Prevalence of Frailty in Patients Undergoing Cardiac Valve Surgery: Comparison of Frailty Tools

Abstract Background There is no consensus among tools for assessing frailty. Objective To evaluate the prevalence of frailty according to different tools in patients referred for elective valve cardiac surgery. Methods This is a cross-sectional study. All patients were ≥ 18 years of age, clinically stable. The following patients were excluded: those unable to perform the tests because of physical, cognitive, or neurological limitations; those requiring non elective/emergency procedures or hemodynamic instability. During the preoperative cardiology visit, frailty was assessed by the Short Physical Performance Battery (SPPB), the Frailty Deficit Index (FDI), handgrip strength, and gait speed 3m. For the entire analysis, the statistical significance was set at 5%. Results Our cohort consisted of 258 subjects. From the total cohort, 201 were ≤ 70 years of age (77.9%), the predominant etiology according to rheumatic disease (50.7% vs 8.8%; p=0.000) with double mitral lesion (24.9% vs 0%; p=0.000). Frailty was present in 32.9% according SPPB, 29.1% with reduced muscular strength. and 8.9% with FDI. Handgrip strength was weaker in elderly patients (26.7 vs 23.6; p=0.051) and gait speed was lower in the younger group, in which 36% were considered frail (36% vs 14%; p=0.002). Variables associated with frailty were age ≥ 70 years, female gender, aortic stenosis, and regurgitation. Conclusion Frailty in adult patients who will have elective heart valve surgery is present even in the younger groups, although the older group with comorbidities are more frail. Frailty was more clearly shown by the SPPB than by the FDI and handgrip tests.

Internal Validation of a Risk Score for Prediction of Postoperative Atrial Fibrillation after Cardiac Surgery

Abstract Background: Postoperative atrial fibrillation (POAF) after cardiac surgery has great clinical and economic implications. Many attempts have been made to identify risk factors aiming at a better evaluation of prophylactic treatment strategies. Objective: To perform an internal validation of a risk score for POAF. Methods: A prospective cohort of 1,054 patients who underwent myocardial revascularization and/or valve surgery was included. The risk score model was developed in 448 patients, and its performance was tested in the remaining 606 patients. Variables with a significance level of 5% in the cohort were included and subjected to a multiple logistic regression model with backward selection. Performance statistics was performed using the c-statistic, the chi-square and the Hosmer-Lemeshow (HL) goodness-of-fit, Pearson's correlation coefficient. Results: Four variables were considered predictors of outcome: age (≥ 70 years), mitral valve disease, the non-use or discontinuation of beta-blockers and a positive water balance (> 1,500 mL). The ROC curve was 0.76 (95% confidence interval [CI]: 0.72-0.79). The risk model showed a good ability according to the performance statistics - HL test x(2) = 0.93; p = 0.983 and r = 0.99 (Pearson's coefficient). There was an increase in the frequency of POAF with the increase of the score: very low risk = 0.0%; low risk = 3.9%; intermediate risk = 10.9%; and high risk = 60.0%; p < 0.0001. Conclusion: The predictive variables of POAF allowed us to construct a simplified risk score. This scoring system showed good accuracy and can be used in routine clinical practice.

Relationship between emotional states before cardiac valve surgeries with postoperative complications / Relaciones entre el estado emocional antes de la cirugía cardíaca valvar con complicaciones en el post-operatorio / Relações entre o estado emocional antes da cirurgia cardíaca valvar com complicações no pós-operatório

ABSTRACT Objective: To investigate associations between preoperative anxiety and depression symptoms and postoperative complications and the sociodemographic and clinical characteristics of patients undergoing valve repair surgery. Method: Observational, exploratory and prospective study. The consecutive non-probabilistic sample consisted of patients undergoing their first valve repair surgery. Data were collected from September 2013 to September 2015, in a university hospital in the interior of São Paulo, Brazil. Symptoms were assessed using the Hospital Anxiety and Depression Scale and analyzed using Mann-Whitney and Spearman correlation; alpha was established at 5%. Results: Among the 70 participants, depressive symptoms were more frequent among women (p=0.042) and among patients experiencing postoperative agitation (p=0.039) Conclusion: In this study, depressive symptoms were associated with being a woman and postoperative agitation; the same was not true in regard to anxiety symptoms.

