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Background: Healthcare-associated infective endocarditis (HCA-IE), a severe complication of medical care, shows a growing incidence in literature. Objective: To evaluate epidemiology, etiology, risk factors for acquisition, complications, surgical treatment, and outcome of HCA-IE. Methods: Observational prospective case series study (2006-2011) in a public hospital in Rio de Janeiro. Results: Fifty-three patients with HCA-IE from a total of 151 cases of infective endocarditis (IE) were included. There were 26 (49%) males (mean age of 47 ± 18.7 years), 27 (51%) females (mean age of 42 ± 20.1 years). IE was acute in 37 (70%) cases and subacute in 16 (30%) cases. The mitral valve was affected in 19 (36%) patients and the aortic valve in 12 (36%); prosthetic valves were affected in 23 (43%) patients and native valves in 30 (57%). Deep intravenous access was used in 43 (81%) cases. Negative blood cultures were observed in 11 (21%) patients, Enterococcus faecalis in 10 (19%), Staphylococcus aureus in 9 (17%), and Candida sp. in 7 (13%). Fever was present in 49 (92%) patients, splenomegaly in 12 (23%), new regurgitation murmur in 31 (58%), and elevated C-reactive protein in 44/53 (83%). Echocardiograms showed major criteria in 46 (87%) patients, and 34 (64%) patients were submitted to cardiac surgery. Overall mortality was 17/53 (32%). Conclusion: In Brazil HCA-IE affected young subjects. Patients with prosthetic and native valves were affected in a similar proportion, and non-cardiac surgery was an infrequent predisposing factor, whereas intravenous access was a common one. S. aureus was significantly frequent in native valve HCA-IE, and overall mortality was high.

Background: The equations predicting maximal oxygen uptake (VO2max or peak) presently in use in cardiopulmonary exercise testing (CPET) softwares in Brazil have not been adequately validated. These equations are very important for the diagnostic capacity of this method. Objective: Build and validate a Brazilian Equation (BE) for prediction of VO2peak in comparison to the equation cited by Jones (JE) and the Wasserman algorithm (WA). Methods: Treadmill evaluation was performed on 3119 individuals with CPET (breath by breath). The construction group (CG) of the equation consisted of 2495 healthy participants. The other 624 individuals were allocated to the external validation group (EVG). At the BE (derived from a multivariate regression model), age, gender, body mass index (BMI) and physical activity level were considered. The same equation was also tested in the EVG. Dispersion graphs and Bland-Altman analyses were built. Results: In the CG, the mean age was 42.6 years, 51.5% were male, the average BMI was 27.2, and the physical activity distribution level was: 51.3% sedentary, 44.4% active and 4.3% athletes. An optimal correlation between the BE and the CPET measured VO2peak was observed (0.807). On the other hand, difference came up between the average VO2peak expected by the JE and WA and the CPET measured VO2peak, as well as the one gotten from the BE (p = 0.001). Conclusion: BE presents VO2peak values close to those directly measured by CPET, while Jones and Wasserman differ significantly from the real VO2peak.

Background: Studies on atrial fibrillation (AF) in decompensated heart failure (DHF) are scarce in Brazil. Objectives: To determine AF prevalence, its types and associated factors in patients hospitalized due to DHF; to assess their thromboembolic risk profile and anticoagulation rate; and to assess the impact of AF on in-hospital mortality and hospital length of stay. Methods: Retrospective, observational, cross-sectional study of incident cases including 659 consecutive hospitalizations due to DHF, from 01/01/2006 to 12/31/2011. The thromboembolic risk was assessed by using CHADSVASc score. On univariate analysis, the chi-square, Student t and Mann Whitney tests were used. On multivariate analysis, logistic regression was used. Results: The prevalence of AF was 40%, and the permanent type predominated (73.5%). On multivariate model, AF associated with advanced age (p < 0.0001), non-ischemic etiology (p = 0.02), right ventricular dysfunction (p = 0.03), lower systolic blood pressure (SBP) (p = 0.02), higher ejection fraction (EF) (p < 0.0001) and enlarged left atrium (LA) (p < 0.0001). The median CHADSVASc score was 4, and 90% of the cases had it ≥ 2. The anticoagulation rate was 52.8% on admission and 66.8% on discharge, being lower for higher scores. The group with AF had higher in-hospital mortality (11.0% versus 8.1%, p = 0.21) and longer hospital length of stay (20.5 ± 16 versus 16.3 ± 12, p = 0.001). Conclusions: Atrial fibrillation is frequent in DHF, the most prevalent type being permanent AF. Atrial fibrillation is associated with more advanced age, non-ischemic etiology, right ventricular dysfunction, lower SBP, higher EF and enlarged LA. Despite the high thromboembolic risk profile, anticoagulation is underutilized. The presence of AF is associated with longer hospital length of stay and high mortality.

