Preoperative Care – ABC CARDIOL

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Original Article

Impact of 3D Printing on Cardiac Surgery in Congenital Heart Diseases: A Systematic Review and Meta-Analysis

Davi Shunji Yahiro et al. Mariana de Paula Cruz Brenda Ficheira Coelho Ribeiro Luiza Meireles Teixeira … Maria Fernanda Ribeiro Mendes de Oliveira Aurea Lúcia Alves de Azevedo Grippa de Souza Ana Flávia Malheiros Torbey Juliana Serafim da Silveira Claudio Tinoco Mesquita

Abstract

Background

Congenital heart disease (CHD) poses significant challenges in surgical management due to the complexity of cardiac anatomy. Three-dimensional (3D) printing has emerged as a promising tool in preoperative planning, intraoperative guidance, and medical education for CHD surgeries.

Objectives

We aimed to systematically review the literature on the utilization and benefits of 3D printing technology in CHD surgical interventions.

Methods

A systematic search was conducted across PubMed and EMBASE for studies published up to February of 2024. We included controlled and uncontrolled studies investigating the surgical role of 3D printing in CHD patients. We conducted a single-arm meta-analysis estimating the proportion of change in treatment planning due to the use of 3D printed-models. Moreover, studies that compared 3D printing to conventional care were included into the meta-analysis. A p-value < 0.05 was considered statistically significant.

Results

A total of 21 studies met the inclusion criteria, comprising 444 patients undergoing CHD surgeries with 3D printing assistance. Preoperative planning aided by 3D models led to changing surgical decisions in 35 of 75 cases (51.8%; 95% CI 26.6-77.0%, I2=80.68%, p=0.001) and reduced total operative time in 22.25 minutes in favor of the 3D printing group (95%CI 49.95; 5.80 min, I2=0%, p=0.817) but without statistical significance. Albeit in a smaller sample, other endpoints (mechanical ventilation and ICU time) demonstrated some benefit from the technology but without statistical significance.

Conclusions

By providing personalized anatomical models, 3D printing may facilitate surgical planning and execution. More studies are needed to investigate the effects of 3D printing on reducing intervention, hospitalization, and mechanical ventilation times.

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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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Review Article

Myocardial Injury after Non-cardiac Surgery – State of the Art

Antonio José Lagoeiro Jorge et al. Evandro Tinoco Mesquita Wolney de Andrade Martins

Abstract

Approximately 300 million non-cardiac surgeries are performed annually worldwide and adverse cardiovascular events are the main cause of morbidity and mortality in the peri- and postoperative period. Myocardial injury after non-cardiac surgery (MINS) is a new clinical entity associated with adverse cardiovascular outcomes. MINS is defined as myocardial injury that can result in necrosis due to ischemia, marked by increase in biomarker levels. It has prognostic relevance and occurs within up to 30 days after non-cardiac surgery. The diagnostic criteria for MINS are an elevated postoperative measure of troponin judged as secondary to myocardial ischemia, i.e., with no evidence of a non-ischemic etiology, during or within 30 days after non-cardiac surgery, and without the requirement of an ischemic symptom or electrocardiographic finding of ischemia. Recently, patients at higher risk for MINS have been recognized using clinical variables and biomarkers and established protocols for greater surveillance in relation to electrocardiographic monitoring and cardiac troponin dosage. Elderly patients with previous atherosclerotic disease need to measure troponin daily in the postoperative period. The aim of the present work is to describe this new public health problem, its clinical impact and contemporary therapeutic approach.

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Original Article

Determinants of Aortic Prosthesis Mismatch in a Brazilian Public Health System Hospital: Big Patients or Small Prosthesis?

Maria Estefania Otto et al. Fernando Antibas Atik Marcelo do Nascimento Moreira Luiz Carlos Madruga Ribeiro … Bianca Corrêa Rocha de Mello Joyce Gomes Elias Lima Maiara Sanchez Ribeiro Ana Carolina Pereira Matos Domingues Reyna Pinheiro Calzada Armindo Jreige Jr. Larissa Lucas Schloicka Philippe Pibarot

Abstract

Background:

Prosthesis-patient mismatch (PPM) is associated with worse outcomes.

Objective:

Determine the frequency and evaluate preoperatory variables independently associated with severe PPM in a tertiary hospital focused on Public Health Care.

