Análisis ajustado de la mortalidad operatoria en cirugía cardíaca de adultos en Uruguay; 14 años de aplicación y validación del EuroSCORE I ajustado por el Fondo Nacional de Recursos / Adjusted analysis of operative mortality in cardiac surgery of adults in Uruguay, 14 years of application and validation of EuroSCORE I by the Fondo Nacional de Recursos / Análise ajustada da mortalidade operatória em cirurgia cardíaca de adultos no Uruguai, 14 anos de aplicação e validação do EuroSCORE I pelo Fondo Nacional de Recursos

Introducción: la mortalidad posoperatoria ha sido el indicador principal de los resultados a corto y mediano plazo en la evaluación de la cirugía cardíaca. Una forma de analizar dicho evento es mediante los modelos de ajuste del riesgo que identifican variables que predicen su ocurrencia. Uno de los más utilizados es el EuroSCORE I que pro-porciona la probabilidad de morir de cada individuo y que está constituido por 18 variables de riesgo. Objetivos: presentar los resultados de la aplicación y la validación del modelo EuroSCORE I en Uruguay entre los años 2003 y 2020. Metodología: inicialmente se desarrolló una validación externa del EuroSCORE I en la población uruguaya adulta tomando como población de referencia la intervenida entre los años 2003 y 2006. Una vez que se validó el EuroSCORE I, este se aplicó prospectivamente durante los años 2007 al 2020 en su versión original y con el ajuste desarrollado con población del período 2003-2006. Resultados: la aplicación del modelo original encontró que hubo 5 años en los que la razón de mortalidad observada y esperada (MO/ME) fue significativamente mayor que 1. En el período 2007-2020 el EuroScore I no calibró en 6 oca-siones, y fue aplicada la versión ajustada en la evaluación de las instituciones de medicina altamente especializada. La aplicación del modelo ajustado mostró una buena calibración para el período 2007-2020, salvo en el año 2013, y mostró una buena discriminación (área bajo la curva ROC) en todo el período evaluado. Conclusiones: las escalas de riesgo son herramientas metodológicas y estadísticas que tienen gran utilidad para la toma de decisiones en salud. Este trabajo tiene como fortaleza el de presentar datos nacionales aplicando un modelo de riesgo ampliamente utilizado en todo el mundo, lo que nos permite comparar nuestros resultados con los obte-nidos a nivel internacional (EuroSCORE I logístico original) y, por otro lado, evaluar la performance comparativa interna a lo largo de un largo período de tiempo (EuroSCORE I logístico ajustado). Para el futuro resta el desafío de comparar estos resultados, ya sea con un modelo propio o con otros internacionales de elaboración más reciente.

Introduction: postoperative mortality has been the main indicator of short- and medium-term results in the eva luation of cardiac surgery. One way to analyze such outcomes is through risk adjustment models that identify varia bles that predict the occurrence. One of the most used is the EuroSCORE I, which provides the probability of death for each individual and is made up of 18 risk variables. Objectives: present the results of the application and validation of the EuroSCORE I model in Uruguay between 2003 and 2020. Methodology: initially, an external validation of the EuroSCORE I was developed in the Uruguayan adult popula tion, taking as reference population the intervened population between 2003 and 2006. Once the EuroSCORE I was validated, it was applied prospectively during the years 2007 to 2020 in its original version and with the adjustment developed with the population of the period 2003 to 2006. Results: the application of the original model found that there were 5 years during which the observed versus ex pected mortality ratio (OM/ME) was significantly greater than 1. In the period 2007 to 2020, the EuroScore I did not calibrate on 6 occasions, the adjusted version being applied in the evaluation of highly specialized medicine institu tions. The application of the adjusted model showed a good calibration for the period 2007-2020 except in the year 2013 and showed good discrimination (area under the ROC curve) throughout the evaluated period. Conclusions: risk scales are methodological and statistical tools that are very useful for decision-making in health care. This work has the strength of presenting national data applying a risk model widely used across the world, which allows it to be compare with results at an international level (original logistical Euroscore I) and, on the other hand, to evaluate the internal comparative performance over long period of time (adjusted logistic Euroscore I). Up next is the challenge of comparing these results either with our own model or with other more recent international ones.

Introdução: a mortalidade pós-operatória tem sido o principal indicador de resultados a curto e médio prazo na avaliação da cirurgia cardíaca. Uma forma de analisar esse evento é por meio de modelos de ajuste de risco que identificam variáveis que predizem a ocorrência do evento. Um dos mais utilizados é o EuroSCORE I, que fornece a probabilidade de morrer para cada indivíduo e é composto por 18 variáveis de risco. Objetivos: apresentar os resultados da aplicação e validação do modelo EuroSCORE I no Uruguai entre os anos de 2003 e 2020. Metodologia: inicialmente, foi realizada uma validação externa do EuroSCORE I na população uruguaia adulta, tomando como referência a população operada entre 2003 e 2006. Uma vez validado o EuroSCORE I, foi aplicado prospectivamente durante os anos de 2007 a 2020 em sua versão original e com o ajuste desenvolvido com a popu lação do período de 2003 a 2006. Resultados: a aplicação do modelo original constatou que houve 5 anos em que a razão de mortalidade observada versus esperada (MO/ME) foi significativamente maior que 1. No período de 2007 a 2020, o EuroScore I não calibrou em 6 ocasiões, sendo a versão ajustada aplicada na avaliação de instituições médicas altamente especializadas. A aplicação do modelo ajustado mostrou uma boa calibração para o período 2007-2020 exceto no ano de 2013 e apre sentou boa discriminação (área sob a curva ROC) em todo o período avaliado. Conclusões: as escalas de risco são ferramentas metodológicas e estatísticas muito úteis para a tomada de decisões em saúde. O ponto forte deste trabalho é apresentar dados nacionais aplicando um modelo de risco amplamente uti lizado em todo o mundo, que permite comparar com resultados a nível internacional (original Logistic Euroscore I) e, por outro lado, avaliar o comparativo interno desempenho durante um longo período de tempo (Euroscore Logístico I ajustado). Para o futuro, fica o desafio de comparar esses resultados, seja com um modelo próprio ou com outros internacionais de elaboração mais recente.

Valor predictivo prequirúrgico del EuroSCORE I, EuroSCORE II y STS score en pacientes sometidos a cirugía cardíaca: informe preliminar / Pre-surgical predictive value of the EuroSCORE I, EuroSCORE II and STS score in patients undergoing cardiac surgery: preliminary report

