary syndromes (ACS) and coronary artery bypass grafting (CABG) have been tested previously, but little is known about their value in ACS patients undergoing CABG during the index hospitalization.

Objectives

To compare five different RS in ACS patients undergoing CABG during the index hospitalization.

Methods

The analyzed RS were GRACE, TIMI-non-ST-elevation ACS (TIMI-NSTEACS), TIMI-ST-elevation acute myocardial infarction (TIMI-STEMI), ACUITY/HORIZONS (A-H) bleeding, and EuroSCORE II. The RS were evaluated regarding their performance during the in-hospital phase and the long-term follow-up after discharge; a p-value <0.05 was considered significant.

Results

A total of 999 patients were included between 1998 and 2022. The mean time from symptom onset to CABG was 6.3 ± 5.5 days. The areas under the ROC curves were 0.82 (95% CI 0.74 – 0.89, p<0.001) for GRACE, 0.78 (95% CI 0.62-0.93, P=0.004) for TIMI-STEMI, 0.75 (95% CI 0.61-0.83, p<0.001) for EuroSCORE II, 0.67 (95% CI 0.59-0.76, P<0.001) for A-H bleeding, and 0.58 (95% CI 0.49-0.67, p=0.131) for TIMI-NSTEACS. Excluding in-hospital deaths, only GRACE and TIMI-STEMI were significantly associated with long-term mortality (mean follow-up of 5.5 ± 4 years). In the multivariable analyses, the GRACE score was the only RS significantly associated with in-hospital and long-term mortality in all adjusted models.

Conclusion

In patients with ACS who underwent CABG during the index hospitalization, the GRACE score was the only risk score that remained independently associated with both in-hospital and long-term mortality across all developed models, after adjustment for potential confounders. Moreover, the GRACE score performed better than others in predicting in-hospital deaths. These findings may influence the clinical decision-making process in this high-risk population.

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ABCHF

Case Report

Reverse Remodeling After Myocardial Revascularization in Severe Ischemic Heart Disease

Bruna Montingelli Espinola Trento et al. Daniela Gourlart Medeiros Maria Eduarda Soares Bizinelli Manuella Macedo Barão Ana Karyn Ehrenfried Freitas

Introduction

Heart failure with reduced ejection fraction (HFrEF), especially of ischemic etiology, is a challenging condition associated with high morbidity and mortality.¹ Patients with HFrEF frequently present with ventricular remodeling and progressive systolic dysfunction, making early identification of significant coronary artery disease (CAD) essential for defining therapy and optimizing prognosis.

Triple-vessel CAD involving the left main coronary artery (LMCA) constitutes a high-risk scenario. Guidelines recommend surgical revascularization in most cases, particularly in the presence of pronounced left ventricular dysfunction.² Evidence from studies such as STICH/STICHES has demonstrated that coronary artery bypass grafting (CABG) combined with optimized medical therapy in patients with ischemic cardiomyopathy and reduced left ventricular ejection fraction (LVEF) promotes improved long-term outcomes, although the perioperative risk remains high, with mortality up to 8.6% in patients with LVEF < 35%.³

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ABCHF

Viewpoint

The Impact of Revascularization on the Prognosis of Patients with Ischemic Heart Failure in the Contemporary Era: Viewpoint

Luhanda Leonora Cardoso Monti Sousa et al. Luís Henrique Wolff Gowdak

Introduction

The impact of myocardial revascularization on the prognosis of patients with heart failure (HF) and reduced left ventricular(LV) ejection fraction (EF) of ischemic etiology, especially those with EF ≤ 40%, remains one of the most debated topics in contemporary cardiology. Historically, this subgroup of patients with chronic coronary syndrome (CCS) was indicated for revascularization to reduce hard cardiovascular outcomes, according to guidelines, primarily through coronary artery bypass grafting (CABG). However, recent results and the evolution of optimized clinical treatment (OCT), which now includes medications and devices, have questioned the prognostic benefit of revascularization in this context.^–

The core of the controversy lies in the applicability and impact of the concept of myocardial viability. For a long time, the demonstration of viable hibernating myocardium was considered a prerequisite for indicating revascularization, based on the reasoning that functional recovery of the LV would lead to better long-term outcomes. More recent evidence, however, refutes this concept as a dichotomous criterion.^,

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Original Article

Relationship Between the Naples Prognostic Score and Saphenous Vein Graft Disease after Coronary Artery Bypass Grafting Surgery

Ahmet Karaduman et al. Cemalettin Yılmaz Muhammet Mucahit Tiryaki İsmail Balaban … Mustafa Ferhat Keten Tuba Unkun Servet İzci Suleyman Çağan Efe Elnur Alizade

Abstract

Background

Saphenous vein graft (SVG) patency remains a challenge in cases of coronary artery disease following coronary artery bypass grafting (CABG) surgery. The Naples prognostic score (NPS) constitutes a novel scoring system designed to assess both nutritional status and inflammation.

