Repositório RCAAP

Abstract Cardiac arrhythmias and requirement for permanent pacemaker (PPM) post open-heart surgery are some of the complications that can contribute to significant morbidities postoperatively and delay in normal recovery if not treated promptly. The reported rate of a PPM following isolated, elective coronary artery bypass grafting is < 1%, while following aortic or mitral valve surgery it is reported to be < 5%. There are several perioperative factors that can contribute to the increased likelihood of PPM requirement including preoperative rhythm, severity and location of cardiac ischaemia, perioperative variables, and the cardiac procedures performed. Optimization of such factors can possibly lead to a lower rate of PPM and, therefore, a lower rate of complications. This literature review focuses on PPM following each procedural type and how to minimize it.

Abstract The importance of the vasa vasorum and blood supply to the wall of human saphenous vein (hSV) used for coronary artery bypass grafting (CABG) is briefly discussed. This is in the context of the possible physical link of the vasa vasorum connecting with the lumen of hSV and the anti-ischaemic impact of this microvessel network in the hSV used for CABG.

Abstract A 71 year-old male with a history of multiple excisions of an initial Clark's level V melanoma of the breast followed by combined radiation and interferon treatment, as well as a recurrence, 3 years later, of a BRAF-positive tumor of the shoulder, with subsequent therapy with dabrafenib and trametinib, presented again with progressive intracardiac masses causing significant right ventricular outflow obstruction. Additionally, the patient complained of dyspnea and fatigue on exertion, thus he was scheduled for surgical resection.

Abstract Minimally invasive aortic valve replacement has gained consent due to its good results in terms of minimized surgical trauma, faster rehabilitation, pain control and patient compliance. In our experience, we have tried to replicate the conventional and gold standard approach through a smaller incision. Sparing the right internal thoracic artery, avoiding rib fractures and performing total central cannulation is important to make this procedure minimally invasive from a biological point of view too. In addition, the total central cannulation is pivotal to simplify perfusion and drainage. Moreover, a complete step-by-step procedure optimization and-when possible-the use of sutureless prosthesis help to reduce the cross-clamping and perfusion times. After more than 1000 right anterior thoracotomy (RAT) aortic valve replacements, we have found tips and tricks to make our technique more effective.

Abstract Although aortic valve replacement remains the gold standard treatment for aortic valve diseases like stenosis (AS) or insufficiency, new surgical methods have been developed with a focus in the reconstruction of the aortic valve rather than replacing it. The Ozaki procedure involves a tailored replacement of each individual valvular leaflet with glutaraldehyde-treated autologous pericardium and aims to reproduce the normal anatomy of the aortic valve. Cases of patients with unicuspid aortic valve treated with the Ozaki procedure are uncommon in the litrature and become even more rare when it comes to concomitant diseases like AS and ascending aorta aneurysm. We present the case of a 21-year-old, fit and asymptomatic male, with unicuspid aortic valve with severe stenosis and ascending aorta dilatation, surgically treated with tricuspidization of the aortic valve with glutaraldehyde-treated autologous pericardium and replacement of the ascending aorta with a straight synthetic graft. Postoperative studies showed a fully functional, neo-tailored tricuspid aortic valve with trivial regurgitation. The patient had an uncomplicated recovery, stayed in the intensive care unit for 2 days and was discharged on the 7th postoperative day.

Abstract Aortic valve endocarditis can lead to secondary involvement of aorto-mitral curtain and the adjacent anterior mitral leaflet (AML). The secondary damage to AML is often caused by the infected jet of aortic regurgitation hitting the ventricular surface of the mitral leaflet, or by the pronounced bacterial vegetation that prolapses from the aortic valve into the left ventricular outflow tract. This is called ‘kissing lesion’. We describe a patient with infective endocarditis of the aortic valve causing perforation of both noncoronary cusp of aortic valve and the AML, which is rare.

Abstract Infantile scimitar syndrome (SS) is a rare congenital heart disease and has high mortality. Guidelines have not been established, but surgery is indicated in symptomatic patients. Despite the various surgical approaches, outcomes continue to be disappointing. We present our surgical experience with an infantile SS patient who had stenotic pulmonary veins contralateral to the hypoplastic lung with complicated anatomy. There are few cases with this complex pathology in the literature. Moreover, our patient was the first transplant-free survivor with this complexity in the literature.

