Association Between Body Mass Index, Obesity, and Clinical Outcomes Following Coronary Artery Bypass Grafting in Brazil: An Analysis of One Year of Follow-up of BYPASS Registry Patients

ABSTRACT Objective: To investigate the association between body mass index (BMI), obesity, clinical outcomes, and mortality following coronary artery bypass grafting (CABG) in Brazil using a large sample with one year of follow-up from the Brazilian Registry of Cardiovascular Surgeries in Adults (or BYPASS) Registry database. Methods: A multicenter cohort-study enrolled 2,589 patients submitted to isolated CABG and divided them into normal weight (BMI 20.0-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2), and obesity (BMI > 30.0 kg/m2) groups. Inpatient postoperative outcomes included the most frequently described complications and events. Collected post-discharge outcomes included rehospitalization and mortality rates within 30 days, six months, and one year of follow-up. Results: Sternal wound infections (SWI) rate was higher in obese compared to normal-weight patients (relative risk [RR]=5.89, 95% confidence interval [CI]=2.37-17.82; P=0.001). Rehospitalization rates in six months after discharge were higher in obesity and overweight groups than in normal weight group (χ2=6.03, P=0.049); obese patients presented a 2.2-fold increase in the risk for rehospitalization within six months compared to normal-weight patients (RR=2.16, 95% CI=1.17-4.09; P=0.045). Postoperative complications and mortality rates did not differ among groups during time periods. Conclusion: Obesity increased the risk for SWI, leading to higher rehospitalization rates and need for surgical interventions within six months following CABG. Age, female sex, and diabetes were associated with a higher risk of mortality. The obesity paradox remains controversial since BMI may not be sufficient to assess postoperative risk in light of more complex and dynamic evaluations of body composition and physical fitness.

Joint Recommendations From The Latin American Association of Cardiac and Endovascular Surgery (LACES) and The Cardiovascular Anesthesia Committee of The Latin American Confederation of Anesthesia Societies (CLASA) on the Timing for Cardiac Surgery After COVID-19 Infection

ABSTRACT Introduction: Since the coronavirus disease 2019 (COVID-19) pandemic, cardiac surgeries in patients with previous infection by COVID-19 were suspended or postponed, which led to surgeries performed in patients with an advanced stage of their disease and an increase in the waiting list. There is a heterogeneous attitude in Latin America on the optimal timing to cardiac surgery in patients with previous COVID-19 infection due to scarce data on its outcome. Two Latin American associations joined to establish common suggestions on the optimal timing of surgery in patients with previous COVID-19 infection. Methods: Data collection was performed using a pre-established form, which included year of publication, objective, type of study (prospective/retrospective, descriptive/analytical), number of patients, year of study, waiting time between infection and surgery, type of surgery, morbidity, mortality, and conclusions regarding the association between mortality and morbidity. Final recommendations were approved by the board of directors of Latin American Association of Cardiac and Endovascular Surgery (LACES) and Latin American Confederation of Anesthesia Societies (CLASA). Results: Of the initial 1,016 articles, 11 comprised the final selection. Only six of them included patients who underwent cardiac surgery. According to the analyzed literature, optimal timing for cardiac surgery needs to consider the following aspects: deferable surgery, symptomatic COVID-19 infection, completeness of COVID-19 vaccination. Conclusion: These recommendations derive from the analysis of the scarce literature published at present on outcomes after cardiac surgery in patients with previous COVID-19 infection. These are to be taken as a dynamic recommendation in which Latin American reality was taken into consideration.

Terapia nasal de alto flujo en insuficiencia respiratoria grave por SARS-CoV-2 / High-flow nasal therapy in severe respiratory failure due to SARS-CoV-2