RESUMEN Introducción: en cirugía cardiovascular, el EuroSCORE I, EuroSCORE II y STS score son herramientas que brindan pronóstico e información para la toma de decisiones. Es imperativo evaluar el valor predictivo real de los mismos en nuestro medio. Objetivo: evaluar el valor predictivo de los citados scores en pacientes sometidos a cirugía cardíaca en el área de cardiología del Hospital Nacional. Metodología: estudio de cohortes, retrospectivo, con muestreo no probabilístico de casos consecutivos. La población estuvo constituida por pacientes sometidos a cirugía cardiaca en el periodo comprendido entre enero 2020 a julio 2021. Fueron evaluadas 60 historias clínicas, excluidas 6, quedando finalmente 54 expedientes. Resultado: predominó el sexo masculino 57,14 %, la edad media fue de 60 ± 12 años (rango 26 - 82 años). El EuroSCORE II presentó un riesgo relativo de 10 (IC 95 % 1,3 ­ 90), p=0,004, sensibilidad 80 %, especificidad 78,43 %, VPP 26,67 % (IC 95 % 0,95 a 52,38) y VPN 97,56 % (IC 95 % 91,62 a 100 %). El EuroSCORE I presentó riesgo relativo de 1,6 (IC 95 % 0,2 ­ 10,9) p=0,50, sensibilidad 60 %, especificidad 52,94 %, VPP 11,11 % (IC 95 % 0,00 a 24,82) y VPN 93,10 % (IC 95 % 82,16 a 100 %). El STS score arrojó un riesgo relativo de 3,5 (IC 95 % 0,07 ­ 35), p=0,10, sensibilidad del 20 %, especificidad 93,33 %, valor predictivo positivo del 25 % (IC 95 % 0,00 a 79,93) y valor predictivo negativo 91,30 % (IC 95 % 82,07 a 100 %). La mortalidad global fue 8,93 % y morbilidad 93 %. Conclusión: se demostró un alto valor predictivo negativo en los scores, lo que determinó que pacientes con riesgo bajo e intermedio tuvieran una mortalidad baja.

ABSTRACT Introduction: in cardiovascular surgery, the EuroSCORE I, EuroSCORE II and STS score are tools that provide prognosis and information for decision making. It is imperative to evaluate their real predictive value in our environment. Objective: to evaluate the predictive value of the aforementioned scores in patients undergoing cardiac surgery in the Hospital Nacional cardiology area. Methodology: retrospective cohort study, with non-probabilistic sampling of consecutive cases. The population consisted of patients undergoing cardiac surgery in the period from January 2020 to July 2021. 60 medical records were evaluated, 6 excluded, finally leaving 54 records. Result: male sex predominated 57,14 %, the mean age was 60 ± 12 years (range 26 - 82 years old). The EuroSCORE II presented a relative risk of 10 (95 % CI 1.3 - 90), p = 0.004, sensitivity 80 %, specificity 78,43 %, PPV 26,67 % (95 % CI 0,95 to 52,38) and NPV 97,56 % (95 % CI 91,62 to 100 %). The EuroSCORE I presented a relative risk of 1.6 (95 % CI 0.2 - 10.9) p = 0.50, sensitivity 60 %, specificity 52,94 %, PPV 11,11 % (95 % CI 0.00 a 24,82) and NPV 93,10 % (95 % CI 82.16 to 100 %). The STS score yielded a relative risk of 3,5 (95 % CI 0.07 - 35), p = 0.10, sensitivity of 20 %, specificity 93,33 %, positive predictive value of 25 % (CI 95 % 0 .00 to 79.93) and negative predictive value 91,30 % (95 % CI 82.07 to 100 %). Overall mortality was 8,93 % and morbidity 93 %. Conclusion: a high negative predictive value was demonstrated in the scores, which determined that patients with low and intermediate risk had a low mortality.

Universal definition of perioperative bleeding in cardiac surgery adults and association with mortality in a Mexican Cardiovascular Critical Care Unit / Definición universal de sangrado perioperatorio en cirugía cardiaca adultos y asociación con mortalidad en una Unidad de Terapia Intensiva Cardiovascular de México

Abstract Background: Bleeding as a complication is associated with poorer results in cardiac surgery. There is increasing evidence that the use of blood products is an independent factor of increased morbidity, mortality, and hospital costs. Dyke et al. established the universal definition of perioperative bleeding (UDPB). This classification is more precise defining mortality in relation to the degree of bleeding. Methods: A descriptive and analytical retrospective study of a database of patients underwent cardiac surgery from January 1, 2016, to December 31, 2017, was performed. The primary objective of the study was to look at mortality associated with the degree of bleeding using the UDPB. Results: A total of 918 patients who went to cardiac surgery were obtained. Most of the population was classified as insignificant bleeding class (n = 666, 72.9%), and for massive bleeding the lowest proportion (n = 25, 2.7%). For the primary outcome of 30-day mortality, a significant difference was found between the groups, observing that it increased to a higher degree of bleeding. This was corroborated by multivariate logistic regression analysis that was adjusted to EuroScore II and cardiopulmonary bypass (CPB) duration, finding an independent association of the bleeding class with 30-day mortality (OR, 95%, 5.82 [2.22-15.26], p = 0.0001). Conclusions: We found that the higher the degree in UDPB was associated with higher mortality independently to EuroScore II and CPB duration for adult patients undergoing cardiac surgery.

Resumen Antecedentes: El sangrado como complicación está asociado a peores resultados en cirugía cardiaca. Existe una evidencia cada vez mayor que la transfusión de productos sanguíneos por si solo es un factor independiente de incremento en la morbilidad, mortalidad, y costos hospitalarios. Dyke y colaboradores establecieron la definición universal de sangrado perioperatorio. Esta clasificación es más precisa en definir mortalidad en relación con el grado de sangrado. Material y métodos: Se realizo un estudio descriptivo y analítico de tipo retrospectivo de una base de datos de pacientes que fueron a cirugía cardiaca del 1 enero del 2016 al 31 de diciembre del 2017. El objetivo primario del estudio fue observar la mortalidad asociada con el grado de sangrado utilizando la definición universal de sangrado perioperatorio. Resultados: Se obtuvieron un total de 918 pacientes que fueron a cirugía cardiaca. La mayor parte de la población fue clasificada como clase de sangrado insignificante (n = 666, 72.9%), y para sangrado masivo la menor proporción (n = 25, 2.7%). En el desenlace primario de mortalidad a 30 días se encontró una diferencia significativa entre los grupos, observando que aumentada a mayor clase de sangrado. Esto fue corroborado mediante un análisis multivariado regresión logística que fue ajustado a con EuroScore II y el tiempo de bomba de circulación extracorpórea, encontrando una asociación independiente de la clase de sangrado con mortalidad a 30 días (OR, 95%, 5.82 [2.22-15.26], p = 0.0001). Conclusiones: Encontramos que cuanto mayor era el grado en la UDPB se asociaba con una mayor mortalidad independientemente de EuroScore II y la duración del bypass cardiopulmonar para pacientes adultos sometidos a cirugía cardíaca.

Valor pronóstico del sistema de calificación APACHE II en el postoperatorio de cirugía cardíaca / Prognostic value of APACHE II score in postoperative of cardiac surgery

Resumen Antecedentes y objetivos: El sistema de calificación APACHE II permite predecir la mortalidad intrahospitalaria en terapia intensiva. Sin embargo, no está validado para cirugía cardíaca, ya que no posee buena capacidad diferenciadora. El objetivo es determinar el valor pronóstico de APACHE II en el postoperatorio de procedimientos cardíacos. Materiales y métodos: Se analizó en forma retrospectiva la base de cirugía cardíaca. Se incluyó a pacientes intervenidos entre 2017 y 2018, de los cuales se calculó la puntuación APACHE II. Se utilizó curva ROC para determinar el mejor valor de corte. El punto final primario fue mortalidad intrahospitalaria. Como puntos finales secundarios se evaluó la incidencia de bajo gasto cardíaco (BGC), accidente cerebrovascular (ACV), sangrado quirúrgico y necesidad de diálisis. Se realizó un modelo de regresión logístico multivariado para ajustar a las variables de interés. Resultados: Se analizó a 559 pacientes. La media del sistema de calificación APACHE II fue de 9.9 (DE 4). La prevalencia de mortalidad intrahospitalaria global fue de 6.1%. El mejor valor de corte de la calificación para predecir mortalidad fue de 12, con un área bajo la curva ROC de 0.92. Los pacientes con APACHE II ≥ 12 tuvieron significativamente mayor mortalidad, incidencia de BGC, ACV, sangrado quirúrgico y necesidad de diálisis. En un modelo multivariado, el sistema APACHE II se relacionó de modo independiente con mayor tasa de mortalidad intrahospitalaria (OR, 1.14; IC95%, 1.08-1.21; p < 0.0001). Conclusiones: El sistema de clasificación APACHE II demostró ser un predictor independiente de mortalidad intrahospitalaria en pacientes que cursan el postoperatorio de cirugía cardíaca.

