Coronary Artery Bypass Grafting: A Comparative Exercise between Patients from the BYPASS Registry and Patients from a University Hospital

ABSTRACT Introduction: The coronary artery bypass grafting (CABG) data provided by the Brazilian Registry of Cardiovascular Surgeries in Adults (BYPASS) Registry is a Brazilian reality. Objective: To carry out a comparative exercise between the BYPASS Registry published data and data from patients operated on in a randomly chosen period (2013-2015) at Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP). Methods: This is a retrospective study reviewing 173 electronic medical records of CABG patients from the HCFMRP-USP. These data were compared with the BYPASS Registry published data. Chi-square test was used to verify the changes within the prevalence of adequate/inadequate biochemical tests before and after surgery. The sample was divided into groups consistent with cardiopulmonary bypass (CPB) time (CPB ≤ 120 minutes and CPB > 120 minutes). For the complications, prevalence by the chi-square test was adopted. Significant P-values are < 0.05. Results: The comparative operative data of the BYPASS Registry and the HCFMRP-USP patients were quite similar, except for the isolate use of only arterial grafts, which was more frequent on HCFMRP-USP patients (30.8% vs. 15.9%), and the use of radial artery, also more frequent on HCFMRP-USP patients (48.8% vs. 1.1%) Conclusion: The comparative study suggested that the BYPASS Registry should be a reference for CABG quality control.

Cirurgia de Endocardite Infecciosa. Análise de 328 Pacientes Operados em um Hospital Universitário Terciário / Infective Endocarditis Surgery. Insights from 328 Patients Operated in a University Tertiary Hospital

Resumo Fundamento A endocardite infecciosa (EI) refere-se à infecção da superfície endocárdica do coração e geralmente ocorre em valvas nativas ou protéticas. Objetivo Este estudo teve como objetivo levantar dados de EI refletindo a terapêutica cirúrgica, em um Hospital Universitário do interior do estado de São Paulo - Brasil. Método Abordagem retrospectiva e observacional de 328 pacientes com EI operados entre 1982 e 2020 Resultados Os principais dados (n=121/37%), insuficiência cardíaca congestiva (n=114/35%), valvopatia (n=92/28%), diabetes mellitus (n=85/26%), doença renal crônica (n=59/18%) e febre reumática (49/15%). A insuficiência renal é um dos principais e mais relevantes fatores de risco pré-cirúrgicos para um mau prognóstico. Conclusão Para um melhor resultado clínico e cirúrgico é necessário o diagnóstico sindrômico e etiológico precoce da EI, principalmente em pacientes com múltiplas comorbidades.

Abstract Background Infectious endocarditis (IE) refers to infection of the endocardial surface of the heart and usually occurs in native or prosthetic valves. Objective This study aimed to raise IE data reflecting the surgical therapy in a University Hospital in the interior of the State of Sao Paulo-Brazil. Method Retrospective and observational approach of 328 patients with IE who underwent surgery between 1982 and 2020 Results The main data (n=121/37%), congestive heart failure (n=114/35%), valve disease (n=92/28%), diabetes mellitus (n=85/26%), chronic kidney disease (n=59/18%), and rheumatic fever (49/15%). Renal failure is one of the main and most relevant pre-surgical risk factors for a poor prognosis. Conclusion For a better clinical and surgical outcome, an early syndromic and etiological diagnosis of IE is necessary, especially in patients with multiple comorbidities.

Indigo Carmine Hemodynamic Studies to Treat Vasoplegia Induced by Compound 48/80 in a Swine Model of Anaphylaxis