Methods:

A total of 316 patients submitted to aortic valve replacement, who had echocardiography performed within the first 30 days after surgery, were retrospectively analyzed. The indexed effective orifice area (iEOA) of the prosthesis was used to classify the patients into three groups, according to PPM, considering body mass index (BMI): severe PPM (iEOA) < 0.65 cm²/m²), mild to moderate PPM (iEOA, 0.65 cm²/m² – 0.85 cm²/m²) and without PPM (iEOA > 0.85 cm²/m²) for a BMI < 30 kg/m² and severe PPM (iEOA) < 0.55 cm²/m²), mild to moderate (iEOA, 0.55 cm²/m²– 0.70 cm²/m²) and without PPM (iEOA > 0.7 cm²/m²) for a BMI > 30 kg/m². Statistical significance was considered when p < 0.05.

Results:

iEOA was obtained in 176 patients. The frequency of severe and moderate PPM was 33.4% and 36.2%, respectively. Severe PPM patients were younger and had larger BMI, but smaller left ventricular outflow tract diameter (LVOTD). The independent variables used to predict severe PPM were male gender, BMI > 25 kg/m², age < 60 years, LVOTD < 21 mm, and rheumatic etiology with an area under the ROC curve of 0.82.

Conclusion:

The frequency of severe PPM is high in a Brazilian population representative of the Public Health System, and it is possible to predict PPM from preoperative variables such as rheumatic valvular disease, gender, BMI, age and LVOTD.

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Original Article

Utility of Ultraportable Echocardiography in the Preoperative Evaluation of Noncardiac Surgery

Jean Allan Costa et al. Maria Lucia Pereira Almeida Tereza Cristina Duque Estrada Guilherme Lobosco Werneck … Alexandre Marins Rocha Maria Luiza Garcia Rosa Mario Luiz Ribeiro Claudio Tinoco Mesquita

Abstract

Background:

The ultraportable echocardiogram machine, with relevant portability and easiness in performing diagnoses, when in experienced hands, may contribute to the reliability of preoperative evaluation in noncardiac surgeries.

Objectives:

To assess cardiac function parameters in patients aged older than 60 years, candidates of elective noncardiac surgeries, classified as ASA1 or ASA 2 according to surgical risk.

Methods:

A total of 211 patients referred for elective surgeries, without suspicion of previous heart diseases, were included in the study. Assessment of patients was conducted by conventional echocardiogram using the ultraportable V Scan (GE) device right after the pre-anesthetic clinical evaluation. We assessed the clinical impact of echocardiography results by using a questionnaire addressed to the anesthetist.

Results:

Mean age of patients was 68.9 ± 7.0 years, 154 were women. The most frequent surgeries were: a) facectomy – cataract – 18; b) inguinal hernia surgery – 18; c) Cholecystectomy – 16. We found 58 normal tests (27.5%), 70 (33.2%) with mild valve reflux, and 83 (39.3%) with relevant abnormality, such as increase in heart chamber size, global and/or segmental contractile dysfunction, significant valve dysfunction or other unspecified. Test results caused delay of surgical procedure for a more detailed cardiac evaluation in 20 (9.5%) patients, and change in anesthetic management in 7 (3.3%).

Conclusion:

There was a considerable clinical impact with the use of the ultraportable echocardiography, since one out of every ten patients evaluated had their clinical management changed due to the detection of previously unsuspected, significant heart diseases, with the potential for severe complications.

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Original Article

Cardiac Surgery Costs According to the Preoperative Risk in the Brazilian Public Health System

David Provenzale Titinger et al. Luiz Augusto Ferreira Lisboa Bruna La Regina Matrangolo Luis Roberto Palma Dallan … Luis Alberto Oliveira Dallan Evelinda Marramon Trindade Ivone Eckl Roberto Kalil Filho Omar Asdrúbal Vilca Mejía Fabio Biscegli Jatene

Abstract

Background:

Heart surgery has developed with increasing patient complexity.

Objective:

To assess the use of resources and real costs stratified by risk factors of patients submitted to surgical cardiac procedures and to compare them with the values reimbursed by the Brazilian Unified Health System (SUS).

Method:

All cardiac surgery procedures performed between January and July 2013 in a tertiary referral center were analyzed. Demographic and clinical data allowed the calculation of the value reimbursed by the Brazilian SUS. Patients were stratified as low, intermediate and high-risk categories according to the EuroSCORE. Clinical outcomes, use of resources and costs (real costs versus SUS) were compared between established risk groups.