Abstract Background and objectives: The APACHE II score allows predicting in-hospital mortality in patients admitted to intensive care units. However, it is not validated for patients undergoing cardiac surgery, since it does not have a good discriminatory capacity in this clinical scenario. The aim of this study is to determine prognostic value of APACHE II score in postoperative of cardiac surgery. Materials and methods: The study was performed using the cardiac surgery database. Patients undergoing surgery between 2017 and 2018, with APACHE II score calculated at the admission, were included. The ROC curve was used to determine a cut-off value The primary endpoint was in-hospital death. Secondary endpoints included low cardiac output (LCO), stroke, surgical bleeding, and dialysis requirement. A multivariable logistic regression model was developed to adjust to various variables of interest. Results: The study evaluated 559 patients undergoing cardiac surgery. The mean of APACHE II Score was 9.9 (SD 4). The prevalence of in-hospital death was 6.1%. The best prognostic cut-off value for the primary endpoint was 12, with a ROC curve of 0.92. Patients with an APACHE II score greater than or equal to 12 had significantly higher mortality, higher incidence of LCO, stroke, surgical bleeding and dialysis requirement. In a multivariate logistic regression model, the APACHE II score was independently associated with higher in-hospital death (OR, 1.14; 95CI%, 1.08-1.21; p < 0.0001). Conclusions: The APACHE II Score proved to be an independent predictor of in-hospital death in patients undergoing postoperative cardiac surgery, with a high capacity for discrimination.

Perioperative central venous oxygen saturation and its correlation with mortality during cardiac surgery: an observational prospective study / Correlação entre saturação venosa central de oxigênio perioperatória e mortalidade em cirurgia cardíaca: estudo prospectivo observacional

Abstract Background: Cardiac surgery can produce persistent deficit in the ratio of Oxygen Delivery (DO2) to Oxygen Consumption (VO2). Central venous oxygen Saturation (ScvO2) is an accessible and indirect measure of DO2/VO2 ratio. Objective: To monitor perioperative ScvO2 and assess its correlation with mortality during cardiac surgery. Methods: This prospective observational study evaluated 273 patients undergoing cardiac surgery. Blood gas samples were collected to measure ScvO2 at three time points: T0 (after anesthetic induction), T1 (end of surgery), and T2 (24 hours after surgery). The patients were divided into two groups (survivors and nonsurvivors). The following outcomes were analyzed: intrahospital mortality, length of Intensive Care Unit (ICU) and hospital stay (LOS), and variation in ScvO2. Results: Of the 273 patients, 251 (92%) survived and 22 (8%) did not. There was a significant perioperative reduction of ScvO2 in both survivors (T0 = 78% ± 8.1%, T1 = 75.4% ± 7.5%, and T2 = 68.5% ± 9%; p< 0.001) and nonsurvivors (T0 = 74.4% ± 8.7%, T1 = 75.4% ± 7.7%, and T2 = 66.7% ± 13.1%; p < 0.001). At T0, the percentage of patients with ScvO2< 70% was greater in the nonsurvivor group (31.8% vs. 13.1%; p= 0.046) and the multiple logistic regression showed that ScvO2 is an independent risk factor associated with death, OR = 2.94 (95% CI 1.10−7.89) (p= 0.032). The length of ICU and LOS were 3.6 ± 3.1 and 7.4 ± 6.0 days respectively and was not significantly associated with ScvO2. Conclusions: Early intraoperative ScvO2 < 70% indicated a higher risk of death. A perioperative reduction of ScvO2 was observed in patients undergoing cardiac surgery, with high intraoperative and lower postoperative levels.

Resumo Justificativa: A cirurgia cardíaca pode produzir déficit persistente na razão entre oferta de oxigênio (DO2) e consumo de oxigênio (VO2). A Saturação venosa central de Oxigênio (SvcO2) é uma medida acessível e indireta da razão DO2/VO2. Objetivo: Monitorar a SvcO2 perioperatória e avaliar sua correlação com a mortalidade em cirurgia cardíaca. Método: Este estudo observacional prospectivo avaliou 273 pacientes submetidos a cirurgia cardíaca. Coletamos amostras de sangue para medir a SvcO2 em três momentos: T0 (após indução anestésica), T1 (final da cirurgia) e T2 (24 horas após a cirurgia). Os pacientes foram divididos em dois grupos (sobreviventes e não sobreviventes). Os seguintes desfechos foram analisados: mortalidade intra-hospitalar, tempo de permanência na Unidade de Terapia Intensiva (UTI) e de internação hospitalar, e variação na SvcO2. Resultados: Dos 273 pacientes, 251 (92%) sobreviveram e 22 (8%) não. Houve queda significante da SvcO2 perioperatória nos sobreviventes (T0 = 78% ± 8,1%, T1 = 75,4% ± 7,5% e T2 = 68,5% ± 9%; p< 0,001) e nos não sobreviventes (T0 = 74,4% ± 8,7%, T1 = 75,4% ± 7,7% e T2 = 66,7% ± 13,1%; p< 0,001). No T0, a porcentagem de pacientes com SvcO2< 70% foi maior no grupo não sobrevivente (31,8% vs. 13,1%; p = 0,046) e a regressão logística múltipla mostrou que a SvcO2 é um fator de risco independente associado ao óbito, OR = 2,94 (95% IC 1,10 − 7,89) (p = 0,032). O tempo de permanência na UTI e de hospitalização foi de 3,6 ± 3,1 e 7,4 ± 6,0 dias, respectivamente, e não foi significantemente associado à SvcO2. Conclusões: Valores precoces de SvcO2 intraoperatória < 70% indicaram maior risco de óbito em pacientes submetidos à cirurgia cardíaca. Observamos redução perioperatória da SvcO2, com altos níveis no intraoperatório e mais baixos no pós-operatório.

