Thoracic Surgery – ABC CARDIOL

ABCIC

Case Report

Giant Atrial Myxoma in a Pregnant Patient: A Case Report

Roberto Ramos Barbosa et al. Caio Badiani Prando Victor Macedo Bianchini Lucas Crespo de Barros … Larissa Novaes Paganini Gracielly Barros Darlan Dadalt Sergio Luis Santos Guedes Vinicius Eduardo Araújo Costa Marcus Gustavo Tito Tiago Bernardo Nery Marcio Vinicius de Nardi de Angeli Maria Eduarda Vichi Gomes Viana Mariana Oliveira Roncato João Paulo Moulin Auad Guilherme Freitas Fernandes de Oliveira Renato Giestas Serpa Osmar Araujo Calil Luiz Fernando Machado Barbosa

Introduction

Atrial myxoma is the most prevalent primary heart tumor.^, Clinical manifestations of myxomas are usually nonspecific, and they may present with dyspnea, fatigue, reduced functional capacity, edema, and, eventually, cerebral embolic events with focal neurological deficits. Although they are classified as benign neoplasms, most commonly located in the left atrium, they can cause obstruction of intracardiac blood flow and, when friable, systemic embolism with consequent tissue ischemia.^,

In spite of higher prevalence in women (65%), diagnosis during pregnancy is considered uncommon, with greater challenges in treatment and an increased risk of fetal death. We report the case of a pregnant patient with a complication of atrial myxoma that manifested during labor.

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ABC

Review Article

Implementing Cardiac Prehabilitation in Brazil: Building an Evidence-based Framework for Surgical Outcomes

Flavia Mazzoli-Rocha et al. Ricardo Stein Carolin Steinmetz Monika Sadlonova … Audrey Borghi-Silva Thomas Schmidt

Abstract

Patients undergoing cardiac surgery often face multiple challenges, including comorbidities, frailty, and psychosocial factors, which complicate recovery. Multimodal prehabilitation programs have emerged as a promising strategy to address these issues, aiming to reduce the length of hospital stay, mitigate pulmonary complications, and enhance functional recovery.

This Review Article examines the components and benefits of a comprehensive cardiac prehabilitation program, with a focus on exercise-based prehabilitation. Additionally, it underscores the importance of integrating prehabilitation into Brazilian clinical guidelines as a valuable preoperative opportunity.

Emerging evidence, albeit of low to moderate quality, suggests that exercise-based prehabilitation, as a unimodal approach or integrating a multimodal program, can significantly improve functional capacity and postoperative outcomes in patients undergoing elective cardiac surgery. International guidelines have already supported cardiac prehabilitation as a valuable approach in this context. Globally, ongoing multicenter intervention trials seek to refine this evidence, pinpointing the ideal patient population and the most effective cardiac prehabilitation program. Given the growing burden of cardiovascular disease in Brazil, there is an unmet need for local research to assess the benefits of prehabilitation in patients undergoing cardiac surgery.

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ABCHF

Review Article

History and Application of Mechanical Assist Devices as a Bridge to Heart Transplant: A Review and Perspectives in Brazil

Alvaro Perazzo et al. Fabio Antônio Gaiotto Samuel Padovani Steffen Shirlyne Fabianni Dias Gaspar … Vanessa Simioni Faria Rebeca Cavalcante Silva Ferreira Aline Carbonera Danielle Louvet Guazzelli Jael Andrea Rioja Gamboa Leonardo Flud Ideal Helen Lima Gomes Alexandre Targino Gomes Falcão Filho Andre Loureiro Fernandes Luiza Hermanny Campos Camila Lambert Steffen Carolina Limongi Renato Leal Varjão Monica Samuel Avila Luis Fernando Bernal da Costa Seguro Sandrigo Mangini Fabiana Goulart Marcondes-Braga Gabriel Barros Aulicino Iascara Wozniak de Campos Ronaldo Honorato Barros Santos Domingos Dias Lourenço Filho Mariusz Kowalewski Daniele Ronco Matteo Matteucci Paolo Meani Claudio Francesco Russo Michele di Mauro Silvia Mariani Antonio Loforte Dominik Wiedmann Fernando Bacal Glenn Whitman Prakash Punjabi Roberto Lorusso Fabio Biscegli Jatene

