Patient Safety – ABC CARDIOL

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Research Letter

Simulation in Cardiovascular Medicine Education: Innovation, Safety, and Competency-Based Training

André Luiz Lisboa Cordeiro et al. Tiago Veltri Ormastroni da Trindade Rinaldo Antunes Barros

The incorporation of simulators into cardiovascular medicine education represents one of the most significant transformations in contemporary medical training. In a scenario marked by high clinical complexity, rapid technological evolution, and time-dependent decision-making, simulation emerges as a pedagogical strategy capable of integrating theoretical knowledge, technical skills, and non-technical competencies in a structured and safe manner.^, However, despite its growing adoption, simulation-based education should be interpreted within the context of its current evidence base, which still presents important limitations, particularly regarding its direct impact on patient-centered outcomes.

Contemporary cardiology, characterized by rapid advances in pharmacological therapies, complex interventional procedures, and sophisticated cardiac imaging, requires professionals not only to acquire new skills but also to maintain continuous proficiency. In this context of rapid evolution and increasing demands for safety and effectiveness, simulation positions itself as an important ally. Nevertheless, its role should be understood as complementary rather than substitutive to real clinical exposure. These needs are reinforced by the newly established National Curricular Guidelines for the Undergraduate Medical Course (DCNs 2025), which explicitly advocate the provision of “protected, controlled, and technically adequate learning environments, such as skills laboratories and clinical simulation,” aiming at patient safety and the analysis of error as a pedagogical tool, while also emphasizing that clinical training in real healthcare environments must remain predominant throughout medical education. This vision aligns with the already consolidated experience of programs that train simulation multipliers, which are essential for the continuing education of health professionals within the SUS and for the training of students and residents.

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ABCIC

Editorial

"Triple Rule-Out": Including the Abdominal Aorta With a Clear Conscience?

Tiago A. Magalhães

Less is More – Less Radiation Dose, More Patient Safety

The main strength of the study lies in its methodological approach. The authors selected patients who had previously undergone the TRO CTA protocol including the abdominal aorta with full electrocardiographic synchronization. After obtaining consent, they performed a new examination using the partial electrocardiographic synchronization protocol, enabling a robust comparison through a “matched case-control” model. This approach minimizes bias related to anatomical and technical variability among different individuals.

The results were interesting. The dose reduction was significant: the mean effective dose of the protocol with partial ECG synchronization was 47.9% lower than that of the protocol with full synchronization (17.0 mSv vs. 32.6 mSv, p<0.001). It is noteworthy that this reduction in radiation dose was not accompanied by a compromise in image quality. The quantitative assessment of attenuation values in critical vascular regions – such as the ascending aorta, descending aorta, abdominal aorta, and pulmonary trunk – showed no statistically significant differences. Similarly, the subjective qualitative evaluation demonstrated equivalence between the two protocols in terms of image quality of the assessed anatomical structures.

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ABCIC

Editorial

Intracardiac Echocardiography: Current Status, Clinical Benefits, and Future Perspectives

Renner Augusto Raposo Pereira et al. Daniel Moreira Costa Moura

Intracardiac echocardiography (ICE) is an ultrasound imaging technique capable of providing real-time, high-quality visualization of cardiac structures and their adjacent tissues through a catheter with a transducer inserted directly into the heart chambers, typically via transfemoral venous access. By allowing direct and precise visualization of intracardiac anatomy, ICE has been increasingly used to guide structural interventions and catheter ablations for cardiac arrhythmias, as well as to enable immediate detection of intraoperative complications.

Initial clinical investigations began in the 1960s, focusing on the assessment of atrial septal defects. Since then, ICE has evolved significantly. The introduction of the phased-array transducer, the addition of color Doppler functionality, and advancements in manipulation systems have enabled its widespread clinical application. The latest version of phased-array ICE features a position sensor at the catheter tip, allowing real-time integration with three-dimensional electroanatomic mapping systems used in complex ablations. The ability to precisely maneuver the catheter, combined with its versatile positioning, makes ICE a valuable tool for anatomic navigation and real-time monitoring during complex interventions.