Objectives

Our study aimed to explore the association between the NPS and SVG disease in patients with a previous history of CABG surgery.

Methods

A total of 702 patients who had undergone CABG surgery and underwent coronary angiography were reviewed retrospectively. SVG disease was defined as the presence of ≥50% stenosis in at least one SVG. Patients were categorized into two groups based on the presence or absence of SVG disease. Values of p<0.05 were accepted as statistically significant.

Results

The study population consisted of 702 patients, with 269 (38.3%) having degenerative SVGs and 433 (61.7%) without degenerative SVGs. The NPS was higher in the group with saphenous vein degeneration and emerged as a significant predictor of SVG disease (OR: 1.596, 95% CI: 1.198-2.125, p=0.001). Additionally, hypertension (OR: 2.344, 95% CI: 1.137-4.833, p=0.02), chronic kidney disease (OR: 3.337, 95% CI: 1.554-7.168, p=0.002), statin usage (OR: 0.434, 95% CI: 0.239-0.789, p=0.006), time interval since CABG (OR: 1.138, 95% CI: 1.213-1.432, p<0.001), and number of SVGs (OR: 2.708, 95% CI: 1.902-3.855, p<0.001) were significant predictors of SVG disease.

Conclusion

The NPS, a useful tool for assessing inflammation and nutritional status, could provide valuable information about the patency of SVGs following CABG surgery. Patients with elevated NPS after CABG should undergo careful monitoring for the development of SVG disease.

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Original Article

The Effect of Coronary Artery Bypass Graft Surgery on Contractile Function and Symptoms in Patients with Left Ventricular Dysfunction

Fernando Bassan et al. Roberto Esporcatte Marcelo Goulart Correia Octavio Drummond Guina … Guilherme de Souza Weigert Gracielle Christine do Nascimento Oliveira

Abstract

Background

The degree of left ventricular (LV) dysfunction is an independent risk factor for poor outcomes in patients with chronic coronary syndrome. Coronary artery bypass graft (CABG) is the standard care for the management of ischemic heart failure to improve symptoms and prognosis. However, the predictors of improvement are still uncertain.

Objective

To assess the effect of myocardial revascularization on LV function and symptoms in patients with CCS and reduced left ventricular ejection fraction (LVEF), as well as to identify the improvement predictors.

Methods

We retrospectively analyzed the data and clinical status of 136 consecutive patients with LVEF<50% that underwent CABG. During clinical follow-up echocardiographic LV function was reassessed at the short-term (3.6 months) and long-term (30.8 months), and compared to baseline.

Results

Mean pre-operative LVEF was 40.9 ± 8.6% and wall motion score index (WMSI) was 1.99 ± 0.36, both improving at long-term to 48.1 ± 15.0% (p<0.001) and 1.75 ± 0.49 (p<0.001), respectively. We observed that 55.7% of the patients presented an improvement of LVEF≥10% and 58.1% in WMSI ≥10%. Univariate logistic regression analysis revealed that cerebrovascular disease was the only variable to be predictor of LVEF improvement. At the end of follow-up, we observed a reduction in the rate of patients in functional class III/IV when compared to baseline (65.4 vs. 10.3% – p<0.001).

Conclusions

Patients with CCS and reduced LVEF undergoing CABG experienced improvement in both LV contractile function and size, with beneficial response in functional class.