Abstract

Mechanical circulatory support (MCS) devices have evolved significantly over the past decades and play a vital role in managing end-stage heart failure, especially as a bridge to heart transplantation. From the pioneering heart-lung machines to third-generation ventricular assist devices (VADs), MCS technology has advanced to provide more durable, efficient, and safer options for both short- and long-term support. This review outlines the historical development of mechanical assist devices, the types of available supports – ranging from intra-aortic balloon pumps and extracorporeal membrane oxygenation to implantable devices like HeartMate 3 – and their clinical indications and complications. Special attention is given to right ventricular dysfunction, thromboembolic and hemorrhagic complications, and infections, which remain major challenges in the management of patients with MCS devices. In Brazil, despite the growing evidence supporting MCS in critically ill patients, access remains limited due to financial and systemic constraints. The review explores the current landscape of device availability in the country, national guidelines, cost-effectiveness data, and the impact of recent changes in transplant allocation criteria that prioritize patients receiving mechanical support. Notably, the approval of long-term VADs for destination therapy in the public health system in 2024 marks a significant milestone. This review offers a comprehensive perspective on MCS utilization, highlighting both global advances and Brazil-specific challenges. By identifying gaps in access and proposing future directions, it advocates for expanded use of these life-saving technologies to improve survival and quality of life in advanced heart failure patients.

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ABC

Original Article

Clinical and Microbiology Predictors for Therapeutic Failure in Sternal Surgical Site Infections – A Retrospective Cohort Study

Jaqueline Fabiano Palazzo et al. Diego Augusto Medeiros Santos Bruno Adler Maccagnan Pinheiro Besen Caio Sambo … Gabriel Fialkovitz da Costa Leite Samuel Terra Gallafrio Danielle Menosi Gualandro Lani Paola Bonilla Cuello Marcus Vinicius Barbosa Santos Tania Mara Varejão Strabelli Pablo Maria Alberto Pomerantzeff Fabio Biscegli Jatene Rinaldo Siciliano

Abstract

Background

Although sternal surgical site infections (SSI) are an important complication after cardiac surgeries, predictors of treatment failure are poorly studied.

Objectives

The aim of this study is to assess the clinical and microbiology predictors of a sternal SSI therapeutic failure.

Methods

Patients who presented a sternal SSI were retrospectively analyzed. Data regarding demographic characteristics, clinical findings, initial laboratory and radiologic findings and treatment of index sternal SSI were evaluated. Primary outcome was treatment failure, comprising infection relapse (clinical sternal SSI after complete treatment) or infection persistence (outpatient antimicrobial treatment failure). The microbiology was assessed at the index infection and in the outcome. P-values < 0.05 were considered statistically significant.

Results

Among 489 included patients, mean age was 58 years, 265 (55%) were female, 185 (38%) had diabetes mellitus. The overall prevalence of therapeutic failure was 14% (67), occurring in a median of 174 days (±41) after index cardiac surgery. Most frequent etiologies were cocci Gram-positive and Klebsiella pneumoniae. None of laboratory or thoracic tomographic findings presented during the index sternal SSI was related to outcome. After multivariate analysis, Staphylococcus aureus, carbapenem-resistant Gram-negative bacilli (GNB), fungi, diabetes mellitus and presence of mediastinitis/osteomyelitis were positive predictors of therapeutic failure.

Conclusions

Emerging carbapenem-resistant GNB, fungi and S. aureus were etiologies associated with higher risk of therapeutic failure in sternal SSI. DM and deep sternal wound infections were also contributing factors. Its clinical implications and the exact role of multi-resistant microorganism itself are subject for more studies.

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IJCS

Original Article

Mechanical Ventilation Time and Mortality After Coronary Artery Bypass Grafting: A Cohort Study

Tainá Lís de Araujo Dezidério et al. Vanessa Oliveira da Silva Vitória Novaes Macedo André Luiz Lisboa Cordeiro

Abstract

Introduction:

Cardiac surgery is a procedure that requires great assistance and care. In this way, patients are sent to the intensive care unit (ICU), where they are connected to mechanical ventilation (MV). Prolonged treatment of these patients worsens clinical outcomes and leads to mortality.

Objective:

To evaluate the impact of MV time on patients undergoing cardiac surgery.