Validación prospectiva multicéntrica del EuroSCORE II en Argentina / Multicenter prospective validation of the EuroSCORE II in Argentina

Resumen Objetivo: Validar, en forma prospectiva y en múltiples centros, la precisión y utilidad clínica del European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) para predecir la mortalidad operatoria de la cirugía cardíaca en centros de Argentina Método: Entre enero de 2012 y febrero de 2018 se incluyeron en forma prospectiva 2,000 pacientes consecutivos que fueron sometidos a cirugía cardíaca en diferentes centros de Argentina. El punto final fue mortalidad hospitalaria por cualquier causa. La discriminación, calibración, precisión y utilidad clínica del EuroSCORE II se evaluaron en la cohorte global y en los diferentes tipos de cirugías, basándose en las curvas Receiver Operating Characteristics (ROC), bondad de ajuste de Hosmer-Lemeshow, razón de mortalidad observada/esperada, índice de Shannon y curvas de decisión. Resultados: El área ROC del EuroSCORE II estuvo entre 0.73 y 0.80 para todo tipo de cirugía, y el valor más bajo fue para la cirugía coronaria. La mortalidad observada y esperada fue 4.3 y 3.0%, respectivamente (p = 0.034). El análisis de la curva de decisión demostró un beneficio neto positivo para los umbrales por debajo de 0.24 para todo tipo de cirugía. Conclusiones: El EuroSCORE II tuvo un desempeño adecuado en términos de discriminación y calibración para todos los tipos de cirugía, aunque algo inferior para la cirugía coronaria. Si bien en términos generales subestimó el riesgo en los grupos de riesgo intermedio, el comportamiento global fue aceptable. El EuroSCORE II podría considerarse una opción de modelo genérico y actualizado de estratificación del riesgo operatorio para predecir la mortalidad hospitalaria de la cirugía cardíaca en nuestro contexto.

Abstract Objective: To validate prospectively in multiple centers, the accuracy and clinical utility of the European System for Cardiac Operative Risk Evaluation (EuroSCORE II) to predict the operative mortality of cardiac surgery in Argentina. Methods: Between January 2012 and February 2018, 2,000 consecutive adult patients who underwent cardiac surgery in different centers in Argentina were prospectively included. The end-point was in-hospital all-cause mortality. Discrimination, calibration, precision and clinical utility of the EuroSCORE II were evaluated in the global cohort and in the different types of surgeries, based on ROC (Receiver Operating Characteristics) curves, Hosmer-Lemeshow goodness-of-fit test, observed/expected mortality ratio, Shannon index and decision curves analysis. Results: ROC area of the EuroSCORE II was between 0.73 and 0.80 for all types of surgery, being the lowest value for coronary surgery. The observed and expected mortality was 4.3% and 3.0%, respectively (p = 0.034). The decision curve analysis showed a positive net benefit for all thresholds below 0.24, considering all type of surgeries. Conclusion: The EuroSCORE II showed an adequate performance in terms of discrimination and calibration for all types of surgery, although somewhat inferior for coronary surgery. Though in general terms this model underestimated the risk in intermediate risk groups, its overall performance was acceptable. The EuroSCORE II could be considered an optional updated generic model of operative risk stratification to predict in-hospital mortality after cardiac surgery in our context.

Early and long-term outcomes of surgical treatment of ebstein's anomaly

Abstract Objective: This study aimed to evaluate Ebstein's anomaly surgical correction and its early and long-term outcomes. Methods: A retrospective analysis of 62 consecutive patients who underwent surgical repair of Ebstein's anomaly in our institution from January 2000 to July 2016. The following long-term outcomes were evaluated: survival, reoperations, tricuspid regurgitation, and postoperative right ventricular dysfunction. Results: Valve repair was performed in 46 (74.2%) patients - 12 of them using the Da Silva cone reconstruction; tricuspid valve replacement was performed in 11 (17.7%) patients; univentricular palliation in one (1.6%) patient; and the one and a half ventricle repair in four (6.5%) patients. The patients' mean age at the time of surgery was 20.5±14.9 years, and 46.8% of them were male. The mean follow-up time was 8.8±6 years. The 30-day mortality rate was 8.06% and the one and 10-year survival rates were 91.9% both. Eleven (17.7%) of the 62 patients required late reoperation due to tricuspid regurgitation, in an average time of 7.1±4.9 years after the first procedure. Conclusion: In our experience, the long-term results of the surgical treatment of Ebstein's anomaly demonstrate an acceptable survival rate and a low incidence of reinterventions.

Surgical Site Infection Prevention Bundle in Cardiac Surgery / "Bundle" de Prevenção de Sítio Cirúrgico em Cirurgia Cardíaca

Abstract Background: Surgical site infections (SSI) are among the most prevalent infections in healthcare institutions, attributing a risk of death which varies from 33% to 77% and a 2- to 11-fold increase in risk of death. Patients submitted to cardiac surgery are more susceptible to SSI, accounting for 3.5% to 21% of SSI. The mortality rate attributable to these causes is as high as 25%. Prevention of SSI in cardiac surgery is based on a bundle of preventive measures, which focus on modifiable risks. Objective: The objective of this study was to identify SSI risk factors in clean cardiac surgery. Methods: A retrospective cohort study analyzed 1,846 medical records from patients who underwent clean cardiac surgery. Fisher's exact test was used for bivariate comparison, and Poisson regression was used for independent analysis of SSI risk, considering a significance level of p < 0.05. Results: The results of the study comprised a multivariate analysis. The variables that were associated with the diagnosis of SSI were: surgical risk index (OR: 2.575; CI: 1.224-5.416), obesity (OR: 2.068; CI: 1.457-2.936), diabetes mellitus (OR: 1,678; CI: 1.168-2.409), and blood glucose level (OR: 1.004; CI: 1.001-1.007). Conclusions: This study evidenced that complete adherence to the bundle was not associated with a reduction in the risk of surgical infections. Diabetes mellitus, obesity, and surgical risk index assessment were, however, identified to increase association and consequently risk of SSI in cardiac surgery.

Resumo Fundamento: As infecções de sítio cirúrgico (ISC) estão entre as mais prevalentes nas instituições de saúde, atribuindo um risco de morte, variando de 33 a 77%, sendo associado a um aumento de 2 a 11 vezes para o desfecho de óbito. Os pacientes submetidos à cirurgia cardíaca são mais suscetíveis às ISC´s, correspondendo entre as taxas de ISC´s de 3,5% a 21%, e a taxa de mortalidade atribuível a estas causas chegam a 25%. A prevenção de infecção de sítio cirúrgico em cirurgia cardíaca está baseada em medidas preventivas conhecidas como "bundle", focados nos fatores de risco modificáveis. Objetivos: O objetivo deste estudo foi identificar os fatores de risco para ISC´s em cirurgia cardíaca limpa. Métodos: Realizou-se um estudo retrospectivo de Coorte analisando 1846 prontuários de pacientes submetidos à cirurgia cardíaca limpa. Foi utilizado o teste exato de Fischer para a comparação bivariada e regressão de Poisson para análise independente de risco para infecção de sítio cirúrgico. Foi considerado o nível de significância p < 0,05. Resultados: O resultado do estudo compreendeu a uma análise multivariada, e as variáveis que se associaram com o diagnóstico de infecção de sítio cirúrgico foram: índice de risco cirúrgico (OR 2,575 IC 1,224-5,416), obesidade (OR 2,068 IC 1,457-2,936), diabete mellitus (OR 1,678 1,168-2,409); nível de glicemia (OR 1,004 IC 1,001-1,007). Conclusões: Foi evidenciado no estudo que a adesão completa ao "bundle" não se associou com a redução do risco de infecções cirúrgicas. Entretanto, foi identificado que o fato de ter diabetes mellitus, a obesidade e a avaliação através do índice de risco cirúrgico aumentam a associação e consequentemente ao risco de ISC em cirurgia cardíaca.