RESUMEN Objetivo: Investigar la asociación de los síntomas de ansiedad y depresión preoperatorios con complicaciones en postoperatorio y con características sociodemográficas y clínicas de pacientes sometidos a la corrección quirúrgica de valvopatías. Método: Estudio observacional, exploratorio y prospectivo. Muestra consecutiva y no probabilística fue constituida por pacientes sometidos a la primera cirugía de corrección de valvopatías. Los datos fueron recolectados de septiembre/2013 a septiembre/2015, en un hospital universitario del interior del São Paulo. Los síntomas fueron evaluados por el Hospital Anxiety and Depression Scale. Los datos fueron analizados por las pruebas de Mann-Whitney y Correlación de Spearman, alpha=5%. Resultados: Entre los 70 pacientes, fue encontrado mayor presencia de síntomas depresivos entre las mujeres (p=0,042) y en el grupo con agitación (p=0,039) en el postoperatorio. Conclusión: En el grupo estudiado, los síntomas depresivos se asociaron al sexo femenino y la agitación en el postoperatorio, lo que no ocurrió con los síntomas de ansiedad.

RESUMO Objetivo: Investigar a associação dos sintomas de ansiedade e depressão pré-operatórios com complicações no pós-operatório e com características sociodemográficas e clínicas de pacientes submetidos à correção cirúrgica de valvopatias. Método: Estudo observacional, exploratório e prospectivo. Uma amostra consecutiva e não probabilística foi constituída por pacientes submetidos à primeira cirurgia de correção de valvopatias. Os dados foram coletados de setembro/2013 a setembro/2015, em um hospital universitário do interior paulista. Os sintomas foram avaliados pela Hospital Anxiety and Depression Scale. Os dados foram analisados pelos testes de Mann-Whitney e Correlação de Spearman, alpha de 5%. Resultados: Entre os 70 pacientes, encontrou-se maior presença de sintomas depressivos entre as mulheres (p=0,042) e no grupo com agitação (p=0,039) no pós-operatório. Conclusão: No grupo estudado, sintomas depressivos foram associados ao sexo feminino e a agitação no pós-operatório, o que não ocorreu com os sintomas de ansiedade.

Avaliação de refluxos paraprotéticos por meio da ecocardiografia transesofágica tridimensional com Doppler colorido / Evaluation of paravalvular leaks through color Doppler three-dimensional transesophageal echocardiography

Fundamento: Os refluxos paraprotéticos são complicações comuns após cirurgia de troca valvar. A quantificação da gravidade, a localização e a morfologia dos refluxos paraprotéticos podem ser demonstradas por meio da ecocardiografia transesofágica tridimensional. Objetivo: Avaliar a correlação entre gravidade da regurgitação paravalvar, avaliada pela ecocardiografia tradicional bidimensional, usando a largura da vena contracta, e as medidas derivadas da avaliação pela ecocardiografia transesofágica tridimensional (comprimento, largura e área); avaliar o sucesso terapêutico da oclusão de refluxos paraprotéticos, guiada por ecocardiografia transesofágica tridimensional, e a correlação entre as medidas desta e as dos dispositivos para oclusão percutânea. Método: Estudo retrospectivo de 11 pacientes consecutivamente submetidos ao tratamento percutâneo de refluxos paraprotéticos entre 2014 e 2015, avaliados por meio de ecocardiografia transtorácica e ecocardiografia transesofágica tridimensional, no pré-operatório e no intraoperatório. Resultados: De um total de 20 refluxos paraprotéticos, 18 apresentaram sucesso técnico imediato. Não houve correlação entre as medidas da vena contracta bidimensional e as derivadas da ecocardiografia transesofágica tridimensional. Houve correlação forte entre o comprimento do defeito pela ecocardiografia transesofágica tridimensional e o comprimento do dispositivo para oclusão percutânea (rho = 0,929; p < 0,001), além de correlação moderada entre a área do defeito e a do dispositivo para oclusão percutânea (rho = 0,682; p = 0,002). Não houve correlação entre a largura do dispositivo para oclusão percutânea e a do defeito medida pela ecocardiografia transesofágica tridimensional (rho = 0,440; p = 0,067). Conclusão: Não houve correlação entre a medida da vena contracta bidimensional e as medidas derivadas da ecocardiografia transesofágica tridimensional. A escolha dos dispositivos para oclusão percutânea baseada nas medidas da ecocardiografia transesofágica tridimensional apresentou alta taxa de sucesso imediato, com ótima correlação entre o comprimento dos defeitos e dos dispositivos para oclusão percutânea. A correlação entre as áreas foi boa e não houve correlação entre as larguras