Results:

Postoperative mortality rates of low, intermediate and high-risk EuroSCORE risk strata showed a significant linear positive correlation (EuroSCORE: 3.8%, 10%, and 25%; p < 0.0001), as well as occurrence of any postoperative complication EuroSCORE: 13.7%, 20.7%, and 30.8%, respectively; p = 0.006). Accordingly, length-of-stay increased from 20.9 days to 24.8 and 29.2 days (p < 0.001). The real cost was parallel to increased resource use according to EuroSCORE risk strata (R$ 27.116,00 ± R$ 13.928,00 versus R$ 34.854,00 ± R$ 27.814,00 versus R$ 43.234,00 ± R$ 26.009,00, respectively; p < 0.001). SUS reimbursement also increased (R$ 14.306,00 ± R$ 4.571,00 versus R$ 16.217,00 ± R$ 7.298,00 versus R$ 19.548,00 ± R$935,00; p < 0.001). However, as the EuroSCORE increased, there was significant difference (p < 0.0001) between the real cost increasing slope and the SUS reimbursement elevation per EuroSCORE risk strata.

Conclusion:

Higher EuroSCORE was related to higher postoperative mortality, complications, length of stay, and costs. Although SUS reimbursement increased according to risk, it was not proportional to real costs.

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Artigo Original

Prognostic value of perioperative N-terminal pro-B-type natriuretic peptide in noncardiac surgery

Flávia Kessler Borges et al. Mariana Vargas Furtado Ana Paula Webber Rossini Carolina Bertoluci … Vinícius Leite Gonzalez Eduardo Gehling Bertoldi Denis Maltz Grutcki Leandro Gazziero Rech Mariana Magalhães Carisi Anne Polanczyk

BACKGROUND: Preoperative NT-proBNP has been shown to predict adverse cardiac outcomes, although recent studies suggested that postoperative NT-proBNP determination could provide additional information in patients submitted to noncardiac surgery. OBJECTIVE: To evaluate the prognostic value of perioperative NT-proBNP in intermediate and high risk cardiovascular patients undergoing noncardiac surgery. METHODS: This study prospectively enrolled 145 patients aged >45 years, with at least one Revised Cardiac Risk Index risk factor and submitted to intermediate or high risk noncardiac surgery. NT-proBNP levels were measured pre- and postoperatively. Short-term cardiac outcome predictors were evaluated by logistic regression models. RESULTS: During a median follow-up of 29 days, 17 patients (11.7%) experienced major adverse cardiac events (MACE- 14 nonfatal myocardial infarctions, 2 nonfatal cardiac arrests and 3 cardiac deaths). The optimum discriminatory threshold levels for pre- and postoperative NT-proBNP were 917 and 2962 pg/mL, respectively. Pre- and postoperative NT-proBNP (OR 4.7; 95% CI 1.62-13.73; p=0.005 and OR 4.5; 95% CI 1.53-13.16; p=0.006) were significantly associated with MACE. Preoperative NT-proBNP was significantly and independently associated with adverse cardiac events in multivariate regression analysis (adjusted OR 4.2; 95% CI 1.38-12.62; p=0.011). CONCLUSION: NT-proBNP is a powerful short-term marker of perioperative cardiovascular events in high risk patients. Postoperative levels were less informative than preoperative levels. A single preoperative NT-proBNP measurement should be considered in the preoperative risk assessment.

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Artigo Original

Left ventricular diastolic function in morbidly obese patients in the preoperative for bariatric surgery

Irlaneide da Silva Tavares et al. Antonio Carlos Sobral Sousa Raimundo Sotero Menezes Filho Manuel Hermínio de Aguiar-Oliveira … José Augusto Barreto-Filho Amanda Ferreira de Brito Joselina Luzia Menezes Oliveira

