Perspectives in Training and Professional Practice of Cardiac Surgery in Latin America

ABSTRACT Introduction: There is a lack of information about cardiac surgery training and professional practice in Latin American (LATAM) countries. This study is the first comparative analysis of cardiac surgical training and professional practice across LATAM and provides the fundamentals for future academic projects of the Latin American Association of Cardiac and Endovascular Surgery (LACES). Methods: International survey-based comparative analysis of the training and professional practice of cardiac surgeons across LATAM. Trainees (residents/fellows) and staf (graduated) surgeons from LATAM countries were included. Results: A total of 289 respondents (staf surgeons N=221 [76.5%]; residents/fellows N=68 [23.5%]) from 18 different countries participated in the survey. Most surgeons (N=92 [45.3%]) reported being unsatisfied with their salaries. Most respondents (N=181 [62.6%]) stated that it was difficult to obtain a leadership position, and 149 (73.8%) stated that it was difficult to find a job after completing training. Only half of the trainee respondents (N=32 [47.1%]) reported that their program had all resident spots occupied. Only 22.1% (N=15) of residents/fellows were satisfied with their training programs. The majority (N=205 [70.9%]) of respondents would choose cardiac surgery as their specialty again. Most surgeons (N=129 [63.9%]) and residents/fellows (N=52 [76.5%]) indicated that the establishment of a LATAM cardiac surgery board examination would be beneficial. Conclusion: Modernization and standardization of training, as well as greater access to opportunities, may be required in LATAM to increase professional satisfaction of cardiac surgeons and to reduce disparities in the specialty. Such changes may enhance the regional response to the dynamic challenges in the feld.

Impact of the COVID-19 Outbreak on Coronary Artery Bypass Grafting in Brazil

Abstract Background The COVID-19 pandemic has disrupted the routine of emergency centers around the world, including in Brazil, where the crisis has affected the volume of major cardiac surgeries such as coronary artery bypass grafting. Objective To analyze the impact of the COVID-19 pandemic on the number of surgical procedures for coronary artery bypass grafting in Brazil. Methods An ecological, cross-sectional, quantitative, and descriptive study was conducted. Data for the period from July 2018 to June 2019 and from July 2020 to June 2021 were collected from SIHSUS using DATASUS/Tabwin. Results A global reduction of 26.58% was observed in the analyzed population, with on-pump coronary artery bypass grafting decreasing by 28.10%, and off-pump coronary artery bypass grafting reduced by only 10.31%. Conclusion During the pandemic, there was a 26.58% reduction in the number of surgical procedures for myocardial revascularization in Brazil.

Endovascular treatment of the ascending aorta: is this the last frontier in aortic surgery?

Abstract Regardless the successful treatment of the descending aorta with endovascular prosthesis, for the ascending aorta segment, because of several anatomic and physiologic issues, this technique has been considered an alternative only for high-risk or inoperable patients. Despite restricted indications, hundreds of treatments have been performed worldwide, demonstrating its safety and reproducibility if it is done in high-quality centers. Therefore, understanding patients' selection criteria and technique limitations are critical to its application.

Benefício do uso de recuperadores de hemácias em cirurgias cardiovasculares / Benefit from using recycling red blood cells in cardiovascular surgery

Objetivo: Avaliar se o uso de recuperadores de hemácias está indicado nos pacientes submetidos à cirurgia cardiovascular com o uso de circulação extracorpórea. Métodos: Foram estudados 77 pacientes submetidos a cirurgias cardíacas com uso de recuperadores de hemácias e circulação extracorpórea de novembro de 2010 a junho de 2012. A amostra foi subdividida em três grupos, conforme o tempo de circulação extracorpórea. No grupo A ,o tempo de circulação extracorpórea foi menor que 45, no grupo B, de 45 a 90 e, no grupo C, maior que 90 minutos. Analisou-se o volume recuperado e infundido de hemácias, a hemoglobina de pré, trans e pós-operatório, número de unidades de concentrado de hemácias transfundidas, volume globular e hemoglobina do sangue infundido. Resultados: A idade média, dos pacientes, foi de 60,44±12,09 anos, sendo 71,43% do sexo masculino. O grupo A é formado por 5,19%, o B por 81,82% e o C por 12,99% dos pacientes. O volume recuperado e infundido foi, respectivamente, de 1.360,50±511,37 ml e 339,75±87,71 ml no grupo A, 1.436,63±516,06 ml e 518,83±183,0 ml no B e 2.137,00±925,04 ml e 526,20±227,15 ml no C. Em relação às transfusões de concentrado de hemácias, no grupo A foram transfundidas 1,00±2,00 concentrado de hemácias, no B 1,27±1,85 concentrado de hemácias e no C 2,56±2,01 concentrado de hemácias. O sangue infundido tinha um volume globular de 50,97±12,06% e hemoglobina de 19,57±8,35 g/dl. Conclusão: O recuperadores de hemácias podem ser usados em pacientes submetidos à cirurgia cardiovascular com circulação extracorpórea, mas somente em cirurgias com tempo de circulação extracorpórea acima de 45 minutos o reaproveitamento de sangue ...