Background: Paravalvular leaks are a common complication after valve replacement surgery. Quantification of the severity, location and morphology of paravalvular leaks can be obtained by three-dimensional transesophageal echocardiography. Objective: To evaluate the correlation between the severity of paravalvular regurgitation by vena contracta measurement using bidimensional echocardiography, and measurements derived from three-dimensional transesophageal echocardiography (length, width and area). To evaluate the therapeutic success of three-dimensional transesophageal echocardiography-guided paravalvular leaks occlusion and the correlation between three-dimensional transesophageal echocardiography measurements and dimensions of devices for percutaneous occlusion. Method: Retrospective study of 11 patients consecutively submitted to percutaneous paravalvular leaks treatment between 2014 and 2015, using transthoracic echocardiography and between three-dimensional transesophageal echocardiography in the preoperative and intraoperative periods. Results: Out of a total of 20 paravalvular leaks, 18 showed immediate technical success. There was no correlation between the measurements of the bidimensional vena contracta and the measures derived from the three-dimensional transesophageal echocardiography. There was a strong correlation between the defect length measured by the three-dimensional transesophageal echocardiography and the device for percutaneous occlusion length (rho = 0.929; p < 0.001); and moderate between the defect area and the device for percutaneous occlusion area (rho = 0.682,p = 0.002). There was no correlation between the device for percutaneous occlusion width and the defect width measured by three-dimensional transesophageal echocardiography (rho = 0.440; p = 0.067). Conclusion: There was no correlation between the measurement of the bidimensional vena contracta and the measures derived from the three-dimensional transesophageal echocardiography. The choice of devices for percutaneous occlusion based on three-dimensional transesophageal echocardiography measurements showed a high success rate, with an excellent correlation between defect length and devices for percutaneous occlusion length. The correlation between the areas was good, and there was no correlation between the widths

Quadruple valve replacement for carcinoid heart disease

Abstract Introduction: Carcinoid heart disease most frequently involves the tricuspid or, more rarely, the pulmonary valve and presents with right heart failure as 5-HT is metabolized by the lung. Left-sided valve involvement is quite rare. We describe our experience of 3 patients presenting with heart failure secondary to carcinoid heart disease affecting all four cardiac valves. There are only four previous isolated case reports in the literature. Methods: All three patients underwent quadruple valve replacement during a single operation. Right ventricular outflow tract reconstruction with a pericardial patch was performed in all patients. For 24 hours prior to surgery, all patients received intravenous octreotide, which continued in intensive care for at least 24 hours. Results: Mean cross-clamp and bypass times were 175 (range 164-197 minutes) and 210 (range 195-229 minutes) minutes, respectively. Mean intensive treatment unit (ITU) and inpatient stays were 2.3 (range 2-3 days) and 12 (range 9-16 days) days, respectively. One patient was reopened for bleeding 4 hours postoperatively from a ventricular pacing wire site. None required a permanent pacemaker postoperatively. There were no other complications in any patient. The quality of life was excellent at 6-16 months clinic follow-up as they were in NYHA 1. Postoperative echocardiography showed no paravalvular leaks and well-functioning prostheses in all cases. Conclusion: Surgery to replace all four valves is feasible with excellent medium-term survival and a very low rate of complications. Patients with carcinoid heart disease should always be considered for surgery irrespective of the extent of valvular involvement.

Mediastinite após cirurgias valvares cardíacas: revisão integrativa / Mediastinitis after heart valve surgeries: integrative review

A mediastinite é uma infecção do tecido conjuntivo do mediastino, pouco estudada em pacientes submetidos às cirurgias de correção de valvopatias cardíacas. O objetivo deste estudo foiidentificar na literatura as evidências relacionadas à mediastinite em pacientes submetidos às cirurgias para correção de valvopatias cardíacas. Foi realizado uma revisão integrativa com buscas, em cinco bases de dados eletrônicas: LILACS, PubMed, Scopus, EBSCOhoste Web of Science. De acordo com os critérios estabelecidos, quatro artigos foram incluídos para a análise e mostraram aspectos sobre a mediastinite, como: preditores de mortalidade no pré-operatório, contaminação de materiais no intraoperatório etécnica de abordagem cirúrgica. Estudos com enfoque específico à ocorrência de mediastinite nestes pacientes, podem instrumentalizar a equipe de saúde e melhorar a implementação das ações na prática clínica, prevenindo complicações

Mediastinitis is an infection of the connective tissue of the mediastinum that is poorly studied in patients undergoing heart valve repair surgeries. The objective of this study was to identify in the literature the evidence related to mediastinitis in patients undergoing heart valve repair surgeries. An integrative review was performed with searches in five electronic databases, namely: LILACS, PubMed, Scopus, EBSCOhost and Web of Science. According to the established criteria, were included four articles for analysis. They all had aspects about mediastinitis, such as: preoperative mortality predictors, intraoperative material contamination, and surgical approach technique. Studies focused specifically on the occurrence of mediastinitis in these patients can instrumentalize the health team andimprove the implementation of clinical practice actions by preventing complications.

