Repositório RCAAP

FUNDAMENTO: Há poucos dados sobre análises da prevalência e da influência de características psicológicas adversas no prognóstico dos indivíduos submetidos a intervenções coronárias percutâneas. Nenhum estudo abordou essa questão no Brasil. OBJETIVO: Investigar a prevalência de depressão, ansiedade, estresse psicológico e personalidade tipo D, bem como sua associação com eventos cardiovasculares em pacientes submetidos à intervenção coronária percutânea (ICP). MÉTODOS: As características psicológicas foram avaliadas por escalas: inventário de depressão de Beck (IDB), inventário de ansiedade de Beck (IAB), inventário de sintomas de estresse de Lipp para adultos (ISSL) e escala de personalidade tipo D. A meta do estudo foi a ocorrência de eventos cardiovasculares maiores em um seguimento de um ano. RESULTADOS: Durante março e maio de 2006, 137 pacientes foram incluídos. A personalidade tipo D foi identificada em 34% dos casos; 29% apresentaram ansiedade, 25% apresentaram depressão, e 70% dos pacientes apresentaram estresse. Em relação à frequência de características psicológicas de acordo com a ocorrência de eventos cardiovasculares adversos maiores, não houve diferença estatística entre os dois grupos de pacientes no que se refere à depressão (29% vs. 26% p = 0,8), ansiedade (33% vs. 23% p = 0,3), estresse (76% vs. 65% p = 0,3) e personalidade tipo D (33% vs. 32% p = 0,9). No entanto, encontrou-se um escore de afetividade negativa significativamente maior no grupo de pacientes que apresentaram eventos (13,9 vs. 9,8 p = 0,01). CONCLUSÃO: Em pacientes submetidos à intervenção coronária percutânea, a prevalência de efeitos adversos psicológicos característicos foi alta. Eventos adversos cardiovasculares maiores em um ano foram associados à afetividade negativa basal, mas não a outras características psicológicas estudadas.

Abstract Introduction: Cardiac surgery is a highly complex procedure which generates worsening of lung function and decreased inspiratory muscle strength. The inspiratory muscle training becomes effective for muscle strengthening and can improve functional capacity. Objective: To investigate the effect of inspiratory muscle training on functional capacity submaximal and inspiratory muscle strength in patients undergoing cardiac surgery. Methods: This is a clinical randomized controlled trial with patients undergoing cardiac surgery at Instituto Nobre de Cardiologia. Patients were divided into two groups: control group and training. Preoperatively, were assessed the maximum inspiratory pressure and the distance covered in a 6-minute walk test. From the third postoperative day, the control group was managed according to the routine of the unit while the training group underwent daily protocol of respiratory muscle training until the day of discharge. Results: 50 patients, 27 (54%) males were included, with a mean age of 56.7±13.9 years. After the analysis, the training group had significant increase in maximum inspiratory pressure (69.5±14.9 vs. 83.1±19.1 cmH2O, P=0.0073) and 6-minute walk test (422.4±102.8 vs. 502.4±112.8 m, P=0.0031). Conclusion: We conclude that inspiratory muscle training was effective in improving functional capacity submaximal and inspiratory muscle strength in this sample of patients undergoing cardiac surgery.

Abstract Objective: Endovascular techniques to treat abdominal aortic aneurysms results in lower morbidity and mortality rates. However, dilation of the common iliac arteries prevents adequate distal sealing, which compromises the procedure success. The aim of this study is report the long-term outcomes of patients with abdominal aortic aneurysms associated with aneurysm of the common iliac artery following endovascular repair using a bifurcated bell-bottom stent graft. Methods: This is a retrospective study that evaluated patients treated with bifurcated bell-bottom extension stent grafts to repair an infrarenal abdominal aortic aneurysm and who had at least one common iliac artery with dilatation > 1.5 cm for at least 12 months after the endovascular intervention. Results: Thirty-eight patients with a mean age of 70.4±8.2 years were included. Stent graft placement was followed by dilation of the common iliac artery aneurysms in 35.3% of cases; endoleak and reoperation rates were 17.6% and 15.7%, respectively. Younger patients showed a higher rate of artery diameter increase following the procedure. The average arterial dilation was 16% in the first year, 29% in the second year, 57% in the third year and 95% from the fourth year until the end of follow-up. Conclusion: Repair of infrarenal abdominal aortic aneurysms with bifurcated bell-bottom type stents when there is common iliac artery dilation is a good therapeutic option to preserve hypogastric flow. The rate of endoleak was 17.6%, and 15.7% of cases required reoperation. Younger patients are more likely to experience dilation of the common iliac artery after the procedure.