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Editorial

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

Aurora Felice Castro Issa

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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Letter to the Editor

Prediction of Rehospitalization in Cardiac Bypass Surgery

Antônio Rafael Alves de Sá et al. Victoria Alves Prado Mateus Augusto Felix de Melo Pâmela Marillac Rodrigues Feijó de Melo … Maria Clara Filgueira Borba Achilles de Souza Andrade Jorge Fernando Pereira Silva Johnnatas Mikael Lopes

Coronary artery disease, a cardiovascular disease in which there is obstruction of blood flow in the myocardial vessels, causes a large number of deaths in Brazil every year. Myocardial revascularization surgery, associated with antiplatelet, lipid-lowering, and RAAS blocker medications, is the best option for treating and preventing new cases of vascular flow obstruction, thus allowing the restoration of ventricular function, reduction of angina and prevention of acute myocardial infarction. Thus, it has clinical and surgical importance, as it allows the treatment of multiple obstructions and improves patient survival.^,

Percutaneous coronary intervention (PCI) is the most frequently used revascularization procedure in patients with coronary disease and is performed both electively and in acute situations. Unplanned rehospitalizations can be considered an adverse outcome for patients and may be related to complications of the PCI procedure or hospital treatment. Therefore, they are often used as an indicator of the quality of care provided. It is estimated that 1 in 7 patients undergoing PCI are readmitted within 30 days.

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Original Article

Preoperative Predictors of Hospital Readmission within 5 Years Following CABG: Cohort Analysis of the REPLICCAR II Database

Carlos Alberto Sancio Junior et al. Fabiane Letícia de Freitas Gabrielle Barbosa Borgomoni Daniella de Lima Pes … Pedro Horigoshi Reis Pedro Gabriel Melo de Barros e Silva Marcelo Arruda Nakazone Marcos Gradim Tiveron Valquiria Pelisser Campagnucci Luiz Augusto Lisboa Luís Alberto Oliveira Dallan Fabio Biscegli Jatene Omar Asdrúbal Vilca Mejia

Abstract

Background

Reducing hospital readmissions following coronary artery bypass grafting (CABG) surgeries is essential to optimizing medium- and long-term patient outcomes.

Objective

To analyze preoperative predictors associated with all-cause and cardiac readmissions within 5 years following CABG.

Methods

We analyzed 1,387 patients who underwent CABG between June 2017 and July 2019 using data from the multicenter REPLICCAR II registry. Follow-up was carried out by telephone interviews using a questionnaire structured in the REDCap platform. Statistical analysis included univariate and multivariate methods, with Cox regression and internal validation through calibration and discrimination tests. A significance level of 5% was applied.

Results

The cumulative incidence of all-cause readmission was 27.69%, with a mean follow-up of 4.3 years and a mean time to readmission of 2.4 years. Multivariate regression analysis indicated the following predictors of higher all-cause readmission risk: lower body mass index (HR=0.97, p=0.032), history of myocardial infarction (HR=1.27, p=0.024), diabetes mellitus (HR=1.35, p=0.004), renal failure (HR=1.62, p=0.004), and higher STS score (HR=1.22, p<0.001). A moderate correlation was observed between readmission and mortality (Rho=0.55).

Conclusions

This analysis demonstrates that lower body mass index, history of myocardial infarction, diabetes mellitus, renal failure, and elevated STS scores are significant predictors of increased hospital readmission risk following CABG.

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Editorial

Mitral Regurgitation after Acute Myocardial Infarction: A Multi-Faceted Condition

Carlos Henrique Miranda

There are two leading causes of mitral regurgitation (MR) after acute myocardial infarction (AMI). First, the partial or complete papillary muscle rupture leads to MR; in this case, surgical repair is mandatory. Fortunately, the prevalence of this condition is low, around 0.05%. Second, the valve and the subvalvular apparatus are normal, and the MR results from leaflet tethering and regional left ventricular dilatation. The primary mechanism is the separation and excess angulation of the papillary muscle related to the regional wall motion in the myocardial infarction area. This second presentation is called the “functional” phenotype. This functional MR is a common echocardiographic finding after AMI. A recent investigation showed a mild MR in 76%, moderate MR in 21%, and severe MR in 3% of the patients after AMI. Vyas et al. found a significant MR (moderate + severe) prevalence of 7.21% after non-ST elevation myocardial infarction (NSTEMI). An important aspect to highlight is that most previous studies analyzed MR prevalence in all types of myocardial infarction together or ST-elevation AMI alone. The actual prevalence of MR in NSTEMI was unknown, and this study showed a considerable MR prevalence in this setting.

According to other previous studies,^, this recent investigation showed that significant MR worst the patients’ prognosis, increasing the risk of death, pulmonary edema, heart failure, and cardiogenic shock. There are no doubts about the clinical impact of the MR after AMI. The more significant problem is that the mortality associated with this complication has not changed for decades, and there are still many doubts about the better management of these patients. Another feature deserves to be commented on: the clinical repercussions of severe MR are much more documented than those of moderate MR, and this classification is critical in making decisions about the treatment. In this recent investigation, the researchers analyzed the moderate and severe MR together, called significant MR; it was understandable because of the small sample size of severe MR; however, in the clinical setting, these two classifications have entirely different outcomes during the follow-up.