The brazilian registry of adult patient undergoing cardiovascular surgery, the bypass project: results of the first 1,722 patients

Abstract Objective: To report the early results of the BYPASS project - the Brazilian registrY of adult Patient undergoing cArdiovaScular Surgery - a national, observational, prospective, and longitudinal follow-up registry, aiming to chart a profile of patients undergoing cardiovascular surgery in Brazil, assessing the data harvested from the initial 1,722 patients. Methods: Data collection involved institutions throughout the whole country, comprising 17 centers in 4 regions: Southeast (8), Northeast (5), South (3), and Center-West (1). The study population consists of patients over 18 years of age, and the types of operations recorded were: coronary artery bypass graft (CABG), mitral valve, aortic valve (either conventional or transcatheter), surgical correction of atrial fibrillation, cardiac transplantation, mechanical circulatory support and congenital heart diseases in adults. Results: 83.1% of patients came from the public health system (SUS), 9.6% from the supplemental (private insurance) healthcare systems; and 7.3% from private (out-of -pocket) clinic. Male patients comprised 66%, 30% were diabetics, 46% had dyslipidemia, 28% previously sustained a myocardial infarction, and 9.4% underwent prior cardiovascular surgery. Patients underwent coronary artery bypass surgery were 54.1% and 31.5% to valve surgery, either isolated or combined. The overall postoperative mortality up to the 7th postoperative day was 4%; for CABG was 2.6%, and for valve operations, 4.4%. Conclusion: This first report outlines the consecution of the Brazilian surgical cardiac database, intended to serve primarily as a tool for providing information for clinical improvement and patient safety and constitute a basis for production of research protocols.

Tratamiento anticoagulante oral en pacientes sometidos a remplazo valvular en un hospital general de Antofagasta, Chile / Oral anticoagulant treatment (OAT) in patients with cardiac valve replacement at a general hospital in Antofagasta, Chile

Introduccion: La atención de pacientes con reemplazo valvular cardíaco constituye una actividad importante en cardiología. Si bien el recambio valvular representa una alternativa terapéutica eficaz para el manejo de esta patología, muchos pacientes requieren de tratamiento anticoagulante oral (TACO) para lograr mayor sobrevida. Objetivos: Describir los resultados terapéuticos obtenidos en un cohorte de pacientes sometidos a recambio valvular, controlados en el Hospital Regional de Antofagasta. Resultados: Se identificaron 180 pacientes con reemplazo valvular de los cuales 135 cumplieron criterios de inclusión. Hubo 76 mujeres (56,3%), 59 hombres (43,7%); la edad global promedio fue 62 años (28-90), 59 años (30-90) en las mujeres y 64 (36-81) en los hombres. La válvula intervenida fue la aórtica en 69 pacientes (51,1%), mitral en 60 (44,5%), aórtica y mitral en 5 (3,7%), y tricúspide en 1 paciente (0,7%). No hubo casos de recambio valvular pulmonar. Se instalaron 122 válvulas mecánicas (90,4%) y 13 válvulas biológicas (9,6%). El INR promedio fue 2,64 (1,11-5,47). Según válvula intervenida el INR promedio fue: mitral 2,50 (1,11-4,89), aórtica: 2,75 (1,19-5,47), mitral y aórtica: 2,65 (1,28-3,74), y tricúspide: 1,87. Del total de cirugías valvulares, 77 (57,03%) se encontraron dentro del rango terapéutico deseado: (mitral 33/60, Aórtica 43/69 mitral y aórtica 0/5, Tricúspide: 0/1). 58 pacientes (42,97%) se encontraron fuera del rango terapéutico deseado. Conclusion: Los resultados obtenidos en nuestro centro se encuentran por debajo de las recomendaciones nacionales. La dificultad por obtener mejores resultados refuerza el uso de prótesis biológicas y la implementación óptima de un policlínico de tratamiento anticoagulante (TACO).

Background: Care of patients with cardiac valve replacement often includes the need for anticoagulation which prevents complications that may decrease survival rate. Aim: to describe the experience with OAT in a cohort of patients with cardiac valve replacement at the Regional Hospital in Antofagasta Results: 135 out of 180 patients fulfilled inclusion criteria. There were 76 females (56.3%) and 59 males (43.7%), with a mean of 62 years old (28-90), 59 (30-90) in females and 64 (36-81) in males. The valve replaced was the aortic in 69 patients (51.1%), the mitral in 60 (44.5%), both the aortic and the mitral valve in 5 (3.7%). Only 1 patients had a tricuspid valve replaced. 122 mechanical valves (90.4%) and 13 biological valves (9.6%) were implanted. The overall mean INR was 2.64 (1.11 - 5.47). The mean INR value according to the valve replaced was: mitral valve 2.5 (1,11-4,89), aortic valve 2.75 (1.195.47) and mitral plus aortic valve 2.65 (1.28-3.74). Overall, 58 patients were found to be outside the therapeutic target. Conclusion: These results are less satisfactory than those proposed by national guidelines. The anticoagulant clinic must be optimized and more biological rather than mechanical valves should be used for cardiac valve replacement.