Abstract Objective: This work describes the experimental validation of a cardiac simulator for three heart rates (60, 80 and 100 beats per minute), under physiological conditions, as a suitable environment for prosthetic heart valves testing in the mitral or aortic position. Methods: In the experiment, an aortic bileaflet mechanical valve and a mitral bioprosthesis were employed in the left ventricular model. A test fluid of 47.6% by volume of glycerin solution in water at 36.5ºC was used as blood analogue fluid. A supervisory control and data acquisition system implemented previously in LabVIEW was applied to induce the ventricular operation and to acquire the ventricular signals. The parameters of the left ventricular model operation were based on in vivo and in vitro data. The waves of ventricular and systemic pressures, aortic flow, stroke volume, among others, were acquired while manual adjustments in the arterial impedance model were also established. Results: The acquired waves showed good results concerning some in vivo data and requirements from the ISO 5840 standard. Conclusion: The experimental validation was performed, allowing, in future studies, characterizing the hydrodynamic performance of prosthetic heart valves.

Abstract Mitral valve prolapse is a benign condition. Mitral regurgitation is only complicated in patients with severe mitral valve prolapse. Women with mitral valve prolapse in the absence of other cardiovascular disorders tolerate pregnancy well and do not develop remarkable cardiac complications. Nevertheless, serious complications of mitral valve prolapse, including arrhythmia, infective endocarditis and cerebral ischemic events, can be present in pregnancy. Debates remain with regard to the use of prophylactic antibiotics and β-blockers in the pregnant women with mitral valve prolapse. The prognosis of the pregnant patients might be closely related to the pathological and (or) functional changes of the mitral valve. Non-myxomatous mitral valve prolapse poses no or little obstetric risks in terms of pregnancy, labor and neonatal complications; whereas myxomatous mitral valve prolapse is a major etiology of valvular heart disease in women of childbearing age. In the pregnant patients with mitral valve prolapse progressing into major complications, surgical interventions are considered. Medicinal treatment of such patients with β-blockers should be a concern for the fetal safety.

Abstract The historical period called the Middle Ages, a long interval between the 5th and the 15th centuries, is still commonly known as the Dark Ages, especially in the area of health sciences. In the last decades, this "classic" view of the Middle Ages has been gradually modified with advances in historiographical studies and the history of science. During that period in Western Europe, knowledge about the human body suffered a regression in terms of anatomy and physiology, with the predominance of religious conceptions mainly about diseases and their treatments. Knowledge on the cardiovascular system and heart diseases has been classically described as a repetition of the concepts developed by Galen from the dissection of animals and his keen sense of observation. However, the Middle East, especially Persia, was the birth place of a lot of intellectuals who preserved the ancient knowledge of the Greeks while building new knowledge and practices, especially from the 8th to the 13th century. The invasion of the Arabs in North of Africa and the Iberian Peninsula and the eclosion of the Crusades resulted in a greater contact between the East and the West, which in turn brought on the arrival of the Arab medical knowledge, among others, to 12th century Europe. Such fact contributed to an extremely important change in the scientific medical knowledge in the West, leading to the incorporation of different concepts and practices in the field of cardiovascular Medicine. The new way of teaching and practicing Medicine of the great Arab doctors, together with the teaching hospitals and foundations in the Koran, transformed the Medicine practiced in Europe definitely. The objective of this paper is to describe the knowledge drawn up from the Middle Ages about the cardiovascular system, its understanding and therapeutic approach to cardiologists and cardiovascular surgeons.

Abstract Objective: To complement the ISO 5840 standards concerning the duration of left ventricular systole and diastole as a function of changes in heart rates according to in vivo studies from the physiologic literature review. Methods: The systolic and diastolic durations from three in vivo studies were compared with the durations of systole proposed by the ISO 5840:2010 and ISO 5840-2:2015 for hydrodynamic performance assessment of prosthetic heart valves. Results: Based on the in vivo studies analyzed, the systolic durations proposed by the ISO 5840 standard seemed consistent for 45 and 120 beats per minute (bpm), and showed diverse results for the 70 bpm condition. Conclusion: Information on the realistic validation of the operation of left ventricular models for different heart rates were obtained.