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Original Article

Females are Associated with Lower Risks of Long-Term Mortality in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

Chen Bai et al. Jiangang Wang Qing Ye Cheng Zhao

Abstract

Background

In patients who underwent off-pump coronary artery bypass grafting (OPCABG), females were reported to have lower rates of in-hospital mortality rate and postoperative atrial fibrillation than males. However, the association between gender and long-term prognosis following OPCABG is rarely reported.

Objective

This study aims to determine if women benefit more from OPCABG than men by comparing the difference in the risk of long-term all-cause mortality in patients with coronary chronic total occlusion (CTO).

Methods

This is an observational, retrospective cohort study conducted in adult patients (≥18 years) with coronary CTO undergoing OPCABG at our hospital from January 2011 to December 2014. A multivariate Cox proportional hazards model was employed to assess the association of gender with the risk of all-cause mortality. A p-value of <0.05 was considered statistically significant.

Results

Totally 1,256 participants were enrolled, among which 321 (25.6%) were females and 935 (74.4%) were males. During a maximum follow-up of 10 years, the all-cause mortality rate in women was significantly lower than that in men (10.3% vs. 24.3%, p<0.01). Multivariate Cox regression analysis indicated that women were significantly associated with a lower risk of all-cause mortality (HR=0.30, 95% CI: 0.20-0.44; p<0.01) after controlling for potential confounding factors.

Conclusion

Women benefit more from OPCABG surgery than men, as they have a lower risk of long-term all-cause mortality in patients with coronary CTO.

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Editorial

Look Who is Coming Back? Enhancing Predictive Models for Hospital Readmission Post-CABG: Insights and Perspectives

Stephan Lachtermacher

The field of cardiovascular surgery continually evolves, with coronary artery bypass grafting (CABG) serving as a cornerstone procedure for managing severe coronary artery disease. Despite advancements in surgical techniques and perioperative care, the incidence of hospital readmissions within 30 days post-CABG remains a critical concern. These readmissions not only impact patient outcomes but also strain healthcare resources and increase costs. Understanding predictors of readmission is crucial for improving postoperative care strategies and optimizing patient outcomes.

The study titled ” Predictors of 30-Day Hospital Readmission Following CABG in a Multicenter Database: A Cross-Sectional Study” aims to identify variables associated with early readmission post-CABG in a Brazilian population. While the observed readmission rate was lower than current scientific literature, where rates vary between 8.3% and 21.1%,^– it also emphasized non-cardiac-related causes. In this matter, one-third of all readmitted patients had infections as a primary cause. This finding corroborates existing literature highlighting the significant impact of infections, particularly surgical site infections, on readmission rates. Andrade et al. underscore the imperative for stringent infection control measures, including antibiotic prophylaxis and meticulous surgical techniques, to mitigate these complications.^,

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IJCS

Original Article

Quality of Life Assessment of Patients Infected With COVID-19 and Prior Coronary Artery Bypass Graft Surgery in Brazil: Four Years Follow-up

Adnaldo da Silveira Maia et al. Matheus Maia Adnaldo Lucas da Silveira Maia Magaly Arrais dos Santos

Abstract

Background

The COVID-19 pandemic has been a worldwide challenge. In patients with coronary artery disease (CAD), previously submitted to coronary artery bypass graft surgery (CABG), such impact should be analyzed.

Objectives

Evaluate the impact on quality of life of COVID-19 infection in patients with prior CABG.

Methods

Patients undergoing isolated CABG between July 2016 and July 2017 were enrolled. This is an observational, cross-sectional, prospective study. Patients were divided into two groups: Group (COVID-19) and Group (No-COVID), for analysis of variables. The World Health Organization’s (WHO) definitions of confirmed cases were used to define the diagnosis of COVID-19 infection. Quality of life was assessed using the Quality of Life in Cardiovascular Surgery (QLCS) questionnaire, applied 30 days, 6 months, 1 year, and 4 years after surgery. The primary endpoint was improvement in quality of life at 4 years after CABG. The local ethics committee approved the study. Continuous variables were described by their means and standard deviations (SD). Categorical variables were described using absolute or relative frequencies. The items that make up the quality of life questionnaire were added together to calculate the score. A linear mixed model was used to assess the effect of time on the score. The significance level adopted was 5%. The analyses were carried out using R software, version 4.2.1.