Objective: To show if blood salvage is indicated in all patients submitted to cardiovascular surgery with cardiopulmonary bypass. Methods: We studied 77 consecutive patients submitted to cardiac surgery with use of blood salvage and cardiopulmonary bypass from November 2010 to June 2012. The sample was divided in three groups, depending on the time of cardiopulmonary bypass. In group A, the time of cardiopulmonary bypass was smaller than 45, in group B from 45 to 90 and in group C greater than 90 minutes. We analyzed the volume of red cells recovered and infused, the pre, intra and post-operative hemoglobin, the number of packed red cells units which were transfused and hematocrit and hemoglobin blood infused. Results: The average group age was 60.44±12.09 years old, of whom 71.43% were males. The group A was formed by 5.19% of the patients, B by 81.82% and C by 12.99%. The volume of erythrocytes recovered and infused was respectively 1,360.50±511.37 ml and 339.75±87.71 ml in group A, 1,436.63±516.06 ml and 518.83±183.0 ml in B and 2,137.00±925.04 ml and 526.20±227.15 ml in C. About packed red cells transfusions, in group A 1,00±2,00 packed red cells were transfused, in B 1.27±1.85 packed red cells and in C 2.56±2.01 packed red cells. The infused blood had a hematocrit of 50.97±12.06% and hemoglobin of 19.57±8.35 g/dl. Conclusion: That blood salvage can be used in patients submitted to cardiovascular surgery with cardiopulmonary bypass. However, it is only cost-effective in surgeries in which the time of cardiopulmonary bypass is greater than 45 minutes. .

O uso de recuperador de sangue em cirurgia cardíaca com circulação extracorpórea / The use of cell saver system in cardiac surgery with cardiopulmonary bypass

INTRODUÇÃO: O uso de recuperador de sangue (RS) em cirurgia cardíaca é proposto para diminuir o uso de unidades de concentrado de hemácias estocadas (UCH), que aumenta morbidade, mortalidade e reações inflamatórias. OBJETIVO: O objetivo deste estudo é avaliar se o uso do RS diminui o emprego de UCH, é custo/efetivo e traz benefícios ao paciente. MÉTODOS: Estudo prospectivo realizado entre novembro de 2009 e outubro de 2011, em 100 pacientes consecutivos, submetidos à cirurgia cardiovascular com circulação extracorpórea (CEC), hemodiluição mínima e hemofiltração. Os pacientes foram divididos em grupo 1 (sem RS) e 2 (com RS). Os critérios para a reposição de UCH foram instabilidade hemodinâmica e hemoglobina (Hb) <7-8g/dl. Foram analisados dados demográficos, Hb, hematócrito (Ht), drenagem mediastinal e reposição de UCH, em diversos intervalos, e tempos de CEC, UTI e hospital. RESULTADOS: Nos grupos 1 e 2, a idade média foi de 64,2 e 60,6 anos, com predominância do sexo masculino, o EuroSCORE logístico de 10,3 e 9,6 e a mortalidade de 2% e 4%, não relacionada ao estudo. O grupo 2 apresentou incidência de reoperações superior (12 x 6%), mas o número de UCH usado (4,31x1,25) e o tempo de internamento hospitalar (10,8x7,4) foram menores. Realizada análise uni e multivariada, que não demonstrou valores estatisticamente significativos, exceto no uso de UCH. A relação entre o custo do RS e das UCH foi custo/efetiva e o tempo de internamento, menor. CONCLUSÃO: O uso de RS diminui o número de UCH usadas, não é custo/efetivo e mostrou benefícios ao paciente.

