Anemia in cardiac surgery - can something bad get worse?

Abstract Introduction: Anemia and blood transfusion are risk factors for morbidity/mortality in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The objective of this study is to analyze the association of blood transfusion with morbidity/mortality in patients undergoing coronary artery bypass grafting (CABG) under CPB in the state of São Paulo, Brazil. Methods: This is a retrospective analysis using the State of São Paulo Registry of Cardiovascular Surgery from November 2013 to August 2014. Blood transfusion was only considered during surgery or within six hours after surgery. Anemia was defined as hematocrit ≤ 37.5%. Patients < 18 years old were excluded. The sample was divided in four groups - Group I (851, no anemia), Group II (200, anemia without blood transfusion), Group III (181, no anemia and transfusion), and Group IV (258, anemia and transfusion). Results: A total of 1,490 patients were included; 639 (42.9%) were anemic and 439 (29.5%) underwent blood transfusion. Group II showed lower composite morbidity (odds ratio [OR] −0.05; confidence interval [CI] −0.27-0.17; P=0.81) than Group III (OR 0.41; CI 0.23-0.59; P=0.018) or Group IV (OR 0.54; CI 0.31-0.77; P=0.016). Group III was at greater risk of mortality (OR 0.73; CI 0.43-1.03; P=0.02) than Group II, which was exposed only to anemia (OR −0.13; CI −0.55-0.29; P=0.75), or Group IV (OR 0.29; CI −0.13-0.71; P=0.539). Conclusion: Anemia in patients undergoing CABG with CPB is bad, but blood transfusion can be worse, increasing at least 50% the risk for mortality and/or morbidity.

Age, Creatinine and Ejection Fraction Score in Brazil: Comparison with InsCor and the EuroSCORE / Age, Creatinine and Ejection Fraction Score no Brasil: Comparação com o InsCor e o EuroSCORE

AbstractBackground:Risk scores for cardiac surgery cannot continue to be neglected.Objective:To assess the performance of “Age, Creatinine and Ejection Fraction Score” (ACEF Score) to predict mortality in patients submitted to elective coronary artery bypass graft and/or heart valve surgery, and to compare it to other scores.Methods:A prospective cohort study was carried out with the database of a Brazilian tertiary care center. A total of 2,565 patients submitted to elective surgeries between May 2007 and July 2009 were assessed. For a more detailed analysis, the ACEF Score performance was compared to the InsCor’s and EuroSCORE’s performance through correlation, calibration and discrimination tests.Results:Patients were stratified into mild, moderate and severe for all models. Calibration was inadequate for ACEF Score (p = 0.046) and adequate for InsCor (p = 0.460) and EuroSCORE (p = 0.750). As for discrimination, the area under the ROC curve was questionable for the ACEF Score (0.625) and adequate for InsCor (0.744) and EuroSCORE (0.763).Conclusion:Although simple to use and practical, the ACEF Score, unlike InsCor and EuroSCORE, was not accurate for predicting mortality in patients submitted to elective coronary artery bypass graft and/or heart valve surgery in a Brazilian tertiary care center. (Arq Bras Cardiol. 2015; [online].ahead print, PP.0-0).

ResumoFundamento:Escores de risco para cirurgia cardíaca não podem continuar sendo neglicenciados.Objetivo:Avaliar o desempenho do Age, Creatinine and Ejection Fraction Score (ACEF Score) na predição de mortalidade dos pacientes submetidos à cirurgia de revascularização miocárdica e/ou valvar eletiva, e compará-lo a outros escores.Métodos:Estudo de coorte prospectivo no banco de um centro terciário brasileiro. Foram avaliados 2.565 pacientes operados de maneira eletiva entre maio de 2007 e julho de 2009. Para uma análise mais detalhada, o desempenho do ACEF Score foi comparado ao do InsCor e ao do EuroSCORE por meio de testes de correlação, calibração e discriminação.Resultados:Os pacientes foram estratificados em leve, moderado e grave para todos os modelos. A calibração foi inadequada para o ACEF Score (p = 0,046) e adequada para o InsCor (p = 0,460) e o EuroSCORE (p = 0,750). Na discriminação, a área abaixo da curva ROC apresentou-se questionável para o ACEF Score (0,625) e apropriada para o InsCor (0,744) e o EuroSCORE (0,763).Conclusão:Embora simples e prático, o ACEF Score, ao contrário do InsCor e do EuroSCORE, não se mostrou acurado para predizer mortalidade nos pacientes submetidos à cirurgia de revascularização miocárdica e/ou valvar eletiva em centro terciário brasileiro. (Arq Bras Cardiol. 2015; [online].ahead print, PP.0-0).

Surgery of the aortic root: should we go for the valve-sparing root reconstruction or the composite graft-valve replacement is still the first choice of treatment for these patients? / Cirurgia da raiz da aorta: deve-se preservar a valva aórtica ou a operação com o tubo valvulado ainda é a primeira opção de tratamento para esses pacientes?

AbstractObjective:To compare the results of the root reconstruction with the aortic valve-sparing operation versus composite graftvalve replacement.Methods:From January 2002 to October 2013, 324 patients underwent aortic root reconstruction. They were 263 composite graft-valve replacement and 61 aortic valve-sparing operation (43 reimplantation and 18 remodeling). Twenty-six percent of the patients were NYHA functional class III and IV; 9.6% had Marfan syndrome, and 12% had bicuspid aortic valve. There was a predominance of aneurysms over dissections (81% vs. 19%), with 7% being acute dissections. The complete follow-up of 100% of the patients was performed with median follow-up time of 902 days for patients undergoing composite graft-valve replacement and 1492 for those undergoing aortic valve-sparing operation.Results:In-hospital mortality was 6.7% and 4.9%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). During the late follow-up period, there was 0% moderate and 15.4% severe aortic regurgitation, and NYHA functional class I and II were 89.4% and 94%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). Root reconstruction with aortic valve-sparing operation showed lower late mortality (P=0.001) and lower bleeding complications (P=0.006). There was no difference for thromboembolism, endocarditis, and need of reoperation.Conclusion:The aortic root reconstruction with preservation of the valve should be the operation being performed for presenting lower late mortality and survival free of bleeding events.