Results

The total sample consisted of 434 patients who underwent isolated CABG; the mean age was 63 years, with a prevalence of males (71%). Among the patients followed up at the 4-year follow-up (115), 60 (52%) were positive according to the WHO’s definitions. After multiple comparisons, there was a statistical difference in quality of life in all periods (P<0.001). Between patients with and without COVID-19, a statistical difference was observed at 1 and 4 years (p = 0.0039).

Conclusion

Patients who underwent CABG and had a history of COVID-19 infection experienced worsening quality of life within 4 years. There was no difference between groups regarding new acute myocardial infarction (AMI), stroke, or hospitalization.

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Viewpoint

Angina Pectoris and Orbita 2 Trial: Reflections on the Future of Angina Treatment

Eduardo Bello Martins et al. Eduardo Gomes Lima Jaime Paula Pessoa Linhares Filho Henrique Trombini Pinesi … Fabio Grunspun Pitta Carlos Vicente Serrano Júnior

The ORBITA trial

Although the above-mentioned studies have demonstrated some improvement in angina after myocardial revascularization, one of their major limitations is the open nature and a possible placebo effect. In this regard, the ORBITA study showed no benefit of PCI versus a placebo procedure on the primary end-point of an increase in exercise time. ORBITA was a well conducted study that demonstrated the possibility of a placebo component and lack of symptom improvement by PCI. However, several limitations could have influenced these results and have been discussed in the literature, such as the fact that it included patients with non-limiting symptoms, no ischemia in almost a quarter of the participants and short follow-up.

In 2023, the ORBITA 2 trial was finally published in NEJM and addressed for the first time the PCI as a monotherapy for angina relief at a placebo-controlled trial. It provides another piece of the puzzle of angina control and overcomes some of the first ORBITA limitations. ORBITA 2 was an investigator-initiated, multicenter, double-blind, randomized, placebo-controlled trial that was conducted at 14 sites in the United Kingdom and included 301 participants. Patients enrolled had angina or equivalent symptoms, anatomic evidence of severe coronary stenosis and objective evidence of ischemia based on noninvasive imaging or invasive coronary physiology testing. First, antianginal medications were discontinued (median number of antianginal drugs was only 1) and the participants were instructed to use a dedicated smartphone application to report the presence or absence of angina and the number of angina episodes daily. Patients also completed validated questionnaires on symptoms and quality of life. The Canadian Cardiovascular Society (CCS) functional classification was assessed, treadmill exercise test and dobutamine stress echocardiography were also performed. The patients then entered a two-week pre-randomization period during which they reported the number of episodes of angina daily, through the smartphone application. Patients were eligible to proceed to randomization if they reported at least one episode of angina during the symptom assessment phase.

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Original Article

Age, Renal Failure and Transfusion are Risk Predictors of Prolonged Hospital Stay after Coronary Artery Bypass Grafting Surgery

Diego Pereira Gregório de Andrade et al. Fabiane Letícia de Freitas Gabrielle Barbosa Borgomoni Maxim Goncharov … Pedro Gabriel Melo de Barros e Silva Marcelo Arruda Nakazone Valquiria Pelisser Campagnucci Marcos Gradim Tiveron Luiz Augusto Lisboa Luís Alberto Oliveira Dallan Fabio Biscegli Jatene Omar Asdrúbal Vilca Mejia

Abstract

Background:

Identifying risk factors in cardiovascular surgery assists in predictability, resulting in optimization of outcomes and cost reduction.

Objective:

This study aimed to identify preoperative and intraoperative risk predictors for prolonged hospitalization after coronary artery bypass grafting (CABG) surgery in the state of São Paulo, Brazil.

Methods:

A cross-sectional analysis using data from the REPLICCAR II database, a prospective, consecutive, multicenter registry that included CABG surgeries performed between August 2017 and July 2019. The primary outcome was a prolonged hospital stay (PHS), defined as a postoperative period exceeding 14 days. Univariate and multivariate logistic regression analyses were performed to identify the predictors with significance set at p <0.05.