INTRODUCTION: The use of cell saver (CS) in cardiac surgery is proposed to reduce the use of units of packed red blood cells stored (URBC), which increases morbidity, mortality and causes inflammatory reactions. OBJECTIVE: The objective is to evaluate whether the use of CS decreases the use URBC, is cost /effective and beneficial to the patient. METHODS: In a prospective study, between November 2009 and October 2011, 100 consecutive patients who underwent cardiovascular surgery with CPB, hemodilution and hemofiltration, were enrolled. Patients were divided into group 1 (no CS) and 2 (CS). The criteria for the replacement of RBC were hemodynamic instability and hemoglobin (Hb) <7-8g/dl. Demographic data, as well as Hb and hematocrit, mediastinal drainage, number of URBC and CPB, ICU and hospital time, were analysed. RESULTS: In groups 1 and 2 the average age was 64.1 and 60.6 years; predominantly male; the logistic EuroSCORE 10.3 and 9.4; mortality 2% and 4%. Group 2 had a higher incidence of reoperations (12% versus 6%), but the average of URBC used (4.31 versus 1.25) and mean length of hospital stay (10.8 versus 7.4 days) was lower. Univariate and multivariate analysis, were performed, which showed no statistically significant values, except in the use of URBC. The relationship between the CS and the cost of RBC was not cost /effective and length of stay was shorter. CONCLUSION: The use of CS decreases the number of used URBC, is not cost /effective but has shown benefits for patients.

Análise dos resultados imediatos da cirurgia de revascularização do miocárdio com e sem circulação extracorpórea / Analysis of immediate results of on-pump versus off-pump coronary artery bypass grafting surgery

OBJETIVO: Comparar os resultados imediatos da cirurgia de revascularização do miocárdio com e sem circulação extracorpórea (CEC). MÉTODOS: De janeiro de 2007 a janeiro de 2009, 177 pacientes foram submetidos a cirurgia de revascularização do miocárdio (CRM), sendo 92, sem CEC e 85 com CEC. Foram avaliados distribuição demográfica, fatores de risco pré-operatórios, classe funcional e avaliação de risco pelo EuroSCORE. A evolução no pós-operatório foi comparada entre os grupos. RESULTADOS: A média de enxertos por paciente foi de 2,48 ± 0,43, no grupo sem CEC, e 2,90 ± 0,59, no com CEC. No grupo sem CEC, 97,8% dos pacientes receberam um enxerto de artéria torácica interna, enquanto que no grupo com CEC a porcentagem foi de 94,1% (P = 0,03). A taxa de revascularização completa foi similar em ambos os grupos. No grupo sem CEC, a artéria circunflexa foi revascularizada em 48,9% dos casos e, em 68,2%, no grupo com CEC (P = 0,01). A mortalidade hospitalar foi de 4,3% e 4,7%, respectivamente, no grupo sem CEC e com CEC (P = 0,92). Os pacientes operados sem CEC apresentaram menor índice de complicações em relação ao infarto perioperatório (P= 0,02) e ao uso de balão intra-aórtico (P= 0,01). CONCLUSÃO: A cirurgia coronariana sem CEC é um procedimento seguro, com mortalidade hospitalar similar a dos pacientes operados com CEC, com menores taxas de complicações e de incidência de infarto perioperatório, bem como menor necessidade de balão intra-aórtico.

OBJECTIVE: The objective of this study is to compare the immediate results of patients undergoing on-pump versus off-pump coronary artery bypass graft (CABG) surgery. METHODS: From January 2007 to January 2009, 177 patients underwent CABG, being 92 off-pump and 85 onpump. We evaluated the demographics, preoperative risk factors, preoperative functional class and risk assessment by the EuroSCORE. The postoperative evolution was compared between groups. RESULTS: The mean number of grafts per patient was 2.48 ± 0.43 in off-pump group and 2.90 ± 0.59 in on-pump group. In the off-pump group, 97.8% of patients received an internal thoracic artery graft, while on-pump group the percentage was 94.1% (P = 0.03). The rate of complete revascularization was similar in both groups. In off-pump group, the circumflex artery was revascularized in 48.9% and 68.2% in the onpump group (P = 0.01). Hospital mortality was 4.3% and 4.7%, respectively in the off-pump group in the on-pump group (P = 0.92). Off-pump group had fewer complications in relation to perioperative myocardial infarction (P = 0.02) and use of intra-aortic balloon pump (P = 0.01). CONCLUSION: The off-pump CABG is a safe procedure with hospital mortality similar to that observed in on-pump CABG, with lower rates of complications and less need for intra-aortic balloon.

