Coronary artery bypass surgery in Brazil: analysis of the national reality through the bypass registry

Abstract Introduction: Coronary artery bypass grafting (CABG) is the most frequently performed heart surgery in Brazil. Recent international guidelines recommend that national societies establish a database on the practice and results of CABG. In anticipation of the recommendation, the BYPASS Registry was introduced in 2015. Objective: To analyze the profile, risk factors and outcomes of patients undergoing CABG in Brazil, as well as to examine the predominant surgical strategy, based on the data included in the BYPASS Registry. Methods: A cross-sectional study of 2292 patients undergoing CABG surgery and cataloged in the BYPASS Registry up to November 2018. Demographic data, clinical presentation, operative variables, and postoperative hospital outcomes were analyzed. Results: Patients referred to CABG in Brazil are predominantly male (71%), with prior myocardial infarction in 41.1% of cases, diabetes in 42.5%, and ejection fraction lower than 40% in 9.7%. The Heart Team indicated surgery in 32.9% of the cases. Most of the patients underwent cardiopulmonary bypass (87%), and cardioplegia was the strategy of myocardial protection chosen in 95.2% of the cases. The left internal thoracic artery was used as a graft in 91% of the cases; the right internal thoracic artery, in 5.6%; and the radial artery in 1.1%. The saphenous vein graft was used in 84.1% of the patients, being the only graft employed in 7.7% of the patients. The median number of coronary vessels treated was 3. Operative mortality was 2.8%, and the incidence of cerebrovascular accident was 1.2%. Conclusion: CABG data in Brazil provided by the BYPASS Registry analysis are representative of our national reality and practice. This database constitutes an important reference for indications and comparisons of therapeutic procedures, as well as to propose subsequent models to improve patient safety and the quality of surgical practice in the country.

Papel do suporte circulatório nas síndromes coronarianas aguda / The role of circulatory support in acute coronary syndromes

O tratamento da síndrome coronariana aguda obteve expressiva redução da mortalidade graças ao desenvolvimento de novos fármacos e da angioplastia coronariana primária. Entretanto, apesar desta terapêutica ser eficiente e oferecer resultados adequados no tratamento do infarto agudo do miocárdio (IAM), o choque cardiogênico ainda ocorre em 5 a 10% dos casos e continua a ser a principal causa de mortalidade intra-hospitalar. Portanto, temos um desfecho clínico insatisfatório neste grupo de pacientes com prognóstico reservado a curto e longo prazo. O balão intra-aórtico, embora empregado de forma rotineira no tratamento do choque cardiogênico refratário, apresenta benefícios limitados e não apresenta impacto no prognóstico destes pacientes, como demonstrado em ensaios randomizados recentes. Os sistemas de suporte de vida extracorpóreo (ECLS) são considerados dispositivos eficazes para o tratamento do choque cardiogênico refratário no IAM, uma vez que oferecem fluxo sanguíneo adequado e são instalados rapidamente pela canulação de vasos periféricos. Deste modo, permitem a tomada de decisões médicas para a realização de intervenções diagnósticas e terapêuticas – ponte para decisão – para tratamento da causa clínica e anatômica, com resultados clínicos consistentes e encorajadores para autilização deste tipo de tecnologia...

The treatment of acute coronary syndrome has achieved a significant reduction in mortality, thanks to the development of new drugs and primary coronary angioplasty. However, although this therapy is efficient and offers adequate results in the treatment of acute myocardial infarction (AMI), cardiogenic shock still occurs in 5% to 10% of cases, and continues to be the main cause of intra hospital mortality. Therefore, we have an unsatisfactory clinical outcome in this group of patients, with a reserved prognosis in the short and long terms.The intra-aortic balloon pump, although used routinely in the treatment of refractory cardiogenic shock, has limited benefits and does not have any impact on patient prognosis, as demonstrated in recent randomized trials. Extracorporeal life support systems (ECLS) are considered effective devices for the treatment of refractory cardiogenic shock in AMI, as they offer adequate blood flow and are rapidly installed through cannulation of the peripheral veins. They therefore enable medical decision-making for diagnostic and therapeutic interventions – decision-making bridge – for treatment of the clinical and anatomical cause, with consistent and encouraging clinical results for the use of this type of technology...