Results:

The median age was 63 (57-70) years and 26.55% of patients were female. Among the 3703 patients analyzed, 228 (6.16%) had a PHS after CABG, with a median hospital stay of 17 (16-20) days. Predictors of PHS after CABG included age >60 years (OR 2.05; 95% CI 1.43-2.87; p<0.001); renal failure (OR 1.73; 95% CI 1.29-2.32; p <0.001) and intraoperative red blood cell transfusion (OR 1.32; 95% CI 1.07-2.06; p=0.01).

Conclusion:

Age >60 years, renal failure, and intraoperative red blood cell transfusion were independent predictors of PHS after CABG. The identification of these variables can help in multiprofessional strategic planning aimed to enhance results and resource utilization in the state of São Paulo.

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ABCIC

Case Report

Anomalous Origin of the Coronary Artery from an Inappropriate Coronary Sinus

Mário Cruz Couto et al. Fernando Augusto Pacífico Dolly Brandão Lages Michelle Alves de Farias … Liliam de Souza Santos Eduardo Lins Paixão

Abstract

Congenital anomaly of the coronary arteries is a potentially lethal disease, especially in young people. Currently, non-invasive cardiovascular imaging tests have shown better definition of the origin and course of the coronary arteries. Surgical treatment should be indicated in symptomatic patients, while the ideal management of asymptomatic patients remains controversial. We report a case of anomalous origin of the left coronary artery from the right coronary sinus with an interarterial course, in an asymptomatic patient treated with revascularization surgery.

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IJCS

Original Article

Impact of the COVID-19 Outbreak on Coronary Artery Bypass Grafting in Brazil

Felipy de Almeida Machado et al. Rui M. S. Almeida

Abstract

Background

The COVID-19 pandemic has disrupted the routine of emergency centers around the world, including in Brazil, where the crisis has affected the volume of major cardiac surgeries such as coronary artery bypass grafting.

Objective

To analyze the impact of the COVID-19 pandemic on the number of surgical procedures for coronary artery bypass grafting in Brazil.

Methods

An ecological, cross-sectional, quantitative, and descriptive study was conducted. Data for the period from July 2018 to June 2019 and from July 2020 to June 2021 were collected from SIHSUS using DATASUS/Tabwin.

Results

A global reduction of 26.58% was observed in the analyzed population, with on-pump coronary artery bypass grafting decreasing by 28.10%, and off-pump coronary artery bypass grafting reduced by only 10.31%.

Conclusion

During the pandemic, there was a 26.58% reduction in the number of surgical procedures for myocardial revascularization in Brazil.

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ABC

Original Article

Comparison of Cardioplegic Solutions in Coronary Bypass Surgery Over Autophagy and Apoptosis Mechanisms

Elif Funda Sener et al. Zuhal Hamurcu Serpil Taheri Reyhan Tahtasakal … Nesrin Delibasi Deniz Elcik Ecmel Mehmetbeyoglu Aydin Tuncay Fatma Dal Keziban Korkmaz Bayram Isın Gunes Omer Naci Emirogullari

Abstract

Background

Coronary artery disease (CAD) due to myocardial ischemia causes permanent loss of heart tissue.

Objectives

We aimed to demonstrate the possible damage to the myocardium at the molecular level through the mechanisms of autophagy and apoptosis in coronary bypass surgery patients.

Methods

One group was administered a Custodiol cardioplegia solution, and the other group was administered a Blood cardioplegia solution. Two myocardial samples were collected from each patient during the operation, just before cardiac arrest and after the aortic cross-clamp was released. The expressions of autophagy and apoptosis markers were evaluated. The level of statistical significance adopted was 5%.

Results

The expression of the BECLIN gene was significant in the myocardial tissues in the BC group (p=0.0078). CASPASE 3, 8, and 9 gene expression levels were significantly lower in the CC group. Postoperative TnT levels were significantly different between the groups (p=0.0072). CASPASE 8 and CASPASE 9 gene expressions were similar before and after aortic cross-clamping (p=0.8552, p=0.8891). In the CC group, CASPASE 3, CASPASE 8, and CASPASE 9 gene expression levels were not found to be significantly different in tissue samples taken after aortic cross-clamping (p=0.7354, p=0.0758, p=0.4128, respectively).

Conclusions

With our findings, we believe that CC and BC solutions do not have a significant difference in terms of myocardial protection during bypass operations.