Methods:

This is a retrospective cohort study. After surgery, patients were admitted to the ICU and connected to MV. The entire ventilation adjustment and weaning process was conducted according to the unit’s routine. They were divided into two groups, patients who continued on MV for more than eight hours and those who remained for less than eight hours. From this, univariate and multivariate analyses were carried out between predictor variables — MV time, age, sex, and cardiopulmonary bypass (CPB) time — and mortality. We considered p<0.05 as significant.

Results:

A total of 110 patients were evaluated, 25 stayed on MV for more than eight hours. In the univariate analysis, MV time was associated with mortality (HR 0.7 [0.3–0.9], p = 0.01), remaining in the multivariate analysis (HR 0.4 [0.2–0.6), p = 0.01). The other variables were not associated with death outcome.

Conclusion:

MV time of more than eight hours is a predictor of mortality after cardiac surgery, given the contribution of some risk factors.

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ABC

Editorial

The Role of 3D Printing in Cardiac Surgery for Congenital Heart Diseases

3D printing is revolutionizing various industries, enabling the creation of intricate, customized physical models by layering materials such as silicone or polymers based on digital designs. Among its diverse applications, healthcare has seen significant advancements with this technology.

In cardiology, the adoption of 3D modeling has lagged compared to other fields, primarily due to the challenge of depicting the heart’s complex, dynamic nature. This pattern mirrors the initial slow integration of computed tomography and magnetic resonance imaging into cardiac care — technologies that were first widely used in non-cardiac specialties before transforming cardiovascular diagnosis and management.^, Over the last decade, however, 3D printing has emerged as a transformative tool in cardiac surgery, enhancing visualization, preoperative planning, and patient outcomes.

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ABC

Original Article

The Systemic Immune-Inflammation Index Predicts In-Hospital Mortality in Patients Who Underwent On-Pump Cardiac Surgery

İnayet Güntürk et al. Rifat Ozmen Okan Ozocak Ertuğrul Emre Güntürk … Fatma Dagli Cevat Yazici

Abstract

Background:

Systemic immune-inflammation index (SII), a new inflammatory index calculated using platelet, neutrophil, and lymphocyte counts, has been demonstrated to be an independent risk factor for the identification of high-risk coronary artery disease in patients undergoing percutaneous coronary intervention and cardiovascular surgery with cardiopulmonary bypass (CPB). The relationship between SII and CPB-related mortality rates remains unclear.

Objective:

This research was designed to investigate the use of SII to predict in-hospital mortality in patients undergoing cardiac surgery with CPB.

Methods:

Four hundred eighty patients who underwent a cardiac procedure involving CPB over 3 years, were obtained from the hospital’s database. The demographic data, comorbidities, hematological and biochemical profiles, and operative data of the groups were compared. Multiple logistic regression analyses were done to determine independent predictors of mortality. Prognostic factors were assessed by multivariate analysis, and the predictive values of SII, neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR) for mortality were compared. A p-value <0.05 was considered significant.

Results:

Of 480 patients, 78 developed in-hospital mortality after cardiac surgery. SII was an independent predictor of in-hospital mortality (Odds ratio: 1.003, 95% confidence interval: 1.001-1.005, p811.93 with 65% sensitivity and 65% specificity (area under the curve: 0.690). The predictive values of SII, PLR, and NLR were close to each other.

Conclusion:

High preoperative SII scores can be used for early determination of appropriate treatments, which may improve surgical outcomes of cardiac surgery in the future.

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ABC

Original Article

Markers of Tissue Perfusion as Predictors of Adverse Outcomes in Patients with Left Ventricular Dysfunction Undergoing Coronary Artery Bypass Surgery

Thiana Yamaguti et al. José Otavio Costa Auler Junior Luís Alberto Oliveira Dallan Filomena Regina Barbosa Gomes Galas … Ligia Cristina Câmara Cunha Marilde de Albuquerque Piccioni

Abstract

Background:

Cardiac surgery patients may be exposed to tissue hypoperfusion and anaerobic metabolism.

Objective:

To verify whether the biomarkers of tissue hypoperfusion have predictive value for prolonged intensive care unit (ICU) stay in patients with left ventricular dysfunction who underwent coronary artery bypass surgery.