Remodelamento reverso cirúrgico do ventrículo esquerdo: seguimento de 111 meses / Surgical reverse remodelling of the left ventricle: 111 months of follow-up

Objetivo: Apresentar a experiência do Instituto de Cirurgia Cardiovascular do Oeste do Paraná (ICCOP) com o tratamento de aneurismas de ventrículo esquerdo, com a técnica de endoventriculoplastia com exclusão septal (EVES), imediata e o seguimento por 111 meses. Métodos: No período de abril de 1999 a 2006, 28 pacientes foram submetidos a EVES, pelo autor. Foram analisadas, retrospectivamente, variáveis clínicas e ecocardiográficas pré, trans e pós-operatórias tardias. A idade média era de 59,0 ± 9,5 anos, sendo 23 pacientes do sexo masculino. Dezessete pacientes estavam em classe funcional IV e o EuroScore médio foi 8,2 ± 2,3. Os valores pré-operatórios de fração de ejeção, volumes sistólico e diastólico finais do ventrículo esquerdo foram, respectivamente, 32,3 ± 9,2 por cento, 113,9 ± 36,0 ml e 179,2 ± 48,4 ml. Foi aplicada a versão brasileira do questionário de qualidade de vida SF36 no pós-operatório tardio. Resultados: A mortalidade imediata foi de quatro pacientes por síndrome de baixo débito e arritmia. O tempo médio de seguimento pós-operatório foi 5,6 ± 3,2 anos. A fração de ejeção de ventrículo esquerdo foi fator significativo na mortalidade imediata (P=0,0222) e o tempo de parada cardíaca anóxica na tardia (P=0,0123). A análise atuarial de sobrevivência demonstrou uma sobrevida de 82,1 ± 7,2 por cento, e 54,7 ± 22,9 por cento, respectivamente, antes e depois de 107 meses, de seguimento. Conclusões: A cirurgia da EVES é efetiva no tratamento desse grupo de pacientes, com melhora da função ventricular esquerda (de 32,3 para 46,4 por cento) e da qualidade de vida dos pacientes.

Objective: To present the Instituto de Cirurgia Cardiovascular do Oeste do Paraná' (ICCOP) surgical experience, on the treatment of left ventricle aneurysms, by endoventriculoplasty, with septal exclusion (EVSE), and a 111 months follow-up. Methods: Between April 1999 and April 2006, 28 patients were submitted to EVSE, by the author. Pre, trans and late post clinical and echocardiographic variables were analyzed retrospectively. Mean age was 59.0 ± 9.5 years, being 23 male patients. Seventeen patients were in NYHA functional class IV and the mean EuroScore was 8.2 ± 2.3. The mean pre-operative values for ejection fraction, end systolic and diastolic left ventricular volumes were 32.3 ± 9.2 percent, 113.9 ± 36.0 ml e 179.2 ± 48.4 ml, respectively. The BraziliAnVErsion of the SF36 quality of life questionnaire was applied in the late follow up period. Results: Four patients died in the immediate post-operative period, being the major cause of morbidity low cardiac output syndrome and arrhythmias. The mean follow-up period was 5.6 ± 3.2 years. Left ventricle's ejection fraction and aortic cross clamping time were the significant factors for hospital and late mortality with P = 0.0222 and P = 0.0123, respectively. Actuarial survival curve showed a survival of 82.1 ± 7.2 percent, and 54.7 ± 22.9 percent, pre and post 107 months, of follow-up. Conclusion: EVSE' surgery is an effective option to treat this group of patients, with improvement of left ventricular function (from 32.3 to 46.4 percent) and patients' quality of life.