Abstract Introduction: There are many reasons to believe that the nitric oxide/guanosine 3'5' - cyclic monophosphate (or NO/cGMP) pathway on vasoplegic states is underestimated. To study indigo carmine (IC) as an alternative to methylene blue was the investigation rationale. Methods: The IC (3mg/kg intravenous infusion) study protocol included five experimental groups; 1) Control group — saline was injected at 0 and 10 minutes; 2) IC group — IC was injected at 0 and saline at 10 minutes; 3) compound 48/80 (C48/80) group — C48/80 was injected at 0 minute and saline at 10 minutes; 4) C48/80 + IC group — C48/80 was injected at 0 minute and IC at 10 minutes; and 5) IC + C48/80 group — IC was injected at 0 minute and C48/80 at 10 minutes. The studies were carried out by registering and measuring hemodynamic and blood gasometric parameters, including continuous cardiac output. Results: 1) The effects of the drugs (IC and C48/80) were more evident in the first 20 minutes of recording; 2) hypotensive responses were more pronounced in the C48/80 groups; 3) IC isolated or applied before C48/80 caused transient pulmonary hypertension; and 4) after the first 20 minutes, the pressure responses showed stability with apparent hypotension more pronounced in the C48/80 groups. Clinical observations showed significant hemodynamic instability and catastrophic anaphylactic reactions (agitation, pulmonary hypertension, severe bronchospasm, urticaria, high-intensity cyanosis, violent gastric hypersecretion, and ascites). Conclusion: A global results analysis showed differences between groups only in the first 20 minutes of the experiments.

Methylene Blue to Neonatal Septic Shock treatment in neonate pigs,

Abstract Objective The authors design an animal model of neonatal sepsis to analyze the treatment of neonatal septic shock with Methylene Blue (MB) in a swine model. Methods The study design included twenty male newborn pigs divided into four groups: 1) The control group; 2) The sepsis group (induced with lipopolysaccharide); 3) The MB group, and 4) The MB-treated sepsis group. Septic shock was defined as Blood Pressure (BP) dropping 20% below the baseline value. Continuous Blood Pressure (BP), Nitric Oxide (NO) levels, cyclic Guanosine Monophosphate (cGMP), malondialdehyde acid, base excess, lactate, arterial blood gases, hematocrit, and echocardiography were analyzed. Results The BP of the sepsis group treated with MB showed a slight improvement in the first hour after treatment; however, a significant difference was not observed compared to the untreated sepsis group. Besides hemodynamic stability, the current study did not show symptomatic pulmonary hypertension, suggesting that MB was safe in neonates and children. An improvement in Base Excel (BE) levels after MB administration in septic animals may indicate a possible improvement in microcirculation. Conclusion The MB improved biomarkers related to septic shock prognosis, although an improvement in the blood levels could not be detected. MB might be a beneficial drug for hemodynamic instability in infants.

Atrial Septal Aneurysm and Atrial Septal Defect Association - an Uncommon But Well-Recognized Association

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.

Efeito do Diterpeno Manool sobre a Pressão Arterial e Reatividade Vascular em Ratos Normotensos e Hipertensos / Effect of Diterpene Manool on the Arterial Blood Pressure and Vascular Reactivity in Normotensive and Hypertensive Rats

Resumo Fundamento: Diversos estudos têm mostrado que as classes de diterpenos exercem efeito significativo no sistema cardiovascular. Os diterpenos, em particular, estão entre os principais compostos associados às propriedades cardiovasculares, como a propriedade vasorrelaxante, inotrópica, diurética e a atividade hipotensora. Embora o mecanismo de vasorrelaxamento do manool seja visível, seu efeito sobre a pressão arterial (PA) ainda é desconhecido. Objetivo: Avaliar o efeito hipotensor in vivo do manool e verificar o efeito de vasorrelaxamento ex vivo em anéis aórticos de ratos. Métodos: Os animais foram divididos aleatoriamente em dois grupos: normotensos e hipertensos. O grupo normotenso foi submetido à cirurgia sham e adotou-se o modelo 2R1C para o grupo hipertenso. Realizou-se monitoramento invasivo da PA para testes com manool em diferentes doses (10, 20 e 40 mg/kg). Foram obtidas curvas de concentração-resposta para o manool nos anéis aórticos, com endotélio pré-contraído com fenilefrina (Phe) após incubação com Nω-nitro-L-arginina metil éster (L-NAME) ou oxadiazolo[4,3-a]quinoxalina-1-ona (ODQ). Os níveis plasmáticos de óxido nítrico (NOx) foram medidos por ensaio de quimioluminescência. Resultados: Após a administração de manool, a PA se reduziu nos grupos normotenso e hipertenso, e esse efeito foi inibido pelo L-NAME em animais hipertensos apenas na dose de 10 mg/kg. O manool ex vivo promoveu vasorrelaxamento, inibido pela incubação de L-NAME e ODQ ou remoção do endotélio. Os níveis plasmáticos de NOx aumentaram no grupo hipertenso após a administração de manool. O manool induz o relaxamento vascular dependente do endotélio na aorta de ratos, mediado pela via de sinalização NO/cGMP e redução da PA, e também pelo aumento plasmático de NOx. Esses efeitos combinados podem estar envolvidos na modulação da resistência periférica, contribuindo para o efeito anti-hipertensivo do diterpeno. Conclusão: Esses efeitos em conjunto podem estar envolvidos na modulação da resistência periférica, contribuindo para o efeito anti-hipertensivo do diterpeno.