Abstract Infective endocarditis is a rather uncommon disease, but it has significant mortality rates in the pediatric population (5% to 10%). We report a case of an infant patient with multiple vegetation in the tricuspid valve secondary to infective endocarditis caused by Corynebacterium diphtheriae. A tricuspid valvuloplasty was performed with a fenestrated autologous pericardium patch, providing satisfactory outcomes. This technique is simple, innovative, effective, and it could be applied in similar cases.

Abstract Introduction: The coronavirus disease 2019 (COVID-19) pandemic brought an unprecedented lack of control of what was to come. The intent of this document is to provide a balance of how much was ceased to be done for patients with aortic disease, to assess the mortality of these patients, and to show what happened to those who became COVID-19 positive during their hospitalization. Methods: From April 1st to July 31st 2020, the worst period of the pandemic in São Paulo, Brazil, the Institute’s aortic surgical patients operated on were evaluated and those were compared with patients operated during the same period in 2019. Results: In 2019, 88 surgeries were performed; most of them were elective (66 [75%]), 10 were urgent, and 12 were emergency surgeries. In 2020, during the COVID-19 pandemic, we operated on only 31 patients, being 74.2% non-elective surgeries (P<0,001). There was a higher mortality for patients operated on during the pandemic surge of COVID-19 (P<0,001), but it was not specifically related to infected patients. Conclusion: The COVID-19 pandemic had an impact on surgical volume and outcome of patients with aortic disease, although it did not directly increase mortality.

Abstract Introduction: Aortic diseases are among the most serious cardiovascular diseases; the overall mortality rate due to diseases such as aneurysms and aortic dissections has been estimated at 2.78 per 100,000 persons in 2010, with a higher mortality rate in men than women. Our objective was to evaluate the epidemiological profile of patients with acute type A aortic dissection at a cardiology referral center. Methods: A retrospective cross-sectional study was performed at a public cardiac center with 24 patients hospitalized from 1/1/2016 to 12/31/2017 with a confirmed diagnosis of acute type A aortic dissection. Results: Twenty (83.3%) out of 24 patients underwent surgery and four (16.7%) did not undergo surgery. Among those who underwent surgery, 10 (50%) died and 10 (50%) were discharged, and all non-operated patients died (P=0.114) (Fisher's exact test). The male gender predominated (n=19, 79.2%), 86.7% (n=13) of the patients presented body mass index > 25 kg/m2, chest pain was found in 91.7% (n=22), and renal failure was present in 45.8% (n=11) of the cases. Hypertension predominated in 91.7% (n=22) and the main exam was aortic angiotomography in 79.2% (n=19) of the cases. Conclusion: The study presented a small sample size, making it impossible to associate the factors, although the service was considered a high-volume referral center. It is possible that the delay in arriving at the service and the accomplishment of invasive imaging with the use of contrast agents have aggravated the patients’ condition and have been decisive for the increase in lethality, which requires further studies.

Abstract Objective: Del Nido cardioplegia (DNC) has been used in pediatric cardiac surgery for many years with a single dose application and its usage in adult cardiac surgery has been increasing in recent years, with results being published. In this study, we aimed to investigate the effect of DNC on the development of postoperative atrial fibrillation (PoAF). Methods: In this retrospective observational comparative study, 255 patients who underwent isolated on-pump coronary artery bypass grafting, between January 2019 and November 2019, were enrolled. The patients were divided into two groups: DNC (n=132) and blood cardioplegia (BC) (n=123). Intraoperative and postoperative data were evaluated and compared in terms of the development of PoAF. Results: We found that the development of PoAF and the length of hospital stay remain significantly higher in the BC group (P=0.044, P<0.001, respectively). In addition, the aortic cross-clamp time and the cardioplegia volume delivered were significantly lower in the DNC group (P=0.042, P<0.001, respectively). In multivariate logistic regression analysis, only higher cardioplegia volume was determined as an independent predictor for PoAF development (OR 1.001; 95% CI 1.000-1.001; P=0.033). We did not found difference between groups in terms of troponin T, inotropic drug support, need for intraaortic balloon pump and mortality. Conclusion: This study showed that DNC can be used safely in adult coronary bypass surgery and PoAF development effect is reduced.