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Research Letter

Preparing Patients And Optimizing Processes In The Perioperative Period Of Cardiac Surgery: How To Redesign The Flow Of Care After COVID-19

Omar Asdrúbal Vilca Mejia et al. Bruno Mahler Mioto Gabrielle Barbosa Borgomoni Juliana Mendanha Camilo … Danielle Misumi Watanabe Sirlei Pereira Nunes Vanessa Santos Sallai Maraina Pegorini Libório de Lima Jurema da Silva Herbas Palomo Helenice Moreira da Costa Elisandra Trevisan Arita Maria Ignêz Zanetti Feltrim Vera Coimbra Roger Daglius Dias Filomena Regina Barbosa Gomes Galas José Otávio Costa Auler Junior Fabio Biscegli Jatene

Introduction

The lack of proactive care strategies influences the fragmentation of care, deparametrization of processes and extension of hospital times, while evidence has shown that multidisciplinary protocols based on evidence executed by synchronized teams, with standardized processes, proactivity and patient-centered care decrease complications, hospital times and hospital costs.^, In this context, care based on the Enhanced Recovery After Surgery (ERAS) concept revolutionizes traditional flows. Guidelines for cardiac surgery were recently published, producing encouraging results.^,

This approach showed efficiency and safety in hospital discharge within three days after cardiac surgery,^, which is promising in the COVID-19 era, in which surgical queues have grown due to procedural delays, enabling a greater number of visits in less time, reducing the risk of contamination and hospital costs.

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IJCS

Letter to the Editor

Effectiveness of Rapid Response Teams and the Importance of Preprints

Hermano Alexandre Lima Rocha et al. Sabrina Gabriele Maia Oliveira Rocha Antônia Célia de Castro Alcântara

To the Editor of the International Journal of Cardiovascular Sciences,

We have read with interest the Point of View: “Performance of the Rapid Response Systems in Health Care Improvement: Benefits and Perspectives” by Viviane Cordeiro Veiga and Salomón Soriano Ordinola Rojas, published ahead of print in the International Journal of Cardiovascular Sciences on April 15, 2019. Rapid response teams to treat trauma patients in Australia 30 years ago, in 1989. From the outset, the aim was to early recognize signs of deterioration and provide a quick response, hence the name of the methodology. The discussion about the activation criteria is relevant and up to date and was treated in a solid manner by the authors in the introduction of the point of view. Indeed, it is known that this is the cause of part of the heterogeneity of results found in studies on the subject.

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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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IJCS

Editorial

Is Bovine Heparin, an Old Fellow, a Safe Anticoagulation Approach during Extracorporeal Circulation Inside the Cardiac Operating Room?

Ivis Levy Fernandes Martins et al. Christianne Bretas Vieira Scaramello

Antithrombotic agents include anticoagulants, antiplatelet and fibrinolytic drugs. They are prescribed in several situations related to hemostasis disturbances that favor thrombi formation. Since bleeding is a common adverse effect of these drugs, a cost-benefit analysis of antithrombotic therapy prior to surgery should be performed. In order to consider the preoperative therapy for patients undergoing cardiac surgery, the risk of thrombosis must outweigh the risk of bleeding. Nonetheless, the literature has reported the use of anticoagulant therapy with unfractionated heparin (UFH) during extracorporeal circulation (ECC) inside and outside the cardiac operating room.^–

The development of the heart-lung machine made ECC possible. Therefore, heart surgery became a routine practice. The literature describes that complications related to ECC have diminished due to modern monitoring, highly trained staff, special cannulation methods, as well as the latest advances in techniques. However, some authors suggest that guidelines based on more researches would improve the safety of this procedure. During cardiac surgery, ECC preserves the functional characteristics of the heart, provides a clean surgical environment and offers safety to the team.

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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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IJCS

Viewpoint

Performance of the Rapid Response Systems in Health Care Improvement: Benefits and Perspectives

Viviane Cordeiro Veiga et al. Salomón Soriano Ordinola Rojas

Introduction

In the last two decades, the rapid response systems (RRS) have been explored as initiatives to increase the safety of hospitalized patients. The main function is to identify and treat patients at risk, or who are presenting signs of clinical instability, and to prevent adverse events during hospital stay, with a consequent reduction in in-hospital mortality. Every year in the United States, more than 200,000 intrahospital cardiac arrests (CAs) occur, most of which could be avoided. RRS are formed by two health care components called the afferent limb and the efferent limb. The afferent limb is represented by the health care team in the admission units, responsible for the care of hospitalized patients and trained to activate the afferent limb, when physiological changes that predict adverse events are detected, especially cardiac arrests. The efferent limb is represented by a team of health care professionals, who respond to codes, and may be headed by a physician, a nurse or a physiotherapist. The efferent limb is better known as the rapid response team (RRT). In addition to these health care components, the rapid response systems must also have two other components, namely the administrative arm, which provides the necessary documentation and is responsible for the systems daily activities and the quality and governance arm, which contributes to continuous improvement and reassessment of the system. These systems have been implemented around the globe, but still in a non-uniform way in institutions and health systems with different characteristics. However, in Brazil, there are few reports on this issue.^,

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