Clinical registry of cardiovascular surgeries in a university hospital

SUMMARY OBJECTIVES To create and implement a computerized clinical registry to verify in the short-, medium- and long-term the mortality and the incidence of significant surgical outcomes in adult patients submitted to cardiovascular surgeries. METHODS This is a prospective, observational registry-based study aimed at documenting the characteristics of patients undergoing cardiovascular surgery. RESULTS Variables were standardized according to international references from the Society of Thoracic Surgeons (STS), American College of Cardiology (ACC), Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS) and the Department of Informatics of SUS (DATASUS). The standardization was performed in English with an interface in Portuguese to make the data collection easier in the institution. Quality of care indicators, surgical procedure characteristics, in addition to significant cardiovascular outcomes will be measured. Data were collected during the hospitalization until hospital discharge or at the seventh day, in thirty days, six months, twelve months and annually until completing five years. CONCLUSION The importance of a database maintenance with international standards that can be reproducible was evidenced, allowing the evaluation of techniques and assistance and the integration of data among health institutions.

RESUMO OBJETIVO Criar e implantar um registro clínico informatizado para verificar mortalidade e incidência de desfechos cirúrgicos maiores em pacientes adultos submetidos a cirurgias cardiovasculares a curto, médio e longo prazo. METODOLOGIA Trata-se de um estudo observacional do tipo Registro, prospectivo, que visa documentar as características dos pacientes submetidos à cirurgia cardiovascular. RESULTADOS As variáveis foram padronizadas de acordo com referências internacionais padronizadas pela The Society of Thoracic Surgeons (STS), American College of Cardiology (ACC), The Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS) e o Departamento de Informática do SUS (Datasus). A padronização foi realizada na língua inglesa com uma interface em português para facilitar a coleta de dados na instituição. Serão mensurados indicadores de qualidade de atendimento, características do procedimento cirúrgico, além dos principais desfechos cardiovasculares. Os dados serão coletados durante a internação até a alta hospitalar ou até o sétimo dia, em 30 dias, seis meses, 12 meses e anualmente até completar cinco anos. CONCLUSÃO Evidenciou-se a importância da manutenção de banco de dados com padrões internacionais que podem ser reprodutíveis, possibilitando a avaliação de técnicas e assistência integrando os dados entre instituições de saúde.

Clinical and laboratory variables associated with mortality outcome in the post-operative pediatric cardiac surgery / Variables clínicos y laboratorios asociados al desfecho mortalidad en el post-operatorio de cirugía cardíaca pediátrica / Variáveis clínicas e laboratoriais associadas ao desfecho mortalidade no pós-operatório de cirurgia cardíaca pediátrica

Abstract Objective: To identify clinical and laboratory variables associated with mortality outcome in the post-operative pediatric cardiac surgery. Method: Descriptive, retrospective study carried out in three reference centers in Rio de Janeiro State, Brazil, from the collection in 120 medical reports of children with Congenital Heart Disease undergoing surgery. Data were analyzed by using central tendency measures and association tests between variables and mortality. p < 0.05 was considered. Results: We observed the mortality outcome in 10 (7.2%) of the children after analyzing all medical records. The dialysis and extracorporeal circulation times, aortic and surgical clamping variables were associated with mortality outcome (p < 0.05). Conclusion and Implications for practice: The identification of these variables is a major factor for the control of the main post-operative complications, allowing the recognition of subtle clinical alterations requiring attention and immediate intervention with consequent reduction of mortality.

Resumen Objetivo: Identificar las variables clínicas y de laboratorio asociadas con lo desfecho mortalidad en el post-operatório de cirugía cardíaca pediátrica. Método: Estudio descriptivo, retrospectivo, realizado en tres centros de referencia del estado de Rio de Janeiro a partir de la recolección de datos en 120 prontuarios de niños portadores de cardiopatía congénita, sometidos a cirugía. Los datos fueron analizados utilizando medidas de tendencia central y pruebas de asociación entre variables y mortalidad. Se consideró p < 0,05. Resultados: Lo desfecho mortalidad fue observada en 10 (7,2%) niños, del total de prontuarios analizados. Las variables diálisis y los tiempos de circulación extracorpórea, engrape aórtico y quirúrgico, presentaron asociación con lo desfecho mortalidad (p < 0,05). Conclusión e Implicaciones para la práctica: La identificación de esas variables configura factor preponderante para el control de las principales complicaciones derivadas del post-operatorio, posibilitando el reconocimiento de alteraciones clínicas sutiles exigiendo atención e intervención inmediata con consecuente reducción de la mortalidad.

Resumo Objetivo: Identificar as variáveis clínicas e laboratoriais associadas ao desfecho mortalidade no pós-operatório de cirurgia cardíaca pediátrica. Método: Estudo descritivo, retrospectivo realizado em três centros de referência no estado do Rio de Janeiro a partir da coleta em 120 prontuários de crianças portadoras de cardiopatia congênita, submetidos a cirurgia. Os dados foram analisados utilizando-se medidas de tendência central e testes de associação entre as variáveis e mortalidade. Considerou-se p < 0,05. Resultados: Do total de prontuários analisados, o desfecho mortalidade foi observado em 10 (7,2%) das crianças. As variáveis diálise e os tempos de circulação extracorpórea, clampeamento aórtico e cirúrgico apresentaram associação com a mortalidade (p < 0,05). Conclusão e Implicações para a prática: A identificação dessas variáveis configura fator preponderante para o controle das principais complicações decorrentes do pós-operatório, possibilitando o reconhecimento de alterações clínicas sutis exigindo atenção e intervenção imediata com consequente redução da mortalidade.

Risk factors for mortality in children with congenital heart disease delivered at a brazilian tertiary center

Abstract Objective: This study aims to investigate the incidence of postnatal diagnosis of congenital heart disease (CHD) and the predictive factors for hospital mortality. Methods: This retrospective cohort study was conducted at a Brazilian tertiary center, and data were collected from medical records with inclusion criteria defined as any newborn with CHD diagnosed in the postnatal period delivered between 2015 and 2017. Univariate and multivariate analyses were performed to determine the potential risk factors for mortality. Results: During the 3-year period, 119 (5.3%) children of the 2215 children delivered at our institution were diagnosed with CHD. We considered birth weight (P=0.005), 1st min Apgar score (P=0.001), and CHD complexity (P=0.013) as independent risk factors for in-hospital mortality. The most common CHD was ventricular septal defect. Indeed, 60.5% cases were considered as "complex" or "significant" CHDs. Heart surgeries were performed on 38.9% children, 15 of whom had "complex" or "significant" CHD. A mortality rate of 42% was observed in this cohort, with 28% occurring within the initial 24 h after delivery and 38% occurring in patients admitted for heart surgery. Conclusion: The postnatal incidence of CHD at our service was 5.3%. Low 1st min Apgar score, low birth weight, and CHD complexity were the independent factors that affected the hospital outcome.