Abstract Background: Many studies have shown that the diterpenoid classes exert a significant effect on the cardiovascular system. Diterpenes, in particular, are among the main compound links to cardiovascular properties such as vasorelaxant, inotropic, diuretic and hypotensive activity. While the manool vasorelaxation mechanism is visible, its effect on blood pressure (BP) is still unknown. Objective: To evaluate the in vivo hypotensive effect of manool and check the ex vivo vasorelaxation effect in rat aortic rings. Methods: The animals were divided randomly into two groups: normotensive and hypertensive. The normotensive group was sham-operated, and the 2K1C model was adopted for the hypertensive group. Invasive BP monitoring was performed for manool tests at different doses (10, 20 and 40 mg/kg). Concentration-response curves for manool were obtained in the aorta rings, with endothelium, pre-contracted with phenylephrine (Phe) after incubation with Nω-nitro-L-arginine methyl ester(L-NAME) or oxadiazole [4,3-a]quinoxalin-1-one (ODQ). Nitric oxide (NOx) plasma levels were measured by chemiluminescence assay. Results: After manool administration, BP was reduced in normotensive and hypertensive groups, and this effect was inhibited by L-NAME in hypertensive animals only in 10 mg/kg dose. Ex vivo manool promoted vasorelaxation, which was inhibited by L-NAME and ODQ incubation or endothelium removal. NOx plasma levels increased in the hypertensive group after manool administration. Manool elicits endothelium-dependent vascular relaxation in rat aorta mediated by the NO/cGMP signaling pathway and BP reduction, also by NOx plasma increase. These combined effects could be involved in modulating peripheral resistance, contributing to the antihypertensive effect of diterpene. Conclusion: These effects together could be involved in modulating peripheral resistance, contributing to the antihypertensive effect of diterpene.

Fragilidade entre Pacientes não Idosos Submetidos à Cirurgia Cardíaca / Frailty Among Non-Elderly Patients Undergoing Cardiac Surgery

Resumo Fundamento: Geralmente vista como uma característica da velhice, a fragilidade também pode ocorrer em pessoas não idosas, principalmente naquelas que sofrem de doenças crônicas. A fragilidade pode aumentar o risco operatório. Objetivos: Determinar a prevalência de fragilidade em pacientes submetidos à cirurgia de revascularização do miocárdio (CRM) e/ou troca ou reconstrução valvar e/ou cirurgia valvar, bem como a influência da fragilidade nos desfechos pós-operatórios. Métodos: Nosso estudo incluiu 100 adultos que foram submetidos a operações cardíacas eletivas consecutivas. A fragilidade foi avaliada por meio da escala de Fried. Os pacientes também realizaram um teste de caminhada de 6 minutos, e medimos as pressões inspiratória e expiratória máximas. Um valor de p < 0,05 foi considerado significativo. Resultados: De uma coorte de 100 pacientes, com base nos critérios de fragilidade de Fried, 17 pacientes (17%) foram considerados frágeis, 70 (70%) pré-frágeis e apenas 13 (13%) não frágeis. Entre os portadores de valvopatia, 11 (18,6%) foram considerados frágeis e 43 (73%) pré-frágeis. Cinquenta e três por cento dos pacientes considerados frágeis tinham menos de 60 anos (mediana=48 anos). As diferenças no fenótipo de fragilidade entre os pacientes com valvopatia e doença arterial coronariana não foram estatisticamente significativas (p=0,305). A comparação entre pacientes não frágeis, pré-frágeis e frágeis não mostrou diferença significativa na distribuição das comorbidades e do estado funcional cardíaco, independentemente da doença cardíaca. No entanto, a mortalidade hospitalar mostrou-se significativamente maior em pacientes frágeis (29,4%, p=0,026) que em pacientes pré-frágeis (8,6%) e não frágeis (0%). Conclusões: A fragilidade é prevalente mesmo entre pacientes não idosos submetidos a CRM ou cirurgia cardíaca valvar e está associada a maior mortalidade hospitalar pós-operatória.