Resumen El uso de terapia nasal de alto flujo (TNAFO) en pacientes con insuficiencia respiratoria aguda grave (IRAG) por neumonía COVID-19 (NCOVID-19) es debatido. Ante la falta de camas en Unidades de Cuidados Intensivos en el Sistema de Salud Pública de la Provincia del Neuquén, se implementó su uso en salas generales. Con el objetivo de describir la experiencia de uso de la TNAFO en pacientes con IRAG por NCOVID-19, se llevó a cabo este estudio retrospectivo multicéntrico. El resultado primario fue la frecuencia de destete exitoso de TNAFO y la mortalidad intrahospitalaria (MIH). Se analizaron 299 pacientes, de éstos, 120 (40.1%) fueron retirados con éxito de la TNAFO. Esta fracasó en 59.8% (179), 44.1% (132) requirió ventilación mecánica invasiva (VMI) y 15.7% (47) no eran candidatos a la intubación. Un índice ROX ≥ 5 a las 6 h después del inicio, se asoció con el éxito de la TNAFO (OR 0.26 [IC 95% 0.15-0.46] p<0.0001). La MIH general fue del 48.5% (145/299), 70.4% (93/132) en aquellos con VMI, 4.2% (5/120) falleció post destete exitoso de la TNAFO y 100% (47/47) en el grupo no candidatos a la intubación. Los pacientes con TNAFO tuvieron una disminución estadísticamente significativa en la MIH y en días de internación. El uso de TNAFO en salas generales logró una reducción en la utilización de VMI, con una reducción de la mortalidad y días de estada en los internados por NCOVID-19 con IRAG.

Abstract The use of high-flow nasal therapy (HFNT) in patients with severe acute respiratory failure (SARF) due to COVID-19 pneu monia (NCOVID-19) is debated. Given the lack of beds in Intensive Care Units in the Public Health System of the Province of Neuquén, their use was implemented in general wards. This restrospective multicenter study was carried out to describe the experience of using HNFT in patients with SARF due to NCOVID-19. The primary outcome was the frequency of successful weaning from HFNT and in-hospital mortality (IHM). Two hundred ninety-nine patients were analyzed; 120 (40.1%) were successfully withdrawn from HFNT. This failed in 59.8% (179), 44.1% (132) required invasive mechanical ventilation (IMV), and 15.7% (47) was not candidates for intubation. A ROX index ≥ 5 at 6 h after initiation was associated with the success of HFNT (OR 0.26 [IC 95% 0.15-0.46] p<0.0001). The general IHM was 48.5% (145/299), 70.4% (93/132) in patients with IMV, 4.2% (5/120) died after successful weaning from HFNT and 100% (47/47) in the group not candidates for intubation. Patients with TNAFO had a statistically significant decrease in MIH and days of hospitalization. TNAFO in general wards achieved a decrease in the use of IMV, with a reduction in mortality and days of stay in hospitalized for NCOVID-19 with SARF.

COVID-19 in the perioperative period of cardiovascular surgery: the brazilian experience

Abstract Introduction: We investigated the clinical course and outcomes of patients submitted to cardiovascular surgery in Brazil and who had developed symptoms/signs of coronavirus disease 2019 (COVID-19) in the perioperative period. Methods: A retrospective multicenter study including 104 patients who were allocated in three groups according to time of positive real time reverse transcriptase-polymerase chain reaction (RT-PCR) for the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2): group 1, patients who underwent cardiac surgery > 10 days after positive RT-PCR; group 2, patients with a positive RT-PCR within 10 days before or after surgery; group 3, patients who presented positive RT-PCR > 10 days after surgery. The primary outcome was mortality and secondary outcomes were postoperative complications, intensive care unit (ICU) length of stay, and postoperative days of hospitalization. Results: The three groups were similar with respect to age, the European System of Cardiac Operative Risk Evaluation score, and comorbidities, except hypertension. Postoperative complications and death were significantly higher in groups 2 and 3 than in group 1, and no significant difference between groups 2 and 3 was seen. Group 2 showed a high prevalence of surgery performed as an urgent procedure. Although no significant differences were observed in ICU length of stay, total postoperative hospitalization time was significantly higher in group 3 than in groups 1 and 2. Conclusion: COVID-19 affecting the postoperative period of patients who underwent cardiovascular surgery is associated with a higher rate of morbidity and mortality. Delaying procedures in RT-PCR-positive patients may help reduce risks of perioperative complications and death.