Abstract Six months after undergoing a Fontan operation, a 7-year-old boy with right atrial isomerism and a single functional ventricle was admitted to our emergency department with cyanosis. Emergency cardiac catheterization revealed a large veno-venous fistula that began in a left hepatic vein, connected to the left accessory hepatic veins, and drained into the common atrium, resulting in desaturation. The fistula was occluded proximally with an Amplatzer septal occluder, with satisfying results; the patient's systemic arterial saturation decreased during his hospital stay. Three weeks after the first intervention, a second procedure was performed to retrieve the first device and to close the fistula distally. Multiple attempts with different types of gooseneck snares and a bioptome catheter failed to retrieve the first device, so a telescopic method was used to re-screw it. Using a Mullins long sheath and delivery sheath, the delivery cable was manipulated to fit into the slot of the end screw, and the cable was rotated gently in a clockwise direction to re-screw the device. Then, another Amplatzer septal occluder was placed at the distal end of the fistula. In conclusion, distal transcatheter occlusion of intrahepatic veno-venous fistulas might lead to better clinical outcomes in selected patients. Amplatzer septal occluder device can be retrieve without any complication within three weeks.

Abstract Introduction: To obtain the optimal anesthesia depth is not easy in cardiovascular surgery patients where the haemodynamic reserve is limited, due to reasons such as not being able to give the desired dose of anesthetic agent, or the change in the pharmacokinetics of the agent in the heart-lung machine. This study was planned to assess the contribution of bispectral index (BIS) monitoring in the depth of anesthesia. Methods: The patients were divided into 2 groups, and BIS monitoring was used for each patient. Group 1 (G1 n=35): keeping the BIS monitor screen open, the anesthesia need was set. Group 2 (G2 n=35): BIS monitor was tied to the patient and the monitor screen was closed in such a way that the anaesthesist couldn't see the BIS value. When the recording time came, the data on the monitor was recorded. The need for the anesthetic agent was set according to the parameters such as haemodynamics or follow up of pupils, instead of BIS value, by titrating the anesthetic infusion doses. Results: BIS values were similar in both groups before the induction, BIS values in both groups showed a decrease, showing no significant statistical difference (P>0.05). One patient in each group said that he dreamt, and one patient in G2 said that he had heard a noise and felt that he was taken from one place to another. Conclusion: The management should be done with clinical evaluation, haemodynamics and other monitorization methods and BIS monitoring findings together.

Abstract Introduction: Due to late complications associated with the use of conventional prosthetic heart valves, several centers have advocated aortic valve repair and/or valve sparing aortic root replacement for patients with aortic valve insufficiency, in order to enhance late survival and minimize adverse postoperative events. Methods: From March/2012 thru March 2015, 37 patients consecutively underwent conservative operations of the aortic valve and/or aortic root. Mean age was 48±16 years and 81% were males. The aortic valve was bicuspid in 54% and tricuspid in the remaining. All were operated with the aid of intraoperative transesophageal echocardiography. Surgical techniques consisted of replacing the aortic root with a Dacron graft whenever it was dilated or aneurysmatic, using either the remodeling or the reimplantation technique, besides correcting leaflet prolapse when present. Patients were sequentially evaluated with clinical and echocardiographic studies and mean follow-up time was 16±5 months. Results: Thirty-day mortality was 2.7%. In addition there were two late deaths, with late survival being 85% (CI 95% - 68%-95%) at two years. Two patients were reoperated due to primary structural valve failure. Freedom from reoperation or from primary structural valve failure was 90% (CI 95% - 66%-97%) and 91% (CI 95% - 69%-97%) at 2 years, respectively. During clinical follow-up up to 3 years, there were no cases of thromboembolism, hemorrhage or endocarditis. Conclusions: Although this represents an initial series, these data demonstrates that aortic valve repair and/or valve sparing aortic root surgery can be performed with satisfactory immediate and short-term results.