ResumoObjetivo:Analisar comparativamente os resultados da operação de preservação da valva aórtica e do tubo valvulado nas reconstruções da raiz da aorta.Métodos:No período de janeiro de 2002 a outubro de 2013, 324 pacientes foram submetidos à reconstrução da raiz da aorta. Foram 263 tubos valvulados e 61 preservações da valva aórtica (43 reimplantes e 18 remodelamentos). 26% dos pacientes estavam em classe funcional III e IV; 9,6% com síndrome de Marfan e 12% apresentavam valva aórtica bivalvulada. Houve predomínio dos aneurismas sobre as dissecções (81% contra 19%), sendo 7% de dissecções agudas. O seguimento completo de 100% dos pacientes foi realizado com tempo mediano de seguimento de 902 dias para pacientes submetidos à tubo valvulado e de 1492 para aqueles submetidos à preservação da valva aórtica.Resultados:A mortalidade hospitalar foi de 6,7% contra 4,9% respectivamente para tubo valvulado e preservação da valva aórtica (ns). No seguimento tardio, a insuficiência aórtica importante foi de 0% e 5,8%, e a insuficiência cardíaca crônica, classe funcional I e II de 89,4% e 94%, respectivamente, para tubo valvulado e preservação da valva aórtica (ns). A reconstrução da raiz da aorta com a preservação da valva aórtica apresentou menor mortalidade tardia (P=0,001) e menos complicações hemorrágicas (P=0,006). Não houve diferença para tromboembolismo, endocardite ou necessidade de reoperação.Conclusão:A reconstrução da raiz da aorta com a preservação valvar deve ser a operação a ser realizada por apresentar menor mortalidade e sobrevida livre de eventos hemorrágicos.

Surgical treatment of complex aneurysms and thoracic aortic dissections with the Frozen Elephant Trunk technique / Tratamento cirúrgico dos aneurismas complexos e dissecções da aorta torácica utilizando a técnica "Frozen Elephant Trunk"

Abstract Objective: Report initial experience with the Frozen Elephant Trunk technique. Methods: From July 2009 to October 2013, Frozen Elephant Trunk technique was performed in 21 patients (66% male, mean age 56 ±11 years). They had type A aortic dissection (acute 9.6%, chronic 57.3%), type B (14.3%, all chronic) and complex aneurysms (19%). It was 9.5% of reoperations and 38% of associated procedures (25.3% miocardial revascularization, 25.3% replacement of aortic valve and 49.4% aortic valved graft). Aortic remodeling was evaluated comparing preoperative and most recent computed tomography scans. One hundred per cent of complete follow-up, mean time of 28 months. Results: In-hospital mortality of 14.2%, being 50% in acute type A aortic dissection, 8.3% in chronic type A aortic dissection, 33.3% in chronic type B aortic dissection and 0% in complex aneurysms. Mean times of cardiopulmonary bypass (152±24min), myocardial ischemia (115±31min) and selective cerebral perfusion (60±15min). Main complications were bleeding (14.2%), spinal cord injury (9.5%), stroke (4.7%), prolonged mechanical ventilation (4.7%) and acute renal failure (4.7%). The need for second-stage operation was 19%. False-lumen thrombosis was obtained in 80%. Conclusion: Frozen Elephant Trunk is a feasible technique and should be considered. The severity of the underlying disease justifies high mortality rates. The learning curve is a reality. This approach allows treatment of more than two segments at once. Nonetheless, if a second stage is made necessary, it is facilitated. .

Resumo Objetivo: Relatar experiência inicial com a técnica "Frozen Elephant Trunk". Métodos: Entre julho de 2009 e outubro de 2013, 21 pacientes, 66% homens, média de idade de 56±11 anos, 66,7% portadores de dissecção da aorta tipo A de Stanford (9,6% agudas e 57,1% crônicas), tipo B (14,3%, todas crônicas) e aneurismas complexos (19%), foram operados pela técnica Frozen Elephant Trunk. Foram 9,5% de reoperações e 38% com procedimentos associados (25,3% revascularizações do miocárdio, 25,3% troca da valva aórtica e 49,4% tubos valvulados). Remodelamento da aorta foi avaliado com a comparação de angiotomografia pré-operatória e pós-operatória mais recente. Seguimento 100% dos pacientes, tempo médio de 28 meses. Resultados: Mortalidade hospitalar de 14,2%, sendo 50% nas dissecções do tipo A agudas, 8,3% nas tipo A crônicas, 33,3% nas tipo B crônicas e 0% nos aneurismas complexos. Tempos médios de CEC (152±24min), isquemia miocárdica (115±31min) e perfusão cerebral seletiva (60±15min). Principais complicações pós-operatórias foram sangramento (14,2%), acidente vascular encefálico (4,7%), paraplegia (9,5%), intubação>72h (4,7%) e insuficiência renal aguda (4,7%). Houve necessidade de complementação do tratamento (distal ao stent) em 19%. Houve trombose da falsa luz em 80%. Conclusão: Frozen Elephant Trunk é opção técnica a ser utilizada. A gravidade e extensão da doença justificam mortalidade mais elevada. A curva de aprendizado é uma realidade. Esta abordagem permite abordar mais de dois segmentos de aorta em um estágio, mas se necessário segundo estágio, este é facilitado. .