Association of body mass index with short-term outcomes after cardiac surgery: retrospective study and meta-analysis

The relationship between higher body mass index (BMI), decreased morbidity and mortality is known as the "obesity paradox", and has been described in cohorts of patients with hypertension, diabetes, heart failure, coronary and peripheral artery diseases, non-cardiac surgery, and end-stage renal disease. Here we investigated the relationship between BMI and short-term outcomes after adult cardiac surgery to explore the existence of an obesity paradoxical effect. A secondary objective was to perform an updated systematic review to further analyze the association between BMI and 30-day in-hospital mortality after cardiac surgery. A retrospective analysis was performed from a consecutive series of 1823 adult patients who underwent cardiac surgery, that were assigned to five BMI groups: normal weight (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²), class I obese (30-34.9 kg/m²), class II obese (35-39.9 kg/m²), and class III obese or morbidly obese (40-49.9 kg/m²). A systematic review search was performed including controlled trials and observational studies identified in MEDLINE, Embase, SCOPUS, and the Cochrane library (to the end of June 2017). In the present series, overweight and obese patients had similar or slightly lower in-hospital mortality rates after cardiac surgery compared with normal-weight individuals. Conversely, postoperative complication rates increased with higher BMI levels. Most studies included in the review showed that overweight and obese patients had at least the same mortality rate as normal-weight patients, or even a lower death risk. Pooled-data of the meta-analysis provided evidence on the association between higher BMI levels and a lower all-cause in-hospital mortality rate after cardiac surgery.

La relación entre mayor índice de masa corporal (IMC) y menor morbilidad y mortalidad se conoce como "paradoja de la obesidad". Se ha descrito en cohortes de pacientes con hipertensión, diabetes, insuficiencia cardíaca, enfermedad coronaria y arterial periférica, cirugías no cardíacas y enfermedad renal en etapa terminal. Aquí se investigó la relación entre IMC y resultados a corto plazo después de cirugía cardíaca en adultos, y la manifestación de la paradoja de la obesidad. También se realizó una revisión sistemática sobre asociación entre IMC y mortalidad a 30 días de la cirugía cardíaca. Se hizo un análisis retrospectivo de una serie consecutiva de 1823 adultos con cirugía cardíaca, asignados a cinco grupos de IMC: peso normal (18.5-24.9 kg/m²), sobrepeso (25- 29.9 kg/m²), obesidad clase I (30-34.9 kg/m²), clase II (35-39.9 kg/m²), y clase III (40-49.9 kg/m²), y una búsqueda sistemática de ensayos controlados y estudios observacionales en MEDLINE, Embase, SCOPUS y Cochrane (hasta 30/6/2017). En la serie, las tasas de mortalidad hospitalaria fueron similares o ligeramente menores en pacientes con sobrepeso y obesidad comparados con aquellos de peso normal. Pero también las tasas de complicaciones postoperatorias aumentaron con el IMC. La mayoría de los estudios observacionales revisados mostraron que los pacientes con sobrepeso y obesidad tenían al menos similar tasa de mortalidad que aquellos con peso normal, o menor riesgo de muerte. Los datos combinados del metaanálisis evidenciaron asociación entre los niveles de IMC mayores y tasa de mortalidad hospitalaria más baja después de cirugía cardíaca.

External validation of european system for cardiac operative risk evaluation II (euroscore II) for risk prioritization in an iranian population

Abstract Introduction: The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) is a prediction model which maps 18 predictors to a 30-day post-operative risk of death concentrating on accurate stratification of candidate patients for cardiac surgery. Objective: The objective of this study was to determine the performance of the EuroSCORE II risk-analysis predictions among patients who underwent heart surgeries in one area of Iran. Methods: A retrospective cohort study was conducted to collect the required variables for all consecutive patients who underwent heart surgeries at Emam Reza hospital, Northeast Iran between 2014 and 2015. Univariate and multivariate analysis were performed to identify covariates which significantly contribute to higher EuroSCORE II in our population. External validation was performed by comparing the real and expected mortality using area under the receiver operating characteristic curve (AUC) for discrimination assessment. Also, Brier Score and Hosmer-Lemeshow goodness-of-fit test were used to show the overall performance and calibration level, respectively. Results: Two thousand five hundred eight one (59.6% males) were included. The observed mortality rate was 3.3%, but EuroSCORE II had a prediction of 4.7%. Although the overall performance was acceptable (Brier score=0.047), the model showed poor discriminatory power by AUC=0.667 (sensitivity=61.90, and specificity=66.24) and calibration (Hosmer-Lemeshow test, P<0.01). Conclusion: Our study showed that the EuroSCORE II discrimination power is less than optimal for outcome prediction and less accurate for resource allocation programs. It highlights the need for recalibration of this risk stratification tool aiming to improve post cardiac surgery outcome predictions in Iran.

Análisis de mortalidad y estancia hospitalaria en cirugía cardiaca en México 2015: datos del Instituto Nacional de Cardiología / Analysis of mortality and hospital stay in cardiac surgery in Mexico 2015: Data from the National Cardiology Institute

Resumen Objetivo: Analizar las causas de mortalidad hospitalaria de pacientes operados de cirugía cardiaca en México en el año 2015. Identificar los factores de riesgo de mortalidad y realizar una correlación con el tiempo de estancia hospitalaria en terapia intensiva cardiovascular. Método: Estudio de casos y controles. Se estudió la base de datos de la Terapia Intensiva Cardiovascular del Instituto Nacional de Cardiología. Se incluyeron todos los pacientes adultos operados de cirugía cardiaca en el año 2015. Resultados: Se operaron 571 pacientes. La indicación quirúrgica predominante fue la cirugía de cambio valvular único o múltiple, seguida de la cirugía de revascularización coronaria y corrección de cardiopatías congénitas del adulto. La mortalidad global fue de un 9.2% y el 8% falleció en terapia intensiva. Los principales factores de riesgo de muerte fueron la presencia de falla orgánica o hipertensión pulmonar prequirúrgica, y el tiempo prolongado de circulación extracorpórea. La principal causa de muerte fue el choque cardiogénico. La mortalidad hospitalaria observada en esta población fue mayor para los operados de tromboendarterectomía pulmonar, cirugía de enfermedad aórtica compleja y cirugía valvular. Conclusiones: La mortalidad de los pacientes operados de cirugía cardiaca en México difiere levemente de la reportada en la literatura mundial porque se trata mayormente de cirugía multivalvular y de procedimientos quirúrgicos mixtos complejos.

Abstract Objective: To analyse hospital mortality in patients subjected to cardiac surgery in Mexico during the year 2015, and identify the mortality risks factors, and its correlation with days of hospital stay in the cardiovascular intensive care unit. Method: The database of Cardiovascular Intensive Care of the National Institute of Cardiology was examined for this cases and controls study that included only adult patients subjected to cardiac surgery during the year 2015. Results: A total of 571 patients were subjected to a surgical procedure. The predominant indication was single or multiple valve replacement surgery, followed by coronary revascularisation surgery, and correction of adult congenital heart disease. Overall mortality was 9.2, and 8% died in intensive care. The main risk factors for death were preoperative organ failure or pulmo- nary hypertension, and prolonged time with extracorporeal circulation. The primary cause of death was secondary to cardiogenic shock. The hospital mortality observed in this population was higher for patients undergoing pulmonary thromboendarterectomy, complex aortic disease surgery, and valvular surgery. Conclusions: The mortality of patients undergoing cardiac surgery in Mexico differs slightly from that reported in the world literature, primarily because there were more multivalvular surgeries and mixed complex procedures performed.