BACKGROUND: Obesity is a chronic and multifactorial disease, associated with increased cardiovascular risk, especially diastolic heart failure. OBJECTIVE: To evaluate left ventricular diastolic function in morbidly obese patients in the pre-operative for bariatric surgery, correlating it with cardiovascular risk factors and heart structure. METHODS: This is a cross-sectional study with 132 patients eligible for bariatric surgery submitted to transthoracic echocardiography assessment and of cardiovascular risk factors, as follows: 97 women (73.5%), mean age 38.5 ± 10.5 years and BMI of 43.7 ± 7.2 kg / m². Patients were divided into three groups: 61 with normal diastolic function, 24 with mild diastolic dysfunction and 47 with moderate/severe diastolic dysfunction, of which 41 with moderate diastolic dysfunction (pseudonormal pattern) and six with severe diastolic dysfunction (restrictive pattern). RESULTS: Hypertension, age and gender were different in the groups with diastolic dysfunction. Groups with dysfunction had higher left atrial diameter, left ventricular diameter, left atrial volume in four and two chambers, left atrial volume index and left ventricular mass index corrected for body surface area and height. CONCLUSION: The high frequency of left ventricular diastolic dysfunction in the preclinical phase in morbidly obese patients justifies the need for careful echocardiographic assessment, aiming at identifying individuals at higher risk, so that early intervention measures can be carried out.

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Artigo Original

Proposed preoperative risk score for patients candidate to cardiac valve surgery

João Carlos Vieira da Costa Guaragna et al. Luiz Carlos Bodanese Fabiana Lucas Bueno Marco Antonio Goldani

BACKGROUND: To establish a risk score for heart surgery allows the assessment of preoperative risk, informing the patient and defining care during the intervention. OBJECTIVE: To assess preoperative risk factors for death in cardiac valve surgery and construct a simple risk model (score) for in-hospital mortality of patients candidate to surgery at Hospital São Lucas of Pontifícia Universidade Católica do Rio Grande do Sul (HSL-PUCRS). METHODS: The study sample included 1,086 adult patients that underwent cardiac valve surgery between January 1996 and December 2007 at HSL-PUCRS. Logistic regression was used to identify risk and in-hospital mortality factors. The model was developed in 699 patients and its performance was tested in the remaining data (n = 387). The final model was created using the total study sample (n = 1,086). RESULTS: Global mortality was 11.8%: 8.8% of elective cases and 63.8% of emergency cases. At the multivariate analysis, 9 variables remained independent predictors for the outcome: advanced age, surgical priority, female sex, ejection fraction 2.5 mg/dl or undergoing dialysis). The area under the ROC curve was 0.83 (95% CI: 0.78-0.86). The risk model showed good capacity for observed/predicted mortality: the Hosmer-Lemeshow test was x² = 5.61; p = 0.691 and r = 0.98 (Pearson’s coefficient). CONCLUSION: The variables predictive of in-hospital mortality allowed the construction of a simplified risk score for daily practice, which classifies the patient as having low, moderate, high, very high and extremely high preoperative risk.

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Artigo Original

Prevalence of coronary artery disease and preoperative assessment in patients with valvopathy

Roney Orismar Sampaio et al. Vívian Masutti Jonke João L. Falcão Sandra Falcão … Guilherme S. Spina Flávio Tarasoutchi Max Grinberg

BACKGROUND: Coronary angiography has been indicated in the preoperative phase for patients with valvopathy over 35 years of age. However, the actual prevalence of obstructive coronary artery disease (CAD) in this population has been little studied. OBJECTIVE: To assess the prevalence of and the risk factors for CAD in candidates for valve surgery in Brazil. METHODS: Coronary angiography was performed in 3,736 patients who were candidates for valve surgery; prevalence of and risk factors for CAD associated with valvopathy were assessed. RESULTS: CAD was associated with valvopathy in 121 patients (prevalence of 3.42%). In 79 patients (68.1%), CAD was diagnosed by means of preoperative coronary angiography. Of these 79 patients, 50 (63.3%) had isolated aortic valvopathy or aortic valvopathy associated with mitral valvopathy. Smoking habit was observed in 54 patients (68.3%), hypertension in four (43%), family history in 24 (30.3%), diabetes mellitus in 15 (18.9%), and obesity in eight (10.1%). Of the 121 patients, 95.7% were over 50 years of age. Only five (4.3% of the patients with CAD) were below 50 years of age, and all of them had at least one risk factor for CAD. CONCLUSION: CAD prevalence was low in the patients studied. Aortic valvopathy was the most frequent valvopathy associated with CAD, and most patients were over 50 years of age. The ideal age for routine preoperative coronary angiography in patients with valvopathy should be reassessed.

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