Background: Diabetes mellitus and admission blood glucose are important risk factors for mortality in ST segment elevation myocardial infarction patients, but their relative and individual role remains on debate. Objective: To analyze the influence of diabetes mellitus and admission blood glucose on the mortality of ST segment elevation myocardial infarction patients submitted to primary coronary percutaneous intervention. Methods: Prospective cohort study including every ST segment elevation myocardial infarction patient submitted to primary coronary percutaneous intervention in a tertiary cardiology center from December 2010 to May 2012. We collected clinical, angiographic and laboratory data during hospital stay, and performed a clinical follow-up 30 days after the ST segment elevation myocardial infarction. We adjusted the multivariate analysis of the studied risk factors using the variables from the GRACE score. Results: Among the 740 patients included, reported diabetes mellitus prevalence was 18%. On the univariate analysis, both diabetes mellitus and admission blood glucose were predictors of death in 30 days. However, after adjusting for potential confounders in the multivariate analysis, the diabetes mellitus relative risk was no longer significant (relative risk: 2.41, 95% confidence interval: 0.76 - 7.59; p-value: 0.13), whereas admission blood glucose remained and independent predictor of death in 30 days (relative risk: 1.05, 95% confidence interval: 1.02 - 1.09; p-value ≤ 0.01). Conclusion: In ST segment elevation myocardial infarction patients submitted to primary coronary percutaneous intervention, the admission blood glucose was a more accurate and robust independent predictor of death than the previous diagnosis of diabetes. This reinforces the important role of inflammation on the outcomes of this group of patients.

Background: Obesity is defined by excessive accumulation of body fat relative to lean tissue. Studies during the last few years indicate that cardiac function in obese animals may be preserved, increased or diminished. Objective: Study the energy balance of the myocardium with the hypothesis that the increase in fatty acid oxidation and reduced glucose leads to cardiac dysfunction in obesity. Methods: 30-day-old male Wistar rats were fed standard and hypercaloric diet for 30 weeks. Cardiac function and morphology were assessed. In this paper was viewed the general characteristics and comorbities associated to obesity. The structure cardiac was determined by weights of the heart and left ventricle (LV). Myocardial function was evaluated by studying isolated papillary muscles from the LV, under the baseline condition and after inotropic and lusitropic maneuvers: myocardial stiffness; postrest contraction; increase in extracellular Ca2+ concentration; change in heart rate and inhibitor of glycolytic pathway. Results: Compared with control group, the obese rats had increased body fat and co-morbities associated with obesity. Functional assessment after blocking iodoacetate shows no difference in the linear regression of DT, however, the RT showed a statistically significant difference in behavior between the control and the obese group, most notable being the slope in group C. Conclusion: The energy imbalance on obesity did not cause cardiac dysfunction. On the contrary, the prioritization of fatty acids utilization provides protection to cardiac muscle during the inhibition of glycolysis, suggesting that this pathway is fewer used by obese cardiac muscle.