Application of Mechanical Ventilation Weaning Predictors After Elective Cardiac Surgery

ABSTRACT OBJECTIVE: To test several weaning predictors as determinants of successful extubation after elective cardiac surgery. METHODS: The study was conducted at a tertiary hospital with 100 adult patients undergoing elective cardiac surgery from September to December 2014. We recorded demographic, clinical and surgical data, plus the following predictive indexes: static compliance (Cstat), tidal volume (Vt), respiratory rate (f), f/ Vt ratio, arterial partial oxygen pressure to fraction of inspired oxygen ratio (PaO2/FiO2), and the integrative weaning index (IWI). Extubation was considered successful when there was no need for reintubation within 48 hours. Sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were used to evaluate each index. RESULTS: The majority of the patients were male (60%), with mean age of 55.4±14.9 years and low risk of death (62%), according to InsCor. All of the patients were successfully extubated. Tobin Index presented the highest SE (0.99) and LR+ (0.99), followed by IWI (SE=0.98; LR+ =0.98). Other scores, such as SP, NPV and LR-were nullified due to lack of extubation failure. CONCLUSION: All of the weaning predictors tested in this sample of patients submitted to elective cardiac surgery showed high sensitivity, highlighting f/Vt and IWI.

Implante percutâneo de prótese valvar aórtica ­ experiência com o dispositivo reposicionável LotusTM / Percutaneous aortic valve implantation ­ an experience with the LotusTM repositionable device

Introdução: A válvula aórtica transcateter de segunda geração LotusTM foi desenhada para proporcionar ao intervencionista o controle completo de sua liberação durante o procedimento. O presente estudo apresenta a experiência inicial e os desfechos hospitalares de pacientes tratados com essa prótese no Brasil. Métodos: Registro observacional, retrospectivo, que incluiu pacientes com estenose aórtica grave sintomáticos, considerados de alto risco cirúrgico, tratados em sete centros.Resultados: Receberam o dispositivo 31 pacientes, sendo 61,3% do sexo feminino, com idade de 82,9 ± 6,9 anos e escore STS de 6,5 ± 4,1%. A área valvar aórtica foi de 0,73 ± 0,18 cm2 e o gradiente médio de 51,7 ± 13,9 mmHg. Todos os procedimentos foram realizados pela via transfemoral, e a pré-dilatação foi necessária em 65% dos casos. A taxa de sucesso do procedimento foi de 96,7%. Não houve complicação vascular com necessidade de intervenção cirúrgica e nem casos de acidente vascular cerebral. O gradiente médio após o procedimento foi de 10,5 ± 5,8 mmHg e não foram observadas regurgitações aórticas de graus moderado/importante. A taxa de implante de marca-passo definitivo foi de 38,7%, e a permanência hospitalar de 8,5 ± 4,8 dias. Conclusões: Na experiência inicial com o implante da válvula aórtica LotusTM, os resultados hospitalares demostraram a segurança e a eficácia do dispositivo, além de ausência de regurgitação aórtica relevante

Background: The second-generation LotusTM transcatheter aortic valve was designed to provide the interventional cardiologist with complete control of its release during the procedure. This study presents the initial experience and in-hospital outcomes of patients treated with this prosthesis in Brazil. Methods: This observational and retrospective study included patients with symptomatic severe aortic stenosis considered at high surgical risk, treated in seven centers. Results: The device was used in 31 patients, 61.3% female, aged 82.9 ± 6.9 years, and with STS score of 6.5 ± 4.1%. The aortic valve area was 0.73 ± 0.18 cm2 and the mean gradient was 51.7 ± 13.9 mmHg. All procedures were performed by the transfemoral access route, and pre-dilation was necessary in 65% of cases. The success rate of the procedure was 96.7%. There were no vascular complications requiring surgical intervention nor cases of stroke. The mean gradient after the procedure was 10.5 ± 5.8 mmHg; no cases of moderate to severe aortic regurgitation were observed. The rate of permanent pacemaker implantation was 38.7%, and mean in-hospital length of stay was 8.5 ± 4.8 days. Conclusions: In the initial experience with the use of the LotusTM aortic valve, in-hospital results demonstrated the safety and efficacy of the device; no cases of significant aortic regurgitation were observed

Heart valve surgery in patients with homozygous sickle cell disease: A management strategy.