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IJCS

Original Article

Effectiveness of Early Mobilization in Prevention and Rehabilitation of Functional Impairment After Myocardial Revascularization Surgery: A Systematic Review

Marcia Cristina Lacerda das Judas et al. Rodrigo de Freitas Fontes Renata de Moura Larissa dos Santos … Mônica de Almeida Vinicius Gomes

Abstract

Introduction

Myocardial revascularization surgery is associated with high morbidity and mortality, due to factors like the general anesthesia and the surgical procedure itself. Physiotherapy, combined with early mobilization (EM), can provide the patient with better functional parameters.

Objective

To review, identify and describe the effectiveness of EM in the prevention and rehabilitation of functional parameters of coronary artery bypass graft surgery.

Methodology

This is a systematic review conducted between February 2020 and 2021 of randomized clinical trials (RCTs) published in the Cochrane databases Library, LILACS, Scielo and Medline / PubMed. The Physiotherapy Evidence Database (PEDro) scale was used for assessment of the methodological quality of studies included.

Results

Four studies were reviewed. Two articles assessed functional capacity, one using the cycle ergometer and one with inspiratory muscle training (IMT) together with active exercises and early walking. One article reported a reduction in the incidence of atelectasis and pleural effusion with EM and one article reported improvements in the alveolus-artery gradient and inspiratory muscle power using an inspiratory muscle trainer combined with EM.

Conclusion

EM is effective in the prevention and rehabilitation of functional parameters after CABG surgery, by improving functional capacity, respiratory muscle power, quality of life and gas exchange, and reducing the incidence of atelectasis and pleural effusion.

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ABC

Research Letter

Change of Strategy in Coronary Artery Bypass Graft Surgery Waiting List during the COVID-19 Pandemic: One-Year Follow-Up

Franc Jorge Sampaio Santos Pereira et al. Marília Prudente Menezes Gabriela Carolina Santamaria Naranjo José Henrique Herrmann Delamain … José Ribamar Costa Mario Issa Vivian Lerner Amato Fausto Feres Pedro Silvio Farsky

Introduction

The COVID-19 pandemic led to a significant occupation of intensive care beds, causing the suspension of elective cases of coronary artery bypass grafting (CABG).

At the same time, the evolution of techniques for the percutaneous treatment of coronary artery disease (CAD) has expanded the possibilities for this modality, and published studies have not shown a reduction in outcomes in stable patients with moderate/high ischemic burden under optimized clinical treatment (OCT).

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ABC

Letter to the Editor

CHA2DS2-VASc Score: What More Can it Predict?

Adnaldo da Silveira Maia

Dear Editor,

Kalkan et al. assessed the predictive value of the congestive heart failure, hypertension, age, diabetes mellitus, prior stroke, vascular disease, age, sex category (CHA₂DS₂-VASc) score for residual SYNTAX score (rSS) among patients with ST-segment elevation acute myocardial infarction (STEMI). The study included 688 patients divided into a low rSS group (group 1; scores up to 8) and a high rSS group (group 2; scores above 8).

[…]

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IJCS

Original Article

Prevalence of Surgical Myocardial Revascularization in Diabetics and Non-diabetics After Acute Myocardial Infarction

Ariane Maggi Coelho Schwanck et al. Iara Schardosin Bayma de Menezes Marina Casagrande Canto

Abstract

Background

Diabetes mellitus (DM) is a metabolic disorder characterized by persistent hyperglycemia. The main cause of death among diabetics is cardiovascular disease (CVD), which is a precursor to acute myocardial infarction (AMI). Approximately 30% of diabetic patients with AMI require myocardial revascularization surgery (MRS).

Objective

To evaluate the prevalence of MRS in diabetic and non-diabetic patients after AMI in a hospital in the city Criciúma, Brazil, during the period from 2016 to 2019.

Methods

A cross-sectional study was carried out with secondary data collection, with analysis of 215 medical records of diabetic and non-diabetic patients with AMI, submitted or not to MRS during the study period. For statistical analysis, the Shapiro-Wilk test, Pearson’s chi-square test and Fisher’s exact test were used, with a significance level of α = 0.05.

Results

The frequency of diabetic AMI patients with hypertension (88.1%) was significantly higher (p<0.01) than of diabetic AMI patients without hypertension. Although no statistically significant differences were found in the other variables between the groups, smoking, hypertension and dyslipidemia were more prevalent in diabetic than in non-diabetic patients with AMI undergoing MRS.

Conclusion

The prevalence of MRS after AMI in diabetic patients was higher than in non-diabetic patients.

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ABC

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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