Abstract Introduction: Anemia and blood transfusion are risk factors for morbidity/mortality in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The objective of this study is to analyze the association of blood transfusion with morbidity/mortality in patients undergoing coronary artery bypass grafting (CABG) under CPB in the state of São Paulo, Brazil. Methods: This is a retrospective analysis using the State of São Paulo Registry of Cardiovascular Surgery from November 2013 to August 2014. Blood transfusion was only considered during surgery or within six hours after surgery. Anemia was defined as hematocrit ≤ 37.5%. Patients < 18 years old were excluded. The sample was divided in four groups - Group I (851, no anemia), Group II (200, anemia without blood transfusion), Group III (181, no anemia and transfusion), and Group IV (258, anemia and transfusion). Results: A total of 1,490 patients were included; 639 (42.9%) were anemic and 439 (29.5%) underwent blood transfusion. Group II showed lower composite morbidity (odds ratio [OR] −0.05; confidence interval [CI] −0.27-0.17; P=0.81) than Group III (OR 0.41; CI 0.23-0.59; P=0.018) or Group IV (OR 0.54; CI 0.31-0.77; P=0.016). Group III was at greater risk of mortality (OR 0.73; CI 0.43-1.03; P=0.02) than Group II, which was exposed only to anemia (OR −0.13; CI −0.55-0.29; P=0.75), or Group IV (OR 0.29; CI −0.13-0.71; P=0.539). Conclusion: Anemia in patients undergoing CABG with CPB is bad, but blood transfusion can be worse, increasing at least 50% the risk for mortality and/or morbidity.

Abstract Introduction: We aimed to present the risk factors, clinical and laboratory findings, treatment management, and risk factors for morbidity and mortality of infective endocarditis (IE) as well as to relate experiences at our center. Method: We retrospectively analyzed data of 47 episodes in 45 patients diagnosed with definite/possible IE according to the modified Duke criteria between May 2000 and March 2018. Results: The mean age of all patients at the time of diagnosis was 7.6±4.7 years (range: 2.4 months to 16 years). The most common symptoms and findings were fever (89.3%), leukocytosis (80.8%), splenomegaly (70.2%), and a new heart murmur or changing of pre-existing murmur (68%). Streptococcus viridans (19.1%), Staphylococcus aureus (14.8%), and coagulase-negative Staphylococci (10.6%) were the most commonly isolated agents. IE-related complications developed in 27.6% of the patients and the mortality rate was 14.8%. Conclusion: We found that congenital heart disease remains a significant risk factor for IE. The highest risk groups included operated patients who had conduits in the pulmonary position and unoperated patients with a large ventricular septal defect. Surgical intervention was required in most of the patients. Mortality rate was high, especially in patients infected with S. aureus, although the time between the onset of the first symptom and diagnosis was short. Patients with fever and a high risk of IE should be carefully examined for IE, and evaluation in favor of IE until proven otherwise will be more accurate. In high-risk patients with prolonged fever, IE should be considered in the differential diagnosis.

Abstract Introduction: We aimed to identify predictors of morbidity and mortality in patients undergoing isolated mitral valve replacement. Methods: This is a retrospective cohort study with 164 patients who underwent isolated mitral valve replacement at a referral hospital for cardiovascular diseases, which were performed from January 2011 to December 2016. Data were obtained from medical records, including preoperative, intraoperative, and postoperative information. Statistical analysis was performed to calculate odds ratio (OR), unpaired Student's t-test, and binary logistic regression. P-values < 0.05 were considered significant. Results: A total of 69.5% (n=114) of the patients had a diagnosis of rheumatic disease prior to surgery. Mortality rate was 6.7% (n=11). The most observed complication was the occurrence of postoperative arrhythmias (19.5%). On average, patients remained 5.34 days in the intensive care unit. There was a statistically significant enhanced risk of death among patients with previous diagnosis of endocarditis (OR 5.22, 95% confidence interval [CI] 1,368-19,915; P=0.008), reduced ejection fraction (EF) (< 50%) (OR 9.46, 95% CI 2,61-34,35; P<0.001), and mitral regurgitation (MR) (OR 7.7, 95% CI 1.576-37.545; P=0.004). Patients who died were older than those who survived surgery (P<0.001) and had lower preoperative serum hemoglobin levels (P=0.018). Logistic regression showed age and reduced EF at preoperative evaluation as predictors of death. Conclusion: Older age, reduced serum hemoglobin levels, preoperative diagnosis of endocarditis, reduced EF, and MR were associated with postoperative mortality. Age and reduced EF were predictors of death.