Abstract Introduction: Human heart valves are used as replacement valves and have satisfactory functional results compared with conventional prostheses. Objective: Characterize the profile of effective heart donors from the human valve bank of the santa casa de misericórdia de curitiba and analyze the association between the profile variables. Methods: It consists of a retrospective and quantitative study of electronic medical records from heart donors for heart valves. every heart donation made to the bank between january 2004 and december 2014 was studied. Results: 2,149 donations were analyzed, from donors aged 0 to 71 years old, with an average of 34.9 ± 15.03 years old. most donors were male 65.7% (n=1,411) and 34.3% (n=738) were female. among the most frequent causes of the donors' death are trauma at 53% (n=1,139) and cerebral vascular accident at 34.2% (n=735). there was significant statistical association between the analyzed variables. Conclusion: There has been an improvement in brazil's donation rate, being essential that the tissue banks work together with the state and federal district centers for notification, procurement and distribution of organs in order to increase the number of donors.

Abstract A 76-year-old man with situs inversus totalis underwent a successful off-pump three-vessel coronary artery bypass surgery. The postoperative course was uneventful, and the patient was discharged 8 days later. At 9-month follow-up a coronary computed tomography angiography confirmed the viability of all of the grafts, and one year after the operation the patient remained asymptomatic. It comprises the fifth Brazilian case of a coronary surgery in a patient with situs inversus totalis and the first one of the country of a coronary artery bypass surgery without the use of the cardiopulmonary bypass in this condition.

ABSTRACT Objective: α-2-agonists cause sympathetic inhibition combined with parasympathetic activation and have other properties that could be beneficial during cardiac anesthesia. We evaluated the effects of dexmedetomidine as an anesthetic adjuvant compared to a control group during cardiac surgery. Methods: We performed a retrospective analysis of prospectively collected data from all adult patients (> 18 years old) undergoing cardiac surgery. Patients were divided into two groups, regarding the use of dexmedetomidine as an adjuvant intraoperatively (DEX group) and a control group who did not receive α-2-agonist (CON group). Results: A total of 1302 patients who underwent cardiac surgery, either coronary artery bypass graft or valve surgery, were included; 796 in the DEX group and 506 in the CON group. Need for reoperation (2% vs. 2.8%, P=0.001), type 1 neurological injury (2% vs. 4.7%, P=0.005) and prolonged hospitalization (3.1% vs. 7.3%, P=0.001) were significantly less frequent in the DEX group than in the CON group. Thirty-day mortality rates were 3.4% in the DEX group and 9.7% in the CON group (P<0.001). Using multivariable Cox regression analysis with in hospital death as the dependent variable, dexmedetomidine was independently associated with a lower risk of 30-day mortality (odds ratio [OR]=0.39, 95% confidence interval [CI]: 0.24-0.65, P≤0.001). The Logistic EuroSCORE (OR=1.05, 95% CI: 1.02-1.10, P=0.004) and age (OR=1.03, 95% CI: 1.01-1.06, P=0.003) were independently associated with a higher risk of 30-day mortality. Conclusion: Dexmedetomidine used as an anesthetic adjuvant was associated with better outcomes in patients undergoing coronary artery bypass graft and valve surgery. Randomized prospective controlled trials are warranted to confirm our results.

ABSTRACT Introduction: Risk Adjustment for Congenital Heart Surgery 1 (RACHS-1) score is a simple model that can be easily applied and has been widely used for mortality comparison among pediatric cardiovascular services. It is based on the categorization of several surgical palliative or corrective procedures, which have similar mortality in the treatment of congenital heart disease. Objective: To analyze the in-hospital mortality in pediatric patients (<18 years) submitted to cardiac surgery for congenital heart disease based on RACHS-1 score, during a 12-year period. Methods: A retrospective date analysis was performed from January 2003 to December 2014. The survey was divided in two periods of six years long each, to check for any improvement in the results. We evaluated the numbers of procedures performed, complexity of surgery and hospital mortality. Results: Three thousand and two hundred and one surgeries were performed. Of these, 3071 were able to be classified according to the score RACHS-1. Among the patients, 51.7% were male and 47.5% were younger than one year of age. The most common RACHS-1 category was 3 (35.5%). The mortality was 1.8%, 5.5%, 14.9%, 32.5% and 68.6% for category 1, 2, 3, 4 and 6, respectively. There was a significant increase in the number of surgeries (48%) and a significant reduction in the mortality in the last period analysed (13.3% in period I and 10.4% in period II; P=0.014). Conclusion: RACHS-1 score was a useful score for mortality risk in our service, although we are aware that other factors have an impact on the total mortality.