Background: Patients with the homozygous sickle cell disease have increased perioperative mortality. Some indications like heart valve surgery, may justify an exchange blood transfusion to reduce the proportion of hemoglobin S (HbS) and complications. Subjects and Methods: We report two female cases aged 20 and 27, of African origin with homozygous sickle cell anemia who underwent heart valve surgery to treat mitral valve regurgitation. This presentation describes the perioperative considerations including anesthesia and postoperative care. Results: A partial exchange blood transfusion decreased HbS levels from respectively, 90% and 84%, 9% to 27% and 34%, and simultaneously treated the anemia. Neither sickling crisis nor acidosis occurred in any patient, and no special postoperative complication occurred. Average hospital stay was 10 days. Currently, the two patients remain alive and free of cardiac symptoms. Discussion: Although the presence of sickle cell disorders is associated with increased risk of sickling and thus vaso‑occlusive complications, they should not be taken as a contraindication for heart valve surgery. Nevertheless, monitoring of certain parameters such as venous, arterial oxygen content, pH, and body temperature is mandatory for a better outcome. Furthermore, preoperative exchange transfusion has a positive influence on the outcome of surgery and on the survival of patients undergoing heart valves surgery. Avoiding intraoperative hypoxia, hypothermia, and vaso‑constrictive agents, minimizing HbS levels with preoperative exchange transfusion, and ensuring a stress‑free environment with the judicious use of sedatives made surgery relatively safe in these cases.

A propose of pulmonary dysfunction stratification after valve surgery by physiotherapeutic assistance level / Proposta de estratificação da disfunção pulmonar após cirurgia valvar segundo níveis de assistência fisioterapêutica

Abstract Objective: a) to propose and implement an evaluation system; b) to classify the pulmonary involvement and determine levels of physical therapy; c) to check the progress postoperatively. Methods: Patients underwent physiotherapy assessment preoperatively, postoperatively and after 5 days of intervention. They were classified into three levels of care: level 1 - low risk of complication; Level 2 - medium risk; Level 3 - high risk. We used analysis of variance and Kruskal-Wallis and analysis of variance for repeated measures or Friedman. Chi-square test or Fisher for proportions. We considered statistical significance level P<0.05. Results: We studied 199 patients, 156 classified within level 1, 32 at level 2 and 11 at level 3. Thoracoabdominal motion and auscultation changed significantly postoperatively, persisting at levels 2 and 3 (P<0.05). Oxygenation and respiratory rate changed at levels 2 and 3 postoperatively (P<0.05) with recovery at the end. Significant decrease in lung volumes occurred in three levels (P<0.05) with partial recovery at level 1, lung collapse occurred at all levels, with recovery by 56% at level 1, 47% at level 2, 27% at level 3. Conclusion: The proposed assessment identified valve surgery patients who require differentiated physical therapy. Level 1 patients had rapid recovery, while the level 2 showed significant changes with functional gains at the end. Level 3 patients, more committed and prolonged recovery, should receive greater assistance. .

Resumo Objetivo: a) propor e aplicar um sistema de avaliação; b) classificar o comprometimento pulmonar e determinar os níveis de assistência fisioterapêutica; c) verificar a evolução no pós-operatório de cirurgia valvar. Métodos: Pacientes realizaram avaliação fisioterapêutica no pré-operatório, pós-operatório e após 5 dias de intervenção. Foram classificados em três níveis de atenção: nível 1 - baixo risco de complicação; nível 2 - médio risco; nível 3 - alto risco. Utilizou-se Análise de Variância e Kruskal-Wallis e Análise de Variância para medidas repetidas ou Friedmann. Teste qui-quadrado ou Fisher para as proporções. Considerou-se nível de significância estatística P<0,05. Resultados: Foram estudados 199 pacientes, 156 classificados no nível 1, 32 nível 2 e 11 nível 3. Movimento toracoabdominal e ausculta pulmonar alteraram significantemente no pós-operatório, persistindo nos níveis 2 e 3 (P<0,05). Oxigenação e frequência respiratória se modificaram nos níveis 2 e 3 no pós-operatório (P<0,05), com recuperação no final. Diminuição significante dos volumes pulmonares ocorreu nos três níveis (P<0,05), com recuperação parcial no nível 1. Colapso pulmonar ocorreu em todos os níveis, com recuperação em 56% no nível 1, 47% no nível 2, 27% no nível 3. Conclusão: A avaliação proposta identificou pacientes de cirurgia valvar que necessitam de assistência fisioterapêutica diferenciada. Pacientes do nível 1 tiveram rápida recuperação, enquanto os do nível 2 mostraram alterações significativas, com ganhos funcionais no final. Pacientes do nível 3, mais comprometidos e com recuperação prolongada, devem receber maior assistência. .