Abstract Introduction: Valve-reimplantation and remodelling techniques used in aortic reconstruction provide successful early, mid, and long-term results. We present our early and late-term experience with 110 patients with aortic regurgitation (AR) who underwent aortic valve repair (AVr) or valve-sparing aortic root surgeries (VSARS) due to aortic dissection or aortic aneurysm. Methods: Nine hundred eighty-two patients who underwent aneurysm or dissection surgery and aortic valve surgery between April 1997 and January 2017 were analysed using the patient database. A total of 110 patients with AR who underwent AVr or VSARS due to aortic dissection or aortic aneurysm were included in the study. Results: In the postoperative period, a decrease was observed in AR compared to the preoperative period (P<0.001); there was an increase in postoperative ejection fraction (EF) compared to the preoperative values (P<0.005) and a significant decrease in postoperative left ventricle diameters compared to the preoperative values (P<0.001). Kaplan-Meier analysis revealed one, two, four, and five-year freedom from moderate-severe AR as 95%, 91%, 87%, and 70%, respectively. Freedom from reoperation in one, two, and five years were 97.9%, 93.6%, and 81%, respectively. Eight patients (7.4%) underwent AVr during follow-up. Out of the remaining 100 patients, 13 (12%) had minimum AR, 52 (48%) had 1st-2nd degree AR, and 35 (32%) had 2nd-3rd degree AR during follow-up. Conclusion: For the purpose of maintaining the native valve tissue, preserving the EF and the left ventricular end-diastolic diameter, valve-sparing surgeries should be preferred for appropriate patients.

Abstract Introduction: Heart preservation benefits cardiac performance after operations decreasing morbidity but the contribution of the vascular reactivity has been neglected. Objective: We evaluated whether cardioprotective solutions, Krebs-Henseleit (KH), Bretschneider-HTK (BHTK), St. Thomas No. 1 (STH-1), and Celsior (CEL), affect vascular reactivity. Methods: Aortic rings from Wistar rats were used in two protocols. First, the rings were exposed to BHTK, STH-1 or CEL for 1 hour of hypoxia at 37 °C. Second, the rings were exposed to 10 °C or 20 °C for 1 hour under hypoxia. After treatment, the rings were immersed in KH at 37 °C, endothelial integrity was tested and concentration-response curves to phenylephrine were performed. Results: In the first protocol, the solutions did not damage the endothelium; CEL and BHTK reduced KCl-induced contractions but not STH-1; only CEL and BHTK reduced vascular reactivity; there was a positive correlation between Rmax and KCl concentration. At 20 °C, 1 hour under hypoxia, the solutions produced similar KCl-induced contractions without endothelial damage. CEL, BHTK and STH-1 decreased vascular reactivity. At 10 °C, STH-1 increased reactivity but CEL and BHTK decreased. After 1 hour under hypoxia in CEL or BHTK solutions, reactivity was similar at different temperatures. At 20 °C, endothelial damage after exposure to STH-1 produced more vasoconstriction than CEL and BHTK. However, at 10 °C, endothelial damage after CEL and BHTK exposure elicited more vasoconstriction while STH-1 showed a small vasoconstrictor response, suggesting endothelial damage. Conclusion: STH-1 decreased reactivity at 20 °C and increased at 10 °C. CEL promoted greater endothelial modulation at 10 °C than at 20 °C, while STH-1 promoted higher modulation at 20 °C than at 10 °C. Vascular tone was reduced by CEL and BHTK exposure, also depending on the KCl concentration.

Abstract Introduction: The thoracoscopic procedure for tricuspid valve (TV) diseases is a minimally invasive method of treatment. This study focuses on comparing the changes in postoperative inflammatory reaction and myocardial injury markers after thoracoscopic and sternotomy/thoracotomy TV procedures. Methods: We retrospectively analyzed 88 patients (53 males, aged 50.9±16.2 years) with TV diseases (single-valve disease) (72 cases of TV plasty) between January 2018 and April 2019. A total of 56 patients underwent thoracoscopic procedure (50 cases of TV plasty). The leukocyte and C-reactive protein (CRP) levels were monitored as indicators of systemic inflammatory reaction. The lactate dehydrogenase, creatine kinase, creatine kinase myocardial band, aspartate aminotransferase, and troponin-T levels were recorded as markers of myocardial injury. Results: The CRP and white blood cells levels of patients in the sternotomy approach group were continuously higher than those in patients in the thoracoscopic approach group. And the levels of myocardial enzymes in patients in the thoracoscopic approach group were significantly lower than those in patients in the sternotomy approach group. Conclusion: Compared with sternotomy/thoracotomy procedures on TV, the thoracoscopic procedure can reduce postoperative myocardial injury significantly and systemic inflammatory reaction to a certain extent. It is technically feasible, safe, effective, and worthy of widespread adoption in clinical practice.