ABSTRACT Objective: To examine if methylene blue (MB) can counteract or prevent protamine (P) cardiovascular effects. Methods: The protocol included five heparinized pig groups: Group Sham -without any drug; Group MB - MB 3 mg/kg infusion; Group P - protamine; Group P/MB - MB after protamine; Group MB/P - MB before protamine. Nitric oxide levels were obtained by the nitric oxide/ozone chemiluminescence method, performed using the Nitric Oxide Analizer 280i (Sievers, Boulder, CO, USA). Malondialdehyde plasma levels were estimated using the thiobarbiturate technique. Results: 1) Groups Sham and MB presented unchanged parameters; 2) Group P - a) Intravenous protamine infusion caused mean arterial pressure decrease and recovery trend after 25-30 minutes, b) Cardiac output decreased and remained stable until the end of protamine injection, and c) Sustained systemic vascular resistance increased until the end of protamine injection; 3) Methylene blue infusion after protamine (Group P/MB) - a) Marked mean arterial pressure decreased after protamine, but recovery after methylene blue injection, b) Cardiac output decreased after protamine infusion, recovering after methylene blue infusion, and c) Sustained systemic vascular resistance increased after protamine infusion and methylene blue injections; 4) Methylene blue infusion before protamine (Group MB/P) - a) Mean arterial pressure decrease was less severe with rapid recovery, b) After methylene blue, there was a progressive cardiac output increase up to protamine injection, when cardiac output decreased, and c) Sustained systemic vascular resistance decreased after protamine, followed by immediate Sustained systemic vascular resistance increase; 5) Plasma nitrite/nitrate and malondialdehyde values did not differ among the experimental groups. Conclusion: Reviewing these experimental results and our clinical experience, we suggest methylene blue safely prevents and treats hemodynamic protamine complications, from the endothelium function point of view.

ABSTRACT Introduction: Abdominal aortic aneurysm has a lower incidence in the female population, but a higher complication rate. It was been hypothesized that some anatomical differences of abdominal aortic aneurysm in women could be responsible for that. We proposed to analyze our data to understand the differences in the clinical and anatomical characteristics and the outcomes of patients undergoing endovascular aneurysm repair, according to gender. Methods: A retrospective analysis of patients undergoing endovascular aneurysm repair between 2001-2013 was performed. Patients were divided according gender and evaluated regarding age, atherosclerotic risk factors, aneurysm anatomic features, endograft type, anesthesic risk classification, length of stay, reinterventions and mortality. Two statistical studies were performed, first comparing women and men (Group A) and a second one comparing women and men, adjusted by age (Group B). Results: Of the 171 patients, only 5.8% (n=10) were females. Women were older (P<0.05) and the number of women with no atherosclerotic risk factor was significantly higher. The comparison adjusted by age revealed women with statistically less smoking history, less cerebrovascular disease and ischemic heart disease. Women had a trend to more complex anatomy, with more iliac intern artery aneurysms, larger aneurysm diameter and neck angulations statistically more elevated. No other variables were statistically different between age groups, neither reintervention nor mortality rates. Conclusion: Our study showed a clear difference in the clinical characteristics of women. The female population was statistically older, and when compared with men adjusted by age, had less atherosclerotic risk factors and less target organ disease. Women showed a more complex anatomy but with the same outcomes.

ABSTRACT Introduction: In patients with mechanical prosthetic heart valves or atrial fibrillation requiring anticoagulation to prevent thromboembolic events, several factors influence adherence and anticoagulation complications. Objective: To evaluate the factors that interfere with the quality and complications of anticoagulation with vitamin K antagonists. Methods: A retrospective cohort study of 100 patients, in the period from 2011 to 2014, was performed. Anticoagulation conditions in the last year, regarding the presence of complications (embolisms/bleeding) and inadequate treatment were assessed: achievement of less than 8 annual prothrombin times and International Normalized Ratio outside therapeutic target in more than 40% of prothrombin times. Results: There were 31 complications (22 minor bleeding without hospitalization and 9 major complications: 7 bleeding with hospitalization and two emboli); 70 were with International Normalized Ratio outside the target in more than 40% of the tests and 36 with insufficient number of prothrombin times. Socioeconomic factors, anticoagulant type and anticoagulation reason had no relationship with complications or with inadequate treatment. There were more complications in patients with longer duration of anticoagulation (P=0.001). Women had more International Normalized Ratio outside the target range (OR 2.61, CI:1.0-6.5; P=0.04). Patients with lower number of annual prothrombin times had longer times of anticoagulation (P=0.03), less annual consultations (P=0.02) and less dose adjustments (P=0.003). Patients with longer duration of anticoagulation have more complications (P=0.001). Conclusion: There was a high rate of major complications and International Normalized Ratio was outside the goal. Less annual prothrombin times was related to longer duration of anticoagulation, less annual consultations and less dose adjustments. More major complications occurred in patients with longer duration of anticoagulation.