Cardiac surgery in Jehovah's witness patients: experience of a Brazilian Tertiary Hospital

Abstract Introduction: The outcomes of Jehovah's Witness (JW) patients submitted to open heart surgery may vary across countries and communities. The aim of this study was to describe the morbidity and mortality of JW patients undergoing cardiac surgery in a tertiary hospital center in Southern Brazil. Methods: A case-control study was conducted including all JW patients submitted to cardiac surgery from 2008 to 2016. Three consecutive surgical non-JW controls were matched to each selected JW patient. The preoperative risk of death was estimated through the mean EuroSCORE II. Results: We studied 16 JW patients with a mean age of 60.6±12.1 years. The non-JW group included 48 patients with a mean age of 63.3±11.1 years (P=0.416). Isolated coronary artery bypass graft surgery was the most frequent surgery performed in both groups. Median EuroSCORE II was 1.29 (IQR: 0.66-3.08) and 1.43 (IQR: 0.72-2.63), respectively (P=0.988). The mortality tended to be higher in JW patients (18.8% vs. 4.2%, P=0.095), and there was a higher difference between the predicted and observed mortality in JW patients compared with controls (4.1 and 18.8% vs. 2.1 and 4.2%). More JW patients needed hemodialysis in the postoperative period (20.0 vs. 2.1%, P=0.039). Conclusion: We showed a high rate of in-hospital mortality in JW patients submitted to cardiac surgery. The EuroSCORE II may underestimate the surgical risk in these patients.

Do We Need to Personalize Renal Function Assessment in the Stratification of Patients Undergoing Cardiac Surgery? / É Necessário Personalizar a Avaliação da Função Renal na Estratificação de Pacientes Submetidos à Cirurgia Cardíaca?

Abstract Background: Renal dysfunction is an independent predictor of morbidity and mortality in cardiac surgery. For a better assessment of renal function, calculation of creatinine clearance (CC) may be necessary. Objective: To objectively evaluate whether CC is a better risk predictor than serum creatinine (SC) in patients undergoing cardiac surgery. Methods: Analysis of 3,285 patients registered in a prospective, consecutive and mandatory manner in the Sao Paulo Registry of Cardiovascular Surgery (REPLICCAR) between November 2013 and January 2015. Values of SC, CC (Cockcroft-Gault) and EuroSCORE II were obtained. Association analysis of SC and CC with morbidity and mortality was performed by calibration and discrimination tests. Independent multivariate models with SC and CC were generated by multiple logistic regression to predict morbidity and mortality following cardiac surgery. Results: Despite the association between SC and mortality, it did not calibrate properly the risk groups. There was an association between CC and mortality with good calibration of risk groups. In mortality risk prediction, SC was uncalibrated with values > 1.35 mg /dL (p < 0.001). The ROC curve showed that CC is better than SC in predicting both morbidity and mortality risk. In the multivariate model without CC, SC was the only predictor of morbidity, whereas in the model without SC, CC was not only a mortality predictor, but also the only morbidity predictor. Conclusion: Compared with SC, CC is a better parameter of renal function in risk stratification of patients undergoing cardiac surgery.

Resumo Fundamentos: Disfunção renal é preditor independente de morbimortalidade após cirurgia cardíaca. Para uma melhor avaliação da função renal, o cálculo do clearance de creatinina (CC) pode ser necessário. Objetivo: Avaliar objetivamente se o CC é melhor que a creatinina sérica (CS) para predizer risco nos pacientes submetidos à cirurgia cardíaca. Métodos: Análise em 3285 pacientes do Registro Paulista de Cirurgia Cardiovascular (REPLICCAR) incluídos de forma prospectiva, consecutiva e mandatória entre novembro de 2013 e janeiro de 2015. Foram obtidos valores de CS, CC (Cockcroft-Gault) e do EuroSCORE II. Análise de associações da CS e do CC com morbimortalidade foi realizada mediante testes de calibração e discriminação. Por regressão logística múltipla, foram criados modelos multivariados independentes com CS e com CC para predição de risco de morbimortalidade após cirurgia cardíaca. Resultados: Apesar da associação entre a CS e morbimortalidade, essa não calibrou adequadamente os grupos de risco. Houve associação entre o CC e morbimortalidade com boa calibração dos grupos de risco. Na predição do risco de mortalidade, a CS ficou descalibrada com valores >1,35 mg/dL (p < 0,001). A curva ROC revelou que o CC é superior à CS na predição de risco de morbimortalidade. No modelo multivariado sem CC, a CS foi a única preditora de morbidade, enquanto que no modelo sem a CS, o CC foi preditor de mortalidade e o único preditor de morbidade. Conclusão: Para avaliação da função renal, o CC é superior que a CS na estratificação de risco dos pacientes submetidos a cirurgia cardíaca.

Validation of age, creatinine and ejection fraction (ACEF) and Cockcroft-Gault ACEF scores in elective cardiac surgery

The objective of this study was to evaluate the efficacy of age, creatinine and ejection fraction (ACEF) score and the modified ACEFCG model, incorporating creatinine clearance, to predict immediate operative mortality risk of patients undergoing elective cardiac surgery. A retrospective analysis was performed of prospectively collected data between 2012 and 2015, from a series of 1190 adult patients who underwent elective cardiac surgery. Operative risk mortality was assessed with ACEF, ACEFCG and EuroSCORE II. Overall mortality rate was 4.0% (48 cases), while mean mortality rates predicted by ACEF, ACEFCG, and EuroSCORE II were 2.3% (p = 0.014), 6.4% (p = 0.010) and 2.5% (p = 0.038), respectively. Overall observed/predicted mortality ratio was 1.8 for ACEF score, 0.6 for ACEFCG score and 1.6 for EuroSCORE II. The ACEF score demonstrated an adequate overall performance for the low- and intermediate-risk groups, but underestimated mortality for the high risk group. The ACEFCG score discriminatory power systematically improved the area under the ROC curve (AUC) obtained with the ACEF score; however, EuroSCORE II showed the best AUC. Overall accuracy was 56.1% for the ACEF score, 51.2% for the ACEFCG score and 75.9% for EuroSCORE II. For clinical use, the ACEF score seems to be adequate to predict mortality in low- and intermediate-risk patients. Though the ACEFCG score had a better discriminatory power and calibration, it tended to overestimate the expected risk. Since ideally, a simpler risk stratification score should be desirable for bedside clinical use, the ACEF model reasonably met the expected performance in our population.

El objetivo fue evaluar la eficacia de la escala de riesgo de edad, creatinina y fracción de eyección (ACEF) y también ACEFCG, que incorpora la depuración de creatinina, para predecir el riesgo de mortalidad operatoria inmediata tras una cirugía cardiaca electiva. Se realizó un análisis retrospectivo de datos recolectados prospectivamente entre 2012 y 2015, de 1190 adultos sometidos a cirugía cardíaca electiva. El riesgo de mortalidad operatoria se evaluó con ACEF, ACEFCG y EuroSCORE II. La tasa de mortalidad global fue 4.0% (48 casos), mientras que las tasas de mortalidad predichas por ACEF, ACEFCG y EuroSCORE II fueron 2.3% (p = 0.014), 6.4% (p = 0.010) y 2.5% (p = 0.038), respectivamente. La razón mortalidad observada/esperada fue 1.8 para el ACEF, 0.6 para el ACEFCG y 1.6 para el EuroSCORE II. La puntuación de ACEF demostró un desempeño adecuado para los grupos de riesgo bajo y medio, pero subestimó la mortalidad del grupo de alto riesgo. La discriminación del ACEFCG mejoró sistemáticamente el área ROC del ACEF; sin embargo, el EuroSCORE II mostró la mejor área ROC. La precisión global fue 56.1% para el ACEF, 51.2% para el ACEFCG y 75.9% para el EuroSCORE II. Para uso clínico, el modelo ACEF parece ser adecuado para predecir la mortalidad en pacientes de riesgo bajo y medio. Aunque el puntaje de ACEFCG tuvo un mejor poder discriminatorio y calibración, tendió a sobrestimar el riesgo esperado. Considerando que sería ideal contar con un método de estratificación de riesgo más simple para uso clínico al lado de la cama, el modelo ACEF tuvo un desempeño razonable en nuestra población.