Methods:

After approval by the institution’s Ethics Committee and the signing of informed consent, 87 patients with left ventricular dysfunction (ejection fraction < 50%) undergoing coronary artery bypass surgery were enrolled. Hemodynamic and metabolic biomarkers were collected at five time points: after anesthesia, at the end of the surgery, at ICU admission, and at six and twelve hours after. An analysis of variance for repeated measures followed by a Bonferroni post hoc test was used for repeated, continuous variables (hemodynamic and metabolic variables) to determine differences between the two groups over the course of the study period. The level of statistical significance adopted was 5%.

Results:

Thirty-eight patients (43.7%) who presented adverse outcomes were older, higher Euro score (p<0.001), and elevated ΔpCO₂ as analyzed 12 hours after ICU admission (p<0.01), while increased arterial lactate concentration at 6 hours postoperatively was found to be a negative predictive factor (p<0.01).

Conclusions:

Euro SCORE, six-hour postoperative arterial lactate, 12-hour postoperative ΔPCO₂, and eRQ are independent predictors of adverse outcomes in patients with left ventricular dysfunction after cardiac surgery.

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ABC

Original Article

Relationship between Static Lung Compliance and Extubation Failure in Postoperative Cardiac Surgery Patients

Thais Bento Rudge Ramos et al. Luciana Castilho Figueiredo Luiz Claudio Martins Antonio Luis Eiras Falcão … Lígia dos Santos Roceto Ratti Orlando Petrucci Desanka Dragosavac

Abstract

Background:

Static lung compliance, which is seriously affected during surgery, can lead to respiratory failure and extubation failure, which is little explored in the decision to extubate after cardiac surgery.

Objective:

To evaluate static lung compliance in the postoperative period of cardiac surgery and relate its possible reduction to cases of extubation failure in patients submitted to the fast-track method of extubation.

Methods:

Patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) at a state university hospital admitted to the ICU under sedation and residual block were included. Their static lung compliance was assessed on the mechanical ventilator using software that uses least squares fitting (LSF) for measurement. Within 48 hours of extubation, the patients were observed for the need for reintubation due to respiratory failure. The level of significance adopted for the statistical tests was 5%, i.e., p<0.05.

Results:

77 patients (75.49%) achieved successful extubation and 25 (24.51%) failed extubation. Patients who failed extubation had lower static lung compliance compared to those who succeeded (p<0.001). We identified the cut-off point for compliance through analysis of the Receiver Operating Characteristic Curve (ROC), with the cut-off point being compliance <41ml/cmH2O associated with a higher probability of extubation failure (p<0.001). In the multiple regression analysis, the influence of lung compliance (divided by the ROC curve cut-off point) was found to be 9.1 times greater for patients with compliance <41ml/cmH2O (p< 0.003).

Conclusions:

Static lung compliance <41ml/cmH2O is a factor that compromises the success of extubation in the postoperative period of cardiac surgery.

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ABCIC

Case Report

Left Ventricular Aneurysm With Contained Rupture

Priscila Nasser de Carvalho et al. Mariane Higa Shinzato Roberto Tadeu Magro Kroll Andrea Cunha Cortellazzi Aloysio Abdo Silva Campos

Introduction

Left ventricular aneurysms (LVA) and left ventricular pseudoaneurysms (LVPA) are serious complications resulting from transmural myocardial infarction. Their incidence has decreased considerably with the advancements of interventional cardiology, using early revascularization of the compromised coronary artery, preventing ventricular remodeling. Differential diagnosis is often not easy; however, it must be made early.

An LVA occurs months or years after acute myocardial infarction. It is formed by an area of scar tissue and contains the three layers of the ventricular wall (endocardium, myocardium, and pericardium). Its wall is preserved and may contain thrombi. An LVPA is a rare complication that can occur days or months after the infarction. It is formed by the weakened wall that ruptures after the infarction, in a way that this rupture is contained by the pericardium, resulting in discontinuity of the endocardial border. Usually, an LVA is located in the apical and anterior regions, while an LVPA is located in the posterolateral region of the left ventricle.

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ABCIC

Review Article

Three-Dimensional Model Printing in Congenital Heart Disease

Milton Benevides Freitas et al. Jose Luiz Figueiredo Francisco Candido Cajueiro Rafaela Melo Lima … Marcio Handerson Freitas Cristiane Maria Teixeira

Abstract

Introduction:

Three-dimensional (3D) printing refers to a set of methods used to create solid 3D objects, based on digital files. The use of 3D models can improve understanding and knowledge about congenital heart diseases. Their usefulness has been demonstrated in preoperative planning, simulation of interventional procedures, and in surgical decision-making. The objective of this study is to offer a review of the literature on the various rapid prototyping methods and their applicability in medical practice, especially in congenital heart diseases.