Background: The importance of measuring blood pressure before morning micturition and in the afternoon, while working, is yet to be established in relation to the accuracy of home blood pressure monitoring (HBPM). Objective: To compare two HBPM protocols, considering 24-hour ambulatory blood pressure monitoring (wakefulness ABPM) as gold-standard and measurements taken before morning micturition (BM) and in the afternoon (AM), for the best diagnosis of systemic arterial hypertension (SAH), and their association with prognostic markers. Methods: After undergoing 24-hour wakefulness ABPM, 158 participants (84 women) were randomized for 3- or 5-day HBPM. Two variations of the 3-day protocol were considered: with measurements taken before morning micturition and in the afternoon (BM+AM); and with post-morning-micturition and evening measurements (PM+EM). All patients underwent echocardiography (for left ventricular hypertrophy - LVH) and urinary albumin measurement (for microalbuminuria - MAU). Result: Kappa statistic for the diagnosis of SAH between wakefulness-ABPM and standard 3-day HBPM, 3-day HBPM (BM+AM) and (PM+EM), and 5-day HBPM were 0.660, 0.638, 0.348 and 0.387, respectively. The values of sensitivity of (BM+AM) versus (PM+EM) were 82.6% × 71%, respectively, and of specificity, 84.8% × 74%, respectively. The positive and negative predictive values were 69.1% × 40% and 92.2% × 91.2%, respectively. The comparisons of intraclass correlations for the diagnosis of LVH and MAU between (BM+AM) and (PM+EM) were 0.782 × 0.474 and 0.511 × 0.276, respectively. Conclusions: The 3 day-HBPM protocol including measurements taken before morning micturition and during work in the afternoon showed the best agreement with SAH diagnosis and the best association with prognostic markers.

Despite significant therapeutic advancements, heart failure remains a highly prevalent clinical condition associated with significant morbidity and mortality. In 30%-40% patients, the etiology of heart failure is nonischemic. The implantable cardioverter-defibrillator (ICD) is capable of preventing sudden death and decreasing total mortality in patients with nonischemic heart failure. However, a significant number of patients receiving ICD do not receive any kind of therapy during follow-up. Moreover, considering the situation in Brazil and several other countries, ICD cannot be implanted in all patients with nonischemic heart failure. Therefore, there is an urgent need to identify patients at an increased risk of sudden death because these would benefit more than patients at a lower risk, despite the presence of heart failure in both risk groups. In this study, the authors review the primary available methods for the stratification of the risk of sudden death in patients with nonischemic heart failure.

Abstract Introduction: In high-volume trauma centers, especially in developing countries, penetrating cardiac box injuries are frequent. Although many aspects of penetrating chest injuries have been well established, video-assisted thoracoscopy is still finding its place in cardiac box trauma and algorithmic approaches are still lacking. The purpose of this manuscript is to provide a streamlined recommendation for penetrating cardiac box injury in stable patients. Methods: Literature review was carried out using PubMed/MEDLINE and Google Scholar databases to identify articles describing the characteristics and concepts of penetrating cardiac box trauma, including the characteristics of tamponade, cardiac ultrasound, indications and techniques of pericardial windows and, especially, the role of video-assisted thoracoscopy in stable patients. Results: Penetrating cardiac box injuries, whether by stab or gunshot wounds, require rapid surgical consultation. Unstable patients require immediate open surgery, however, determining which stable patients should be taken to thoracoscopic surgery is still controversial. Here, the classification of penetrating cardiac box injury used in Colombia is detailed, as well as the algorithmic approach to these types of trauma. Conclusion: Although open surgery is mandatory in unstable patients with penetrating cardiac box injuries, a more conservative and minimally invasive approach may be undertaken in stable patients. As rapid decision-making is critical in the trauma bay, surgeons working in high-volume trauma centers should expose themselves to thoracoscopy and always consider this possibility in the setting of penetrating cardiac box injuries in stable patients, always in the context of an experienced trauma team.

Abstract Introduction: The objective of this study is to compare the effects of conventional monopolar electrosurgery (CMES) and low-thermal plasma kinetic cautery (PKC) on complications such as bleeding, abnormal wound healing, pain, and drainage in patients who underwent on-pump coronary artery bypass grafting (CABG). Methods: This retrospective clinical study included 258 patients undergoing CABG; the patients were randomized to PKC (PEAK PlasmaBlade, n=153) and CMES (n=105) groups. The patients’ clinical data were examined retrospectively for biochemical variables, postoperative drainage, post-surgery erythrocyte suspension transfusion count, surgical site pain examined with visual analogue scale (VAS), and wound healing. Two-sided P-value > 0.05 was considered as statistically significant. Results: The median post-surgery erythrocyte suspension transfusion number was significantly lower with PKC compared to CMES (0 [0-1] vs. 1 [1-4], respectively, P<0.001). Mean postoperative drain output and time until removal of drain tubes were significantly lower with PKC compared to CMES (300±113 vs. 547±192 and 1.95±1.5 vs. 2.44±1.8; P<0.001 and P=0.025, respectively). Mean VAS score for spontaneous and cough-induced pain were significantly lower with PKC compared to CMES (1.98±1.51 vs. 3.94± 2.09 and 3.76±1.46 vs. 5.6±1.92; P<0.001 for both comparisons). Reoperation due to bleeding was significantly higher with CMES compared to PKC (0 vs. 11 [7.2%], P=0.001). Conclusion: Use of PKC during CABG considerably reduces postoperative drainage, need for blood transfusion, reoperation due to bleeding, and postoperative pain. PCK appears to be a good alternative to CMES for CABG.