Techniques, timing & prognosis of post infarct ventricular septal repair: a re-look at old dogmas

Abstract Objective: The study aimed to identify the factors affecting the prognosis of post myocardial infarction (MI) ventricular septal rupture (VSR) and to develop a protocol for its management. Methods: This was a single center, retrospective-prospective study (2009-2014), involving 55 patients with post MI VSR. The strengths of association between risk factors and prognosis were assessed using multivariate logistic regression analysis. The UNM Post MI VSR management and prognosis scoring systems (UPMS & UPPS) were developed. Results: Thirty-day mortality was 52.5% (35% in the last 3 years). Twenty-eight (70%) patients underwent concomitant coronary artery bypass grafting. Residual ventricular septal defect was found in 3 (7.5%) patients. The multivariate analysis showed low mean blood pressure with intra-aortic balloon pump (OR 11.43, P=0.001), higher EuroSCORE II (OR 7.47, P=0.006), higher Killip class (OR 27.95, P=0.00), and shorter intervals between MI and VSR (OR 7.90, P=0.005) as well as VSR and Surgery (OR 5.76, P=0.016) to be strong predictors of mortality. Concomitant coronary artery bypass grafting (P=0.17) and location (P=0.25) of VSR did not affect the outcome. Mean follow-up was 635.8±472.5 days and 17 out of 19 discharged patients were in NYHA class I-II. Conclusion: The UNM Post-MI VSR Scoring Systems (UPMS & UPPS) help in management and prognosis, respectively. They divide patients into 3 groups: 1) Immediate Surgery - Patients with scores of <25 require immediate surgery, preferably with extracorporeal membrane oxygenation support, and have poor prognosis; 2) Those with scores of 25-75 should be managed with "Optimal Delay" and they have intermediate outcomes; 3) Patients with scores of >75 can undergo Elective Repair and they are likely to have good outcomes.

EuroSCORE subestima el riesgo de mortalidad en cirugía cardiaca valvular de población mexicana / EuroSCORE underestimate the mortality risk in cardiac valve surgery of Mexican population

Resumen: Objetivo: El European System for Cardiac Operative Risk Evaluation (EuroSCORE) estratifica el riesgo quirúrgico en cirugía cardiaca de manera fácil y accesible; se validó en Norteamérica con buenos resultados, pero en muchos países de Latinoamérica se utiliza rutinariamente sin validación previa. Nuestro objetivo fue validar EuroSCORE en pacientes con cirugía valvular en el Instituto Nacional de Cardiología Ignacio Chávez (INCICh) de México. Métodos: Se aplicaron los modelos de EuroSCORE aditivo y logístico para predecir mortalidad en pacientes con cirugía valvular de marzo de 2004 a marzo de 2008. Se usó la prueba de bondad de ajuste de Hosmer-Lemeshow para evaluar la calibración. Se calculó el área bajo la curva ROC para determinar la discriminación. Resultados: Se incluyeron 1,188 pacientes con edades de 51.3 ± 14.5 años, 52% mujeres. Hubo diferencias significativas en la prevalencia de los factores de riesgo entre la población del INCICh y del EuroSCORE. La mortalidad total fue de 9.68% con predichas de 5% y 5.6% por EuroSCORE aditivo y logístico. De acuerdo a EuroSCORE aditivo tenían riesgo bajo 11.3%, intermedio 52.9% y alto 35.9%; para estos grupos la mortalidad fue de 0.7%, 6.4% y 17.4% contra las predichas de 2%, 3.9% y 7.64%. La prueba de Hosmer-Lemeshow tuvo una p < 0.001 para ambos modelos, y el área bajo la curva ROC de 0.707 y de 0.694 para EuroSCORE aditivo y logístico. Conclusión: En el INCICh el 88.7% de los pacientes con cirugía valvular tuvieron riesgo intermedio a alto y EuroSCORE subestimó el riesgo de mortalidad.

Abstract: Objective: The EuroSCORE (European System for cardiac operative risk evaluation) stratifies cardiac risk surgery in easy and accessible manner; it was validated in North America with good results but in many countries of Latin America is used routinely without prior validation. Our objective was to validate the EuroSCORE in patients with cardiac valve surgery at the Instituto Nacional de Cardiología Ignacio Chávez (INCICh) in México. Methods: EuroSCORE additive and logistic models were used to predict mortality in adults undergoing cardiac valve surgery from march 2004 to march 2008. The goodness of fit test of Hosmer-Lemeshow was used to evaluate the calibration. The area under the ROC curve was calculated to determinate discrimination. Results: We included 1188 patients with ages of 51.3 ± 14.5 years, 52% women. There were significant differences in the prevalence of risk factors among the INCICh and the EuroSCORE populations. Total mortality was 9.68% versus 5% and 5.6% predicted by additive and logistic EuroSCORE. According to additive EuroSCORE the risk was low in 11.3%, intermediate in 52.9% and high in 35.9%; for these groups the mortality was .7%, 6.34% and 17.4% against those predicted of 2%, 3.9% and 7.64%. Hosmer-Lemeshow test had a P < .001 for both models and the area under the ROC curve was .707 and .694 for additive and logistic EuroSCORE. Conclusion: In the INCICh 88.7% of patients with cardiac valve surgery had intermediate to high risk and EuroSCORE underestimated the risk of mortality.

Mortality risk after cardiac surgery: application of Inscor in a University Hospital in Brazil's northeast

Abstract Objective: To apply the InsCor in patients undergoing cardiac surgery in a university hospital in Brazil's northeast. Methods: It is a retrospective, quantitative and analytical study, carried out at the University Hospital of the Federal University of Maranhão. InsCor is a remodeling of two risk score models. It evaluates the prediction of mortality through variables such as gender, age, type of surgery or reoperation, exams, and preoperative events. Data from January to December 2015 were collected, using a Physical Therapy Evaluation Form and medical records. Quantitative variables were expressed as mean and standard deviation and qualitative variables as absolute and relative frequencies. Fisher's exact and Kruskal-Wallis tests were applied, considering significant differences when P value was < 0.05. Calibration was performed by Hosmer-Lemeshow test. Results: One hundred and forty-eight patients were included. Thirty-six percent were female, with mean age of 54.7±15.8 years and mean body mass index (BMI) equal to 25.6 kg/m2. The most frequent surgery was coronary artery bypass grafting (51.3%). According to InsCor, 73.6% of the patients had low risk, 20.3% medium risk, and only 6.1% high risk. In this sample, 11 (7.4%) patients died. The percentage of death in patients classified as low, medium and high risk was 6.3, 7.1% and 11.1%, respectively. Conclusion: InsCor presented easy applicability due to the reduced number of variables analyzed and it showed satisfactory prediction of mortality in this sample of cardiac surgery patients.