Methods:

This is a literature review study. Data for discussion were collected by consulting the following electronic database: LILACS, MEDLINE, SCOPUS, and the Scientific Electronic Library Online.

Results:

During the period evaluated by the study, a total of 480 articles were published addressing the topic of 3D printing (TDP) for heart disease, with 196 articles related to TDP for congenital heart disease. Of these, 22 were included in this study.

Conclusion:

TDP is a technology that is still under construction. It has the potential to assist physicians and surgical teams in therapeutic decision-making, to promote learning for students in specialization and postgraduate studies, to contribute to surgical skills training, and to clarify information for family members.

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ABCIC

Review Article

Using Three-Dimensional Printing in Surgical Mitral Valve Repairs

Rodrigo Bahiense Visconti et al. Luciano Herman Juaçaba Belem Antonio Carlos Dos Santos Nogueira Maria Claudia Lembo Cornélio Luis Henrique Weitzel

Abstract

Mitral regurgitation is an important cause of morbidity and mortality, and surgical mitral valve repair continues to be the treatment of choice when feasible. We use three-dimensional echocardiography associated with three-dimensional printing to create surgical models that allow trainees to practice or improve surgical techniques in order to improve the outcomes of surgical repairs, contributing to more advanced medical training.

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ABC

Research Letter

Impact of the First Wave of the COVID-19 Pandemic on Cardiovascular Surgery in Brazil: Analysis of a Tertiary Reference Center

Luiz Augusto Lisboa et al. Omar Asdrúbal Vilca Mejia Elisandra Trevisan Arita Gustavo Pampolha Guerreiro … Lucas Molinari Veloso da Silveira Carlos Manuel de Almeida Brandão Ricardo Ribeiro Dias Luís Roberto Palma Dallan Leonardo Miana Luiz F. Caneo Marcelo Biscegli Jatene Luís Alberto Oliveira Dallan Fabio Biscegli Jatene

Introduction

The novel viral respiratory infection caused by coronavirus disease 2019 (COVID-19), initially known as 2019-nCoV, emerged in late December 2019 in Wuhan, China and quickly spread throughout Asia, Europe, and USA, characterizing the situation as a pandemic. In May 2020, the World Health Organization declared Brazil a new epicenter of the coronavirus pandemic.

With the alarming levels of spread and severity of COVID-19, major disruptions in routine hospital services have occurred, as hospitals adjust in order to increase the capacity to care for patients with SARS-CoV-2. In this context, elective surgeries were postponed in order to optimize health resources and staffing issues and to protect patients from in-hospital viral transmission.

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ABCIC

Case Report

Atypical Presentation of Ventricular Septal Defect Following Myocardial Infarction

Eduardo Cavalcanti Lapa Santos et al. Sandro Gonçalves Lima Brivaldo Markman Filho Andréa Bezerra de Melo da Silveira Lordsleem … George Augusto da Fonseca Carvalho Antunes Lima Priscila Costa dos Santos Moreira

[…]

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ABC

Research Letter

Infective Endocarditis in the Elderly: Distinct Characteristics

Luiz Henrique Braga Lemos et al. Leonardo Ribeiro da Silva Marcelo Goulart Correa Wilma Golebiovski … Clara Weksler Rafael Quaresma Garrido Giovanna Ferraiuoli Barbosa Cristiane da Cruz Lamas

Introduction

Infectious endocarditis (IE) is a serious disease with a mean in-hospital mortality of 20%.^– It has shown an increasing incidence, and the rise in its prevalence among the elderly population deserves to be highlighted.^– In elderly patients with IE, there are differences regarding the clinical presentation, complications, presence of comorbidities, therapeutic approach and mortality.^{, –} IE guidelines do not specifically address the elderly population and it is not clear to what extent they can be appropriately used in these patients.^{, ,} The elderly population has clearly benefited from medical progress, with diagnostic-therapeutic techniques that influence the increase in life expectancy and less invasive procedures. One example is the transcatheter aortic valve implantation in the management of aortic valve diseases. However, these procedures, together with the increasing implantation of cardiovascular electronic devices (CED) contribute to infections such as IE. Comorbidities are found in more than half of the elderly, with the consequent need for long-term care from health professionals, which increases the probability of acquiring IE.^, The diagnosis of IE in the elderly is often delayed or forgotten. Manifestations may be nonspecific, attributed to aging and other conditions. Fever may be absent, with the presence of mental confusion only. IE can present with complications similar to those of other conditions, such as heart failure (HF), cerebrovascular accident (CVA) or systemic embolism attributable to atrial fibrillation.^, In Brazil, despite a growing elderly population, to date there is no published article about IE in this group. The aim of our study was to describe the elderly group in our adult IE cohort and compare them with non-elderly individuals, highlighting the differences between the groups.