Efficacy of Goal-Directed Therapy Using Bioreactance Cardiac Output Monitoring after Valvular Heart Surgery

PURPOSE: We compared the efficacy of postoperative hemodynamic goal-directed therapy (GDT) using a pulmonary artery catheter (PAC) and bioreactance-based noninvasive cardiac output monitoring (NICOM) in patients with atrial fibrillation undergoing valvular heart surgery. MATERIALS AND METHODS: Fifty eight patients were randomized into two groups of GDT with common goals to maintain a mean arterial pressure of 60-80 mm Hg and cardiac index > or =2 L/min/m2: the PAC group (n=29), based on pulmonary capillary wedge pressure, and the NICOM group (n=29), based on changes in stroke volume index after passive leg raising. The primary efficacy variable was length of hospital stay. Secondary efficacy variables included resource utilization including vasopressor and inotropic requirement, fluid balance, and major morbidity endpoints. RESULTS: Patient characteristics and operative data were similar between the groups, except that significantly more patients underwent double valve replacement in the NICOM group. The lengths of hospital stay were not different between the two groups (12.2+/-4.8 days vs. 10.8+/-4.0 days, p=0.239). Numbers of patients requiring epinephrine (5 vs. 0, p=0.019) and ventilator care >24 h (6 vs. 1, p=0.044) were significantly higher in the PAC group. The PAC group also required significantly larger amounts of colloid (1652+/-519 mL vs. 11430+/-463 mL, p=0.004). CONCLUSION: NICOM-based postoperative hemodynamic GDT showed promising results in patients with atrial fibrillation undergoing valvular heart surgery in terms of resource utilization.

Evaluation of variables responsible for hospital mortality in patients with rheumatic heart disease undergoing double valve replacement / Avaliação de variáveis responsáveis pela mortalidade hospitalar em pacientes portadores de doença reumática submetidos à dupla troca valvar

Objective: To describe the hospital mortality and associated clinical and echocardiographic variables in patients with rheumatic disease who underwent double valve replacement surgery. Methods: This is a cross sectional descriptive study of mortality, performed in a referral hospital in Salvador, Bahia. Records from patients with rheumatic disease who underwent double valve replacement surgery during the years 2007-2011 were analyzed. Results: The studied sample comprises 104 patients and 60 (57.7%) were male. The mean age was 38.04±14.45. Sixty five bioprostheses and 38 mechanical prostheses were used in these patients at the time of surgery. There were statistically significant differences between the two groups, when we analyzed the following variables: the mean age (36.30±13.03 vs. 45.35±17.8 years-old, P=0.011), mean hemoglobin (11.10±2.19 vs. 9.22±2.26 g/dL, P=0.002), mean hematocrit (34.22±5.86 vs. 28.44±6.62%, P<0.001). New York Heart Association functional class III and IV (NYHA) (P=0.022) was statistically associated with mortality. Conclusion: We concluded that the mean hemoglobin/hematocrit level and the NYHA functional class was the major variables associated to the mortality among these patients. Based on these data one may concern about the patient best moment for surgery and the patient hemoglobin level. .

Objetivo: Descrever a mortalidade hospitalar em pacientes reumáticos submetidos à cirurgia de dupla troca valvar e sua relação com variáveis clínicas e ecocardiográficas. Métodos: Trata-se de um estudo de corte transversal. Foram estudados pacientes maiores que 18 anos, com valvopatia reumática que foram submetidos à cirurgia de DTV do período de janeiro de 2007 a dezembro de 2011 no Hospital Ana Nery - Salvador - Bahia. A coleta de dados se deu por meio de consulta aos prontuários dos pacientes. Resultados: Foram estudados 104 pacientes, 60 (57,7%) eram do sexo masculino. A média de idade da população estudada foi de 38,04±14,45 anos. Foram utilizadas 65 próteses biológicas e 38 próteses metálicas. Houve diferença estatisticamente significante entre os grupos comparados, pacientes que obtiveram alta versus pacientes que foram a óbito, em relação às seguintes variáveis: média de idade dos pacientes que receberam alta para casa e foram a óbito, respectivamente (36,30±13,03 vs. 45,35±17,8, P=0,011); média de hemoglobina, (11,10±2,19 vs. 9,22±2,26 g/dL, P=0,002); média do hematócrito, (34,22±5,86 vs. 28,44±6,62%, P<0,001). As classes funcionais III e IV (New York Heart Association) estiveram associadas estatisticamente com a mortalidade (P=0.022). Conclusão: Os dados encontrados no estudo apresentam uma população pouco estudada na qual os principais achados foram a média do nível de hemoglobina/hematócrito e classe funcional NYHA. Deve se levar em conta esses dados para a escolha do melhor momento de cirurgia para essa população. .

Acute kidney injury based on KDIGO (Kidney Disease Improving Global Outcomes) criteria in patients with elevated baseline serum creatinine undergoing cardiac surgery / Lesão renal aguda baseada nos critérios KDIGO (Kidney Disease: Improving Global Outcomes) em pacientes com creatinina sérica elevada submetidos à cirurgia cardíaca