The Anaortic Technique with Bilateral Internal Thoracic Artery Grafting - Filling the Gap in Coronary Artery Bypass Surgery

Abstract Coronary artery bypass grafting (CABG) has consolidated its role as the most effective procedure for treating patients with advanced atherosclerotic coronary artery disease, reducing the long-term risk of myocardial infarction and death compared to other therapies and relieving angina. Despite the recognized benefits afforded by surgical myocardial revascularization, a subset of higher-risk patients bears a more elevated risk of perioperative stroke. Stroke remains the drawback of conventional CABG and has been strongly linked to aortic manipulation (cannulation, cross‐clamping, and side-biting clamping for the performance of proximal aortic anastomoses) and the use of cardiopulmonary bypass. Adoption of off-pump CABG (OPCAB) is demonstrated to lower the risk of perioperative stroke, as well as reducing the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay. However, increased risk persists owing to the need for the tangential ascending aorta clamping to construct the proximal anastomosis. The concept of anaortic (aorta no-touch) OPCAB (anOPCAB) stems from eliminating ascending aorta manipulation, virtually abolishing the risk of embolism caused by aortic wall debris into the brain circulation. The adoption of anOPCAB has been shown to further decrease the risk of postoperative stroke, especially in higher-risk patients, entailing a step forward and a refinement of outcomes provided by the primeval OPCAB technique. Therefore, anOPCAB has been the recommended technique in patients with cerebrovascular disease and/or calcification or atheromatous plaque in the ascending aorta and should be preferred in patients with high-risk factors for neurological damage and stroke.

Inspiratory Muscle Weakness is Related to Poor Short-Term Outcomes for Heart Transplantation

Abstract Introduction: In heart transplantation (HT) recipients, several factors are critical to promptly adopting appropriate rehabilitation strategies and may be important to predict outcomes way after surgery. This study aimed to determine preoperative patient-related risk factors that could adversely affect the postoperative clinical course of patients undergoing HT. Methods: Twenty-one hospitalized patients with heart failure undergoing HT were evaluated according to respiratory muscle strength and functional capacity before HT. Mechanical ventilation (MV) time, reintubation rate, and intensive care unit (ICU) length of stay were recorded, and assessed postoperatively. Results: Inspiratory muscle strength as absolute and percentpredicted values were strongly correlated with MV time (r=-0.61 and r=-0.70, respectively, at P<0.001). Concerning ICU length of stay, only maximal inspiratory pressure (MIP) absolute and percent-predicted values were significantly associated. The absolute -MIP- was significantly negatively correlated with ICU length of stay (r=-0.58 at P=0.006) and the percent-predicted MIP was also significantly negatively correlated with ICU length of stay (r=-0.68 at P=0.0007). No associations were observed between preoperative functional capacity, age, sex, and clinical characteristics and MV time and ICU length of stay in the cohort included in this study. Patients with respiratory muscle weakness had a higher prevalence of prolonged MV, reintubation, and delayed ICU length of stay. Conclusion: An impairment of preoperative MIP was associated with poorer short-term outcomes following HT. As such, inspiratory muscle strength is an important clinical preoperative marker in patients undergoing HT.

La Unidad Febril de Urgencias del Hospital Muñiz frente a COVID-19, HIV y tuberculosis / The Febrile Emergency Unit at Muñiz Hospital facing COVID-19, HIV and tuberculosis

Resumen Para hacer frente a la pandemia causada por el SARS CoV-2, en la Ciudad Autónoma de Buenos Aires se establecieron Unidades Febriles de Urgencias anexas a los hospitales de alta compleji dad. Se realizó un estudio observacional y retrospectivo con el objeto de evaluar el perfil de las personas que consultaron durante el período comprendido entre las semanas epidemiológicas 28 y 42, 2020. Se recibieron 12 571 consultas, el promedio de edad fue 38.2 años y 6801 (54.1%) pacientes eran varones. Se realizaron 9501 hisopados (RT-PCR para SARS-CoV-2) y 2499 (26.3%) fueron confirmados positivos. La edad media de los confirmados para COVID-19 fue 37.9 años, 1367 (54.7%) eran varones y 143 (5.7%) requirieron internación en la primera consulta. Tantos como 6097 (48.5%) participantes contaban con obra social o medicina prepaga. Consultaron solo 160 pacientes con HIV, se diagnosticó coinfección HIV/COVID-19 en 39/160 (24.4%) infectados con HIV y requirieron internación 9/39 (23.1%) coinfectados. Consultaron 128 pacientes con tuberculosis (TB), se diagnosticó coinfección TB/COVID-19 en 31/128 (24.2%) y requirieron internación 8/31 (25.8%) coinfectados. La triple asociación HIV/TB/COVID-19 fue constatada en 2 pacientes. Contrariamente a lo esperado, las dos principales enfermedades atendidas en el hospital, TB y HIV, estuvieron poco representadas en la consulta, pero el requerimiento de internación para los coinfectados fue elevado. Esto puede deberse a consulta tardía por restricciones de movilidad y asistencia durante la cuarentena. Nuestros datos también indican que el sector público de la ciudad debió absorber demanda insatisfecha del sector privado.