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IJCS

Editorial

Lower Rate of Blood Transfusion after Heart Surgery in a Tertiary Hospital

Leonardo Secchin Canale

Special interest in surgical bleeding and methods to limit its occurrence is growing after the possibility that transfusion of blood products might be causally related to complications and negative outcomes has been raised. In the same vein, studies have been conducted to evaluate whether limiting blood product transfusions (ie, being more conservative in the indication for it) would increase the safety of transfusion or even reduce some patterns of complications. The current study is a contribution to this larger discussion.

Moraes et al. report the experience of a large tertiary center in bleeding patterns after heart operations. Four hundred and twenty-three patients (51% coronary artery bypass surgery and 33% valve operations) were evaluated for total bleeding and for the use of blood products. Perioperative bleeding was measured by weighing sponges, a validated method for a difficult enterprise. Postoperative bleeding was determined by the total chest tube output in the first 24 h after the end of the operation.

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IJCS

Editorial

Surgical Mortality in Infective Endocarditis: Is There a Gender Paradox?

Daniel Seabra et al. Cristina Gavina

Cardiovascular diseases (CVD) represent a global pandemic. Although mortality due to CVD has been decreasing with improvement in diagnosis and treatment, it remains the most frequent cause of death worldwide both in men and women.

Gender impacts several key aspects in CVD, such as epidemiology, pathophysiology, clinical manifestations, disease progression, response to treatment and prognosis, in areas like coronary artery disease and heart failure. However, few studies analyzed the influence of gender in infectious endocarditis (IE) management and outcomes.^,

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IJCS

Original Article

Women Undergoing Mitral Valve Replacement: A Retrospective Analysis

Júlia Lasserre Moreira et al. Pedro Henrique Andrade Araújo Salvatore Barletta José Augusto Baucia

Abstract

Background

Although cardiovascular disease is the leading cause of death in women, few data exist on risk factors and treatment of these diseases in women. This leads to a delay in the institution of appropriate therapies and worse outcomes in this population.

Objective

We aimed to identify predictors of morbidity and mortality in women undergoing isolated mitral valve replacement.

Methods

This was a retrospective cohort study with 104 women who underwent isolated mitral valve replacement at a referral hospital for treatment of cardiovascular diseases, performed from January 2011 to December 2016. Data were obtained from medical records. Statistical analysis was performed to calculate odds ratio, unpaired Student’s t-test, and binary logistic regression. P values <0.05 were considered statistically significant.

Results

Mean age of patients was 43.73 (±13.85) years. Most patients had a diagnosis of rheumatic disease prior to surgery (76%; N=79). Mortality rate was 4.9% (N = 5). There was a statistically higher risk of death among patients with reduced ejection fraction (EF) (<50%) (OR = 14.833, 95% CI 2.183 – 100.778, P=0.001) and older age (P = 0.009). There was an inverse association between a previous diagnosis of rheumatic disease and death (OR = 0.064, 95% CI 0.007 – 0.606, P=0.002). Logistic regression showed reduced EF at preoperative evaluation as a predictor of death and a diagnosis of rheumatic disease as a protective factor.

Conclusion

Older age and reduced EF were associated with postoperative mortality. Reduced EF was a predictor of death, and rheumatic disease was associated with better surgical outcomes.

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ABC

Original Article

Heyde’s Syndrome: Therapeutic Strategies and Long-Term Follow-Up

Vitor Emer Egypto Rosa et al. Henrique Barbosa Ribeiro João Ricardo Cordeiro Fernandes Antonio de Santis … Guilherme Sobreira Spina Milena Ribeiro Paixão Lucas José Tachotti Pires Marcelo Bettega Tarso Augusto Duenhas Accorsi Roney Orismar Sampaio Flávio Tarasoutchi

Abstract

Background

Heyde’s syndrome is the association of severe aortic stenosis with episodes of gastrointestinal bleeding due to angiodysplastic lesion. Little is known about the factors associated with new episodes of bleeding and long-term outcomes. Furthermore, most data are restricted to case reports and small case series.