Cardiopulmonary bypass increases the risk of vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure / O uso da circulação extracorpórea aumenta o risco de síndrome vasoplégica em pacientes com insuficiência renal crônica hemodialítica submetidos à revascularização cirúrgica do miocárdio

AbstractObjective:Coronary artery bypass grafting is currently the best treatment for dialysis patients with multivessel coronary artery involvement. Vasoplegic syndrome of inflammatory etiology constitutes an important postoperative complication, with highly negative impact on prognosis. Considering that these patients have an intrinsic inflammatory response exacerbation, our goal was to evaluate the incidence and mortality of vasoplegic syndrome after myocardial revascularization in this group.Methods:A retrospective, single-center study of 50 consecutive and non-selected dialysis patients who underwent myocardial revascularization in a tertiary university hospital, from 2007 to 2012. The patients were divided into 2 groups, according to the use of cardiopulmonary bypass or not (off-pump coronary artery bypass). The incidence and mortality of vasoplegic syndrome were analyzed. The subgroup of vasoplegic patients was studied separately.Results:There were no preoperative demographic differences between the cardiopulmonary bypass (n=20) and off-pump coronary artery bypass (n=30) group. Intraoperative data showed a greater number of distal coronary arteries anastomosis (2.8 vs. 1.8, P<0.0001) and higher transfusion rates (65% vs. 23%, P=0.008) in the cardiopulmonary bypass group. Vasoplegia incidence was statistically higher (P=0.0124) in the cardiopulmonary bypass group (30%) compared to the off-pump coronary artery bypass group (3%). Vasoplegia mortality was 50% in the cardiopulmonary bypass group and 0% in the off-pump coronary artery bypass group. The vasoplegic subgroup analysis showed no statistically significant clinical differences.Conclusion:Cardiopulmonary bypass increased the risk for developing postoperative vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure.

ResumoObjetivo:O melhor tratamento atual para os pacientes dialíticos com acometimento coronariano multiarterial é a revascularização cirúrgica do miocárdio. Dentre as complicações pós-operatórias, a síndrome vasoplégica de etiopatogenia inflamatória torna-se importante pelo impacto altamente negativo no prognóstico. Considerando que esses pacientes possuem uma exacerbação intrínseca da resposta inflamatória, nosso objetivo foi avaliar a incidência e a mortalidade da síndrome vasoplégica no pós-operatório de revascularização miocárdica nesse grupo.Métodos:Estudo retrospectivo, unicêntrico, de 50 pacientes dialíticos consecutivos e não selecionados, submetidos à revascularização miocárdica, em um hospital terciário universitário, no período de 2007 a 2012. Esses pacientes foram divididos em 2 grupos, de acordo com o emprego ou não da circulação extracorpórea. A incidência e a mortalidade da vasoplegia foram analisadas nos grupos. Após a identificação dos pacientes quanto à presença de vasoplegia, este subgrupo foi estudado separadamente.Resultados:Não houve diferenças demográficas pré-operatórias entre os grupos com circulação extracorpórea (n=20) e sem circulação extracorpórea (n=30). Dados intraoperatórios demonstraram maior número de artérias coronárias revascularizadas (2,8 vs. 1,8; P<0,0001) e maior necessidade de transfusão (65% vs. 23%; P=0,008) no grupo circulação extracorpórea. A incidência de vasoplegia foi estatisticamente maior (P=0,0124) no grupo circulação extracorpórea (30%) em comparação ao grupo sem circulação extracorpórea (3%). A mortalidade dos pacientes com vasoplegia foi 50% no grupo circulação extracorpórea e 0% no grupo sem circulação extracorpórea. A análise do subgrupo vasoplégico não demonstrou diferenças clínicas estatisticamente significantes.Conclusão:O emprego da circulação extracorpórea na revascularização cirúrgica do miocárdio em pacientes com insuficiência renal crônica dialítica aumentou o risco para desenvolvimento de síndrome vasoplégica pós-operatória.

Sildenafil melhora a função ventricular direita no receptor de transplante cardíaco / Sildenafil improves right ventricular function in a cardiac transplant recipient

Relatamos caso de um paciente submetido a transplante cardíaco ortotópico, onde se utilizou um doador marginal pela piora clínica do receptor, que apresentava choque cardiogênico por disfunção de ventrículo direito secundária a hipertensão pulmonar associado à vasoplegia. Obtivemos recuperação hemodinâmica do paciente, com redução da resistência vascular pulmonar, retirada de drogas vasoativas e recuperação da função do ventrículo direito após a introdução de sildenafil.

Revascularizaçäo do miocárdio em pacientes com transplante renal / Myocardial revascularization in renal transplant patients

OBJECTIVE - To assess the results of surgical myocardial revascularization in renal transplant patients. METHODS - From 1991 to 2000, 11 renal transplant patients, whose ages ranged from 36 to 59 (47.5±8) years, 8 males and 3 females, underwent myocardial revascularization. The time interval between renal transplantation and myocardial revascularization ranged from 25 to 120 (mean of 63.8±32.7) months. RESULTS - The in-hospital mortality rate was 9 percent. One patient died on the 4th postoperative day from septicemia and respiratory failure. The mean graft/patient ratio was 2.7±0.8. Only 1 patient required slow hemodialysis during 24 hours in the postoperative period, and no patient had a definitive renal lesion or lost the transplanted kidney. The actuarial survival curves after 1, 2, and 3 years were, respectively, 90.9 percent, 56.8 percent, and 56.8 percent. CONCLUSION - Renal transplant patients may undergo myocardial revascularization with no lesion in or loss of the transplanted kidney