Abstract Background: Usually viewed as a characteristic of old age, frailty may also occur in non-elderly people, primarily in those suffering from chronic disease. Frailty may increase operative risk. Objectives: To determine the prevalence of frailty patients undergoing coronary artery bypass (CABG) and/or heart valve replacement or reconstruction and/or heart valve surgery, as well as the influence of frailty on postoperative outcomes. Methods: Our study comprised 100 adults who underwent consecutive elective cardiac operations. Frailty was assessed using the Fried scale. Patients also performed a 6-minute walk test, and we measured maximal inspiratory and expiratory pressures. A p value <0.05 was considered significant. Results: Of a cohort of 100 patients, based on the Fried frailty criteria, 17 patients (17%) were considered frail, 70 (70%) pre-frail and only 13 (13%) were non-frail. Among patients with valvular heart disease, 11 (18.6%) were considered frail and 43 (73%) pre-frail. Fifty three percent of the patients considered frail were less than 60 years old (median=48 years old). The differences in frailty phenotype between patients with valvular heart disease and coronary artery disease were not statistically significant (p=0.305). A comparison between non-frail, pre-frail, and frail patients showed no significant difference in the distribution of comorbidities and cardiac functional status, regardless of their cardiac disease. However, hospital mortality was significantly higher in frail patients (29.4%, p=0.026) than in pre-frail patients (8.6%) and non-frail patients (0%). Conclusions: Frailty is prevalent even among non-elderly patients undergoing CABG or valvular heart surgery and is associated with higher postoperative hospital mortality.

Post-traumatic giant left ventricular pseudoaneurysm: a multimedia presentation

Abstract Traumatic left ventricular pseudoaneurysms are rare and surgical correction is the treatment of choice. In this article, it is reported a case of a myocardial stab injury with primary suture and development of a giant pseudoaneurysm, five years later, that underwent surgical repair.

Right atrium tumor extension through the inferior vena cava. considerations about nine cases operated under cardiopulmonary bypass

Abstract Introduction: Adrenocortical and renal cell carcinomas rarely invade the right atrium (RA). These neoplasms need surgical treatment, are very aggressive and have poor prognostic and surgical outcomes. Case series: We present a retrospective cohort of nine cases of RA invasion through the inferior vena cava (four adrenocortical carcinomas and five renal cell carcinomas). Over 13 years (2002-2014), nine patients were operated in collaboration with the team of urologists. Surgery was possible in all patients with different degrees of technical difficulty. All patients were operated considering the imaging examinations with the aid of CPB. In all reported cases (renal or suprarenal), the decision to use CPB with deep hypothermic circulatory arrest (DHCA) on surgical strategy was decided by the team of urological and cardiac surgeons. Conclusion: Data retrospectively collected from patients of public hospitals reaffirm: 1) Low incidence with small published series; 2) The selected cases did not represent the whole historical casuistry of the hospital, since they were selected after the adoption of electronic documentation; 3) Demographic data and references reported in the literature were presented as tables to avoid wordiness; 4) The series highlights the propensity to invade the venous system; 5) Possible surgical treatment with the aid of CPB in collaboration with the urology team; 6) CPB with DHCA is a safe and reliable option; 7) Poor prognosis with disappointing late results, even considering the adverse effects of CPB on cancer prognosis are expected but not confirmed.