Objective

To assess the clinical, laboratory and echocardiography profile of patients with Heyde’s syndrome who underwent valve intervention or drug therapy.

Methods

Prospective cohort of 24 consecutive patients from 2005 to 2018. Clinical, laboratory and echocardiography data were assessed, as well as those related to valve intervention and outcomes after diagnosis. A P <0.05 was used to indicate statistical significance.

Results

Half of the 24 patients presented with bleeding requiring blood transfusion on admission. Angiodysplasias were more frequently found in the ascending colon (62%). Valve intervention (surgical or transcatheter) was performed in 70.8% of the patients, and 29.2% remained on drug therapy. News episodes of bleeding occurred in 25% of the cases, and there was no difference between clinical and intervention groups (28.6 vs 23.5%, p = 1.00; respectively). Mortality at 2-year and 5-year was 16% and 25%, with no difference between the groups (log-rank p = 0.185 and 0.737, respectively).

Conclusions

Patients with Heyde’s syndrome had a high rate of bleeding requiring blood transfusion on admission, suggesting that it is a severe disease with high mortality risk. No difference was found between clinical and intervention group regarding the rate of rebleeding and late mortality.

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IJCS

Editorial

Prolonged Ventilation after CABG: an Important Issue

Leonardo Secchin Canale

Coronary artery bypass surgery (CABG) is the most commonly performed heart operation in most countries, and its mortality and morbidity results are one of the most studied and scrutinized in the world. As a large operation involving long surgical times, sternotomy and cardiopulmonary bypass, long-term postoperative ventilation is a dreaded possible complication. Failure to wean from the ventilator can result both as a consequence of previous risk factors and as a cause of future morbidity and mortality. Not only it impacts patients’ well-being and recovery times, but also can lead to further complications such as lung infections, sepsis, loss of general muscle function and need for tracheostomy.

Therefore, the current study of Dallazen-Sartori et al. is a timely and useful attempt to better characterize the incidence and risk factors for the development of prolonged ventilation (PV) after CABG. As previous authors did before, the authors focus on preoperative and per-operative factors to try to expose, by multiple logistic regressions, which ones are causally associated to PV in order to construct a practical Risk Score. It is needless to stress the importance of such a study in our Brazilian population, which might behave differently from well-known previous reports from other countries. Unfortunately, we still face a paucity of local and regional studies that would better represent our own results, outcomes and challenges. The situation when we need to base our decisions in external sources of data instead of using the national one happens very often. The current study by Dallazen-Sartori et al, is an attempt to change that.

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IJCS

Original Article

Risk Score for Prolonged Mechanical Ventilation in Coronary Artery Bypass Grafting

Fernanda Dallazen-Sartori et al. Luciano Cabral Albuquerque João Carlos Vieira da Costa Guaragna Ellen Hettwer Magedanz … João Batista Petracco Rodrigo Bodanese Mario Bernardes Wagner Luiz Carlos Bodanese

Abstract

Background

Prolonged mechanical ventilation (MV) after cardiac surgery imposes a significant burden on the patient in terms of morbidity and financial hospital costs.

Objective

To develop a risk score model to predict prolonged MV in patients undergoing coronary artery bypass grafting (CABG) surgery.

Methods

This was a historical cohort study of 4165 adult patients undergoing CABG between January 1996 and December 2016. MV for periods ≥ 12 hours was considered prolonged. Logistic regression was used to examine the relationship between risk predictors and prolonged MV. The variables were scored according to the odds ratio. To build the risk score, the database was randomly divided into 2 parts: development data set (2/3) with 2746 patients and internal validation data set (1/3) with 1419 patients. The final score was validated in the total database and the model’s accuracy was tested by performance statistics. Significance was established at p < 0.05.