Abstract Objective: To determine the possible risk factors associated with hepatic dysfunction during open-heart surgeries. Methods: After excluding 71 patients, 307 patients with possible low and moderate cardiac risk who underwent either coronary artery bypass graft surgery (CABG) (n=176) or valve repair surgery (mitral valve, mitral and aortic valves and/or tricuspid valve) (n=131) were investigated prospectively during a 6-month period. Hyperbilirubinemia is defined as an occurrence of a plasma total bilirubin concentration >34 µmol/L (2 mg/dL) in any measurement during the postoperative period; the patients were divided into groups with or without postoperative hyperbilirubinemia. The collected parameters were: alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), total bilirubin (TBil), gamma-glutamyl transpeptidase (GGT) and albumin. The parameters were collected preoperatively and postoperatively on days 1, 3 and 7. Preoperative, intraoperative, and postoperative risk factors were investigated. Logistic regression analysis was performed to identify the risk factors for postoperative hyperbilirubinemia. Results: Postoperative hyperbilirubinemia was observed in 7 of 176 patients (4%) who underwent CABG, and in 11 of 131 patients (8.4%) who underwent valve replacement surgeries. Independent risk factors for early postoperative hyperbilirubinemia were found as: ejection fraction (EF), aortic cross-clamp (ACC) time, intensive care unit stay and extubation time (P<0.001). In comparison to CABG procedures, postoperative hyperbilirubinemia was observed more frequently in patients undergoing valve surgeries (P=0.027). Conclusion: Low EF and prolonged ACC time are significant independent risk factors for early postoperative hyperbilirubinemia during open-heart surgeries with cardiopulmonary bypass. Valve surgeries show a higher incidence of hyperbilirubinemia in comparison to CABG.

Abstract Introduction: In this study, we aimed to compare Del Nido cardioplegia (DNC) with blood cardioplegia (BC) in aortic valve replacement. Methods: A two-year single-institute retrospective cohort study was accomplished. Subjects who underwent aortic valve replacement surgery were divided into two groups (DNC and BC) and outcomes were compared. Results: Preoperative demographics and clinical data of the patients in both groups were similar. The time until cardiac arrest following administration of the first dose of cardioplegia was statistically significantly shorter in the BC group (47.0 sec. 25-103) than in the DNC group (63.0 sec. 48-140) (P=0.012). Cross-clamping time was longer in the BC group (48.7±12.3 min. vs. 41.5±11.8 min.) (P=0.041). Cardiopulmonary bypass time was statistically significantly shorter in the DNC group (BC 60.8±18.5 min., DNC 53.7±15.2 min.) (P=0.046). The rate of postoperative use of intravenous positive inotropic support drugs (dopamine, dobutamine, norepinephrine, etc.) for more than two hours was significantly higher in the BC group (20 [23.5%] in the BC group and nine [17.3%] in the DNC group) (P=0.035). Creatine kinase myocardial band and troponin I levels were slightly lower in patients receiving DNC, but no statistically significant difference was detected. Conclusion: Del Nido cardioplegia is safe and can be used efficiently as an alternative to blood cardioplegia in isolated aortic valve replacement surgery.

Abstract With transcatheter aortic valve implantation (TAVI) technology expanding its indications for low-risk patients, the number of TAVI-eligible patients will globally grow, requiring a better understanding about the second-best access choice. Regarding the potential access sites, the transfemoral retrograde route is recognized as the standard approach and first choice according to current guidelines. However, this approach is not suitable in up to 10-15% of patients, for whom an alternative non-femoral access is required. Among the alternative non-femoral routes, the transaxillary approach has received increasing recognition due to its proximity and relatively straight course from the axillary artery to the aortic annulus, which provides a more accurate device deployment. Here we discuss some particular aspects of the transaxillary access, either percutaneously performed or by cutdown dissection.