Abstract Introduction: In this study, Anzer propolis, which can only be obtained from the Eastern Black Sea region in Turkey, is studied for its effect on spinal cord ischemia/reperfusion injury. Methods: A total of 12 healthy male New Zealand White rabbits with an average weight of 3.0 to 3.5 kg were separated into two blind and randomized groups: the ischemia/reperfusion group (n=6) and the treatment group (n=6). Each rabbit in the treatment group was given a dose of 100 mg/kg of ethanol-dissolved Anzer propolis orally 1 hour before surgery. Blood samples were examined at the 0th hour and postoperatively at the 24th and 48th hours. Tissue samples were taken at the 48th hour during the sacrification. Results: There was a statistically significant difference between the two groups in terms of postoperative Tarlov scoring (P=0.012). There was a difference between the two groups in terms of the blood levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) at the 48th hour, myeloperoxidase (MPO) at the 24th and 48th hours, ischemia-modified albumin (IMA) at the 24th hour, and intercellular adhesion molecule-1 (ICAM-1) and total oxidant status (TOS) at the 48th hour (P<0.005). There was also a difference between the two groups in terms of apoptotic index data obtained with the terminal deoxynucleotidyl transferase (TdT)‐mediated dUTP nick‐end labelling (TUNEL) method in the histopathological examination (P=0.001). In the transmission electron microscopic (TEM) analysis, while ischemia/reperfusion group generally had axon-myelin separation, axoplasmic dissolution and myelin separation, the propolis treatment group had normal myelin sequencing. Discussion: In our study, after biochemical, histopathological, ultrastructural and neurological functional examination, it was demonstrated that Anzer propolis has sufficient neuroprotective effect on spinal cord ischemia/reperfusion injury in rabbits.

Abstract Atrial septal aneurysm (ASA) is an uncommon but well-recognized cardiac abnormality. This educational text reviews the case of a 54-year-old female presenting an ASA related to a small ostium secundum atrial septal defect. The considerable signs and symptoms, interestingly, have not been justified by the clinical and hemodynamic investigations. So, we opted for a better imaging investigation with cardiac catheterization and transesophageal echocardiography. The surgical process was earlier indicated and performed with aid of cardiopulmonary bypass.

Abstract A 32-month-old girl with patent ductus arteriosus, false tendon of left ventricle, mild pulmonary hypertension, and chronic cardiac insufficiency (cardiac function level I-II) was misdiagnosed with Marfan Syndrome and there was no improvement in her physical growth after operation for this disease. The preterm baby was finally diagnosed with Myhre Syndrome by clinical phenotypes and mutation of SMAD4 gene.

Abstract Introduction: Coronary artery ectasia (CAE) is one of the uncommon cardiovascular disorders and its prognosis is still debated. Objective: We aimed to review long-term follow-up data in patients with CAE and to evaluate the prognosis of CAE patients with coronary slow flow phenomenon (CSFP). Methods: This study had a prospective design and 143 patients with CAE were included. The angiographic and demographic characteristics were reviewed in detail. The patients were categorized, based on concomitant coronary artery stenosis detected by angiography, as CCAE group (n=87, ≥30% luminal stenosis) and ICAE group (n=56, <30% luminal stenosis) and also categorized by the coronary flow as CSFP group (n=51) and normal flow coronary ectasia - NCEA group (n=92). All patients were re-evaluated at 6-month intervals. Follow-up data, cardiovascular (CV) mortality, hospitalization and major adverse cardiac events (MACE) were collected. The level of statistical significance was set at 5%. Results: Patients were followed up for an average of 56.9±7.4 months. During the follow-up, statistically significant differences were found in hospitalization, CV mortality and MACE between the CCAE and ICAE groups (P=0.038, P=0.003, P=0.001, respectively). The CSFP and NCEA groups were also compared. There was a statistical difference with respect to hospitalization between the CFSP and NCEA groups (P=0.001), but no difference was observed in terms of MACE and CV mortality (P=0.793 and P=0.279). Conclusion: CSFP accompanying CAE may be a predictor of hospitalization. Significant atherosclerotic plaques coexisting with CAE may be predictive for MACE.