Results

Prolonged MV was observed in 783 (18.8%) patients. Predictors of risk were age ≥ 65 years, urgent/emergency surgery, body mass index ≥ 30 kg/m², chronic kidney disease, chronic obstructive pulmonary disease, and cardiopulmonary bypass time ≥ 120 minutes. The area under the ROC curve was 0.66 (95% CI, 0.64-0.68; p<0.001), the Hosmer-Lemeshow chi-square test was χ²: 3.38 (p=0.642), and Pearson’s correlation was r = 0.99 (p<0.001), indicating the model’s satisfactory ability to predict the occurrence of prolonged MV.

Conclusion

Selected variables allowed the construction of a simplified risk score for daily practice, which may classify the patients as having low, moderate, high, and very high risk. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

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Editorial

Myocardial Protection in Cardiac Surgery – What is the Ideal Method?

Ahmad Ali Abdouni

The study of myocardial protection has improved together with cardiac surgery, aiming to prevent intraoperative myocardial injury, which can lead to ventricular dysfunction, arrhythmias, low cardiac output and other complications, often irreversible ones.

Since the first cardiac surgeries with cardiopulmonary bypass (CPB) in 1953 performed by Dr. Gibbon at Massachusetts General Hospital, several methods of myocardial protection have been studied, allowing more extensive cardiac surgeries to be performed, with longer aortic clamping time. In the first surgeries, hypothermia was the method used for myocardial protection, but it showed to be insufficient for longer periods of ischemia.

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IJCS

Editorial

Neuromuscular Electrical Stimulation: A Promising Modality of Exercise Training in Cardiovascular Rehabilitation Phase I?

Sergio Chermont et al. Mônica Quintão

There are currently few indications for the use of neuromuscular electrical stimulation (NMES) in cardiac patients that are based on systematic reviews or even meta-analyses from the perspective of evidence-based practice. Therefore, the therapeutic potential of NMES is probably still poorly explored. Previous studies have shown benefits of NMES in patients with stable chronic heart failure (CHF). However, we wonder whether the application of this technique in cardiac patients has been extensively explored. We are certainly dealing with a new therapeutic possibility so far rarely recommended and employed in patients with cardiovascular diseases, especially in intrahospital cardiovascular rehabilitation. In this scenario, what could be added to the current knowledge and its main indications?

In the absence of well-defined protocols, feasibility and safety studies may be considered as a starting point for further studies and for paving the way clinical trials and to determine whether or not the conduct is favorable for a patient`s specific clinical condition. So, what would be the role of NMES in heart surgery?

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IJCS

Original Article

Neuromuscular Electrical Stimulation on Hemodynamic and Respiratory Response in Patients Submitted to Cardiac Surgery: Pilot Randomized Clinical Trial

Telma Cristina Fontes Cerqueira et al. Manoel Luiz de Cerqueira Neto Auristela Julia Guilhermino Carvalho Géssica Uruga Oliveira … Amaro Afrânio de Araújo Filho Vitor Oliveira Carvalho Lucas de Assis Pereira Cacau Walderi Monteiro da Silva Júnior José Teles de Mendonça Valter Joviniano de Santana Filho

Abstract

Background:

Neuromuscular electrical stimulation seems to be a promising option to intensify the rehabilitation and improve the exercise capacity of patients in the immediate postoperative period of cardiac surgery.

Objective:

This study aimed to evaluate the hemodynamic (heart rate, systolic blood pressure, diastolic blood pressure, and mean blood pressure) and respiratory (respiratory rate and oxygen saturation) responses to neuromuscular electrical stimulation in the immediate postoperative period in patients submitted to cardiac surgery and to verify its feasibility and safety.

Methods:

This is a pilot randomized controlled trial, wherein critical patients in the immediate postoperative period of cardiac surgery were randomly assigned to a control group, using sham neuromuscular electrical stimulation, or an experimental group, submitted to neuromuscular electrical stimulation sessions (FES), for 60 min, with a 50-Hz frequency, 200-µs pulse duration, time on: 3 s, and time off: 9 s. Data distribution was evaluated by the Shapiro-Wilk test. The analysis of variance was used and a p-value < 0.05 was considered significant.

Results:

Thirty patients were included in the study. The neuromuscular electrical stimulation was applied within the first 23.13 ± 5.24 h after cardiac surgery, and no changes were found regarding the hemodynamic and respiratory variables between the patients who underwent neuromuscular electrical stimulation, and those in the control group.

Conclusions:

In the present study, neuromuscular electrical stimulation did not promote changes in hemodynamic and respiratory responses of patients in the immediate postoperative period of cardiac surgery.

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