ABSTRACT Objective: To summarize the effect of mild hypothermia on function of the organs in patients with multiple organ dysfunction syndrome after cardiopulmonary bypass surgery. Methods: The patients were randomly divided into two groups, northermia group (n=71) and hypothermia group (n=89). We immediately began cooling the hypothermia group when test results showed multiple organ dysfunction syndrome, meanwhile all patients of two groups were drawn blood to test blood gas, liver and kidney function, blood coagulation function, and evaluated the cardiac function using echocardiography from 12 to 36 hours. We compared the difference of intra-aortic balloon pump, extracorporeal membrane oxygenation rate and mortality within one month after intensive care unit admission. Results: Among the 160 patients, 36 died, 10 (11.24%) patients were from the hypothermia group and 26 (36.6%) from the northermia group (P <0.05). In northermia group, 45 (63.38%) patients used intra-aortic balloon pump and 4 (5.63%), extracorporeal membrane oxygenation; in hypothermia group, 35 (39.32%) patients used intra-aortic balloon pump and 2 (2.25%), extracorporeal membrane oxygenation（ P <0.05). The patients' heart rate decreased significantly in the hypothermia group. The heart rate of hypothermia group is significantly slower than the northermia group at the 36th hour (P <0.05). But the mean arterial pressure of hypothermia group is significantly higher than the northermia group at the 36th hour (P <0.05). In hypothermia group, PO2, SvO2 and lactate were improved significantly compared to pre-cooling (P <0.05), and they were significantly better than the northermia group at the 36th hour (P <0.05%). Prothrombin time and activated partial thromboplastin time have no significantly difference between the two groups (P >0.05). But the platelet count has significantly difference between the two groups at the 36th hour (P <0.05). The aspartate transaminase, alanine transaminase and creatinine were improved significantly in the hypothermia group, and they were significantly better than the northermia group (P <0.05). Conclusion: Mild hypothermia is feasible and safe for patients with multiple organ dysfunction syndrome after cardiopulmonary bypass surgery.

ABSTRACT Fungal endocarditis is a rare and fatal condition. The Candida and Aspergillus species are the two most common etiologic fungi found responsible for fungal endocarditis. Fever and changing heart murmur are the most common clinical manifestations. Some patients may have a fever of unknown origin as the onset symptom. The diagnosis of fungal endocarditis is challenging, and diagnosis of prosthetic valve fungal endocarditis is extremely difficult. The optimum antifungal therapy still remains debatable. Treating Candida endocarditis can be difficult because the Candida species can form biofilms on native and prosthetic heart valves. Combined treatment appears superior to monotherapy. Combination of antifungal therapy and surgical debridement might bring about better prognosis.

ABSTRACT The perspective of the integrated health system has a network of care with multiple integration dimensions among subsystems as nuclear representation, relating the clinical aspects and governance to the representations and collective values. The normative integration aims to ensure coherence between the system of representations and values of society simultaneously with the interfaces of clinical and functional integration. It builds a bridge with governance, which allows, through their skills, management of all system components, encouraging cooperation, communication and information, in order to ensure the population under their responsibility to access excellence services, exceeding their expectations. The integration of care consists of a durable coordination of clinical practices for those who suffer from health problems in order to ensure continuity and full range of the required professional services and organizations, coordinated in time and space, in accordance with the available knowledge. It is possible to establish the type of health equipment for each level of care for patients with congenital heart diseases. This strategy intends to offer timely care in appropriate moments and places, efficiently, operating cooperatively an interdependently, with ongoing exchange of its resources. Thus, situational integration establishes the system connection with the assessment environment that proposes to carry out value judgment, guided by an objective worldview, about an intervention or any of its components, in order to objectify the decision making.