Abstract Introduction: Risk scores are important tools for predicting adverse events in cardiac surgery, but their accuracy varies when applied to different populations. The objective of this study is to evaluate the performance of the Brazilian score InsCor as a predictor of mortality after coronary artery bypass grafting (CABG) compared to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Society of Thoracic Surgeons (STS) scores. Methods: This is an observational and retrospective study, with patients undergoing surgical myocardial revascularization in a cardiology hospital in Salvador (Bahia, Brazil), between 2010 and 2015. InsCor, STS, and EuroSCORE were compared for accuracy in predicting mortality within 30 days after surgery. Discrimination capacity of models was assessed using areas under receiver operating characteristic (ROC) curves. Significance level was 5%. Results: Four hundred sixty-one patients were evaluated (mean age 63 [± 8.6] years, 77% men). Thirty-day mortality was 2.6%. InsCor classified 88, 210, and 163 patients as having low, medium, and high risk of death, respectively. According to EuroSCORE and STS, 379 and 430 patients were classified as having low risk and 77 and 29 as medium risk, respectively. Area under the ROC curve was 0.734 (P=0.002) for InsCor, 0.615 (P=0.027) for EuroSCORE, and 0.623 (P=0.033) for STS. ROC curve of InsCor maintained statistical significance after adjustment for other models. Conclusion: The InsCor score, derived from a Brazilian sample, showed good predictive accuracy of death up to 30 days in patients undergoing CABG in relation to STS and EuroSCORE scores.

Abstract The coarctation of the aorta is a relatively highly prevalent congenital heart disease and may be diagnosed as an underline cause of hypertension in adolescents and adults. The gold standard treatment for coarctation of the aorta in these patients is being replaced - from open surgery to endovascular therapy. Some prostheses have been developed to treat the coarctation with less acute and chronic complications. The Dominus® Coarctation Aorta (Braile Biomédica) is the first self-expandable prosthesis created specifically to treat coarctation of the aorta, reducing possible acute complications, like aortic rupture or aortic dissection. Here, we discuss the step-by-step method for using this prosthesis.

Abstract Introduction: High leuko-glycaemic index (LGI) (> 2000) has been associated with poor prognosis in many critical care settings. However, there is no evidence of LGI’s prognostic value in the postoperative period of coronary artery bypass grafting (CABG). This study aims to analyze the prognostic value of LGI in the postoperative period of CABG. Methods: Single-center retrospective analysis of prospectively collected data was performed. Consecutive adult patients undergoing CABG between 2007 and 2019 were included. Blood glucose levels and white blood cells count were evaluated in the immediate postoperative period. LGI was calculated by multiplying both values and dividing them by 1,000 and analyzed in quartiles. Receiver operating characteristic curve was used to determine the best cutoff value. The primary combined endpoint was in-hospital mortality, low cardiac output (LCO), or acute kidney injury (AKI). Secondary endpoints included in-hospital death, AKI, atrial fibrillation, and LCO. Results: The study evaluated 3,813 patients undergoing CABG (88.5% male, 89.8% off-pump surgery, aged 64.6 years [standard deviation 9.6]). The median of LGI was 2,035. Presence of primary endpoint significantly increased per LGI quartile (9.2%, 9.7%, 11.8%, and 15%; P<0.001). High LGI was associated with increased occurrence of in-hospital mortality, LCO, AKI, and atrial fibrillation. The best prognostic cutoff value for primary endpoint was 2,000. In a multivariate logistic regression model, high LGI was independently associated with in-hospital death, LCO, or AKI. Conclusion: High LGI was an independent predictor of in-hospital mortality, LCO, or AKI in postoperative period of CABG. It was also associated with higher in-hospital death.