Introduction: Preoperatively elevated serum creatinine (SCr) is considered an independent risk factor for morbidity and mortality after cardiac surgery. The aim of this study was to apply the Kidney Disease Improving Global Outcomes classification for acute kidney injury in a population of patients with preoperatively elevated serum creatinine who underwent cardiac surgery (coronary artery bypass grafting or cardiac valve surgery) and to evaluate the acute worsening of renal function as a predictor of 30-day mortality. Methods: This was a single-center retrospective study that included patients from the Postoperative Cardiac Surgery Intensive Care Unit of the Hospital de Base, São José do Rio Preto Medical School. Demographics, type of surgery, laboratory data and pre, peri and postoperative data were obtained from a prospectively collected database. From January 2003 to June 2013, 2,878 patients underwent cardiac surgery, either coronary artery bypass grafting or cardiac valve surgery, at the Hospital de Base of São José do Rio Preto Medical School. Out of those, 918 showed elevated preoperative serum creatinine, with SCr > 1.30 mg/dL for men and > 1.00 mg/dL for women. Five hundred and forty nine patients (60%) undergoing coronary artery bypass grafting and 369 patients (40%) undergoing cardiac valve surgery. A Multivariate Cox Proportional Hazard Model (stepwise) was used to assess the relationship between AKI and mortality at 30 days. Results: Out of the 918 patients studied, 391 (43%) had postoperative AKI: 318 (35%) had Kidney Disease Improving Global Outcomes stage 1, 27 (2.9%) had Kidney Disease Improving Global Outcomes stage 2, and 46 (5.0%) had Kidney Disease Improving Global Outcomes stage 3. Patients in every stage of acute kidney injury showed progressive increase in EuroSCORE values, 30-day mortality ratescardiopulmonary bypass duration, and intensive care length of stay. Among patients classified ...

Introdução: Creatinina sérica (CSr) elevada no período pré-operatório é considerada um fator de risco independente para morbidade e mortalidade em cirurgia cardíaca. Avaliar o impacto da lesão renal aguda pelos critérios Kidney Disease Improving Global Outcomes como preditor de mortalidade em 30 dias em pacientes submetidos à revascularização miocárdica ou cirurgia valvar com creatinina sérica pré-operatória elevada. Métodos: Este foi um estudo retrospectivo de centro único que incluiu pacientes da Unidade de Cuidados Intensivos em Pós-operatório de Cirurgia Cardíaca do Hospital de Base, Faculdade de Medicina de São José do Rio Preto. Dados demográficos, tipos de cirurgia, dados laboratoriais e informações pré, peri e pós-operatórias foram obtidos a partir de uma coleta prospectiva de banco de dados. Foram considerados 2878 pacientes consecutivamente submetidos à revascularização miocárdica ou cirurgia valvar no período de janeiro de 2003 a junho de 2013. Destes, 918 indivíduos apresentavam creatinina sérica alterada no pré-operatório (CrS > 1.30 mg/dL para homens e > 1.00 mg/dL para mulheres), compreendendo 549 pacientes (60%) submetidos à revascularização miocárdica e 369 pacientes (40%) submetidos à cirurgia valvar. O modelo de riscos proporcionais de Cox foi utilizado para avaliar a relação entre lesão renal aguda e mortalidade em 30 dias. Resultados: Nesta casuística, 391 pacientes (43%) apresentaram lesão renal aguda no pós-operatório, sendo 318 (35%) Kidney Disease Improving Global Outcomes estágio 1, 27 (2,9%) Kidney Disease Improving Global Outcomes estágio 2 e 46 (5,0%) Kidney Disease Improving Global Outcomes estágio 3. EuroSCORE, mortalidade em 30 ...

Sotalol: A rescue drug in the face of life-threatening refractory ventricular tachycardia.

We describe postoperative refractory ventricular tachycardia (VT) in a patient following aortic and mitral valve replacement. Following an uneventful separation from cardiopulmonary bypass with dobutamine, the patient developed recurrent VT, 4 hours into the postoperative period. The VT did not respond to standard doses of xylocard, magnesium and amiodarone. Electrolyte and acid base parameters were normal. Multiple cardioversions failed to revert back to a stable rhythm. Intra‑aortic balloon pumping was instituted and overdrive right ventricular pacing was unsuccessful. Following intravenous sotalol 80 mg, the VT came under control and reverted to a nodal rhythm, which required atrial pacing for the next 8 hours. Oral sotalol therapy was continued at 40 mg daily. The VT did not recur.

Use of right ventricular support with a centrifugal pump in post-valve surgery right ventricular failure: a case series

The optimal treatment method for right ventricular failure after valve surgery complicated by a low cardiac output has not been determined, although several case reports have been published on patients with ventricular failure and arrhythmia who were bridged to cardiac transplantation using biventricular or left ventricular assist devices. This case series illustrates successful circulatory support of 4 patients with prolonged low cardiac outputs and right ventricular failure and arrhythmias after valvular heart surgery with or without severe pulmonary hypertension. In-hospital death occurred in one patient and 3 patients were discharged from the hospital with good general condition. At two years' follow-up, 2 patients were in functional class one but another patient underwent laparotomy for multiple splenic abscesses and died from multiple organ failure