Abstract Febrile Emergency Units were annexed to tertiary hospitals to face the pandemic caused by SARS CoV-2 in Buenos Aires City. We performed a retrospective observational study in order to evaluate the profile of people consulting the Unit annexed to the Muñiz Hospital, during the period comprising epidemiological weeks 28 to 42, 2020. The total number of consultations was 12 571; 6801 (54.1%) patients were male, and the average age was 38 years. A total of 2499 (26.3 %) of 9501 swabs resulted positive for SARS-CoV-2 when analyzed by RT-PCR. The average age of confirmed COVID-19 patients was 37.9 years; 1367 (54.7%) were male and 143 (5.7%) required hospitalization at the first consultation. As many as 6097 (48.5%) participants were beneficiaries of social security or prepaid medicine. Only 160 (1.3%) were HIV positive, with COVID-19 coinfection diagnosed in 39/160 (24.4%), of which 9 (23.1%) required hospitalization. Only 128 (1%) had tuberculosis (TB); TB/CO VID-19 coinfection was diagnosed in 31 of them (24.2%), and 8/31 (25.8%) required hospitalization. The triple association HIV/TB /COVID-19 was reported in only 2 patients. Contrary to expectations, TB and HIV, the two main diseases treated in our hospital, were under-represented in this Emergency Unit, but the requirement of hospitalization for coinfected patients was quite frequent. This may be due to late consultation caused by mobility and assistance restrictions during quarantine. Interestingly, our data also indicate that the city's public sector had to absorb unsatisfied demand from the private sector and suburban population.

Cardiovascular involvement in COVID-19: not to be missed

Abstract In December 2019, a striking appearance of new cases of viral pneumonia in Wuhan led to the detection of a novel coronavirus (SARS-CoV2). By analyzing patients with severe manifestations, it became apparent that 20 to 35% of patients who died had preexisting cardiovascular disease. This finding warrants the important need to discuss the influence of SARS-CoV2 infection on the cardiovascular system and hemodynamics in the context of clinical management, particularly during mechanical ventilation. The SARS-CoV2 enters human cells through the spike protein binding to angiotensin-converting enzyme 2 (ACE2), which is important to cardiovascular modulation and endothelial signaling. As ACE2 is highly expressed in lung tissue, patients have been progressing to acute respiratory injury at an alarming frequency during the Coronavirus Disease (COVID-19) pandemic. Moreover, COVID-19 leads to high D-dimer levels and prothrombin time, which indicates a substantial coagulation disorder. It seems that an overwhelming inflammatory and thrombogenic condition is responsible for a mismatching of ventilation and perfusion, with a somewhat near-normal static lung compliance, which describes two types of pulmonary conditions. As such, positive pressure during invasive mechanical ventilation (IMV) must be applied with caution. The authors of this review appeal to the necessity of paying closer attention to assess microhemodynamic repercussion, by monitoring central venous oxygen saturation during strategies of IMV. It is well known that a severe respiratory infection and a scattered inflammatory process can cause non-ischemic myocardial injury, including progression to myocarditis. Early strategies that guide clinical decisions can be lifesaving and prevent extended myocardial damage. Moreover, cardiopulmonary failure refractory to standard treatment may necessitate the use of extreme therapeutic strategies, such as extracorporeal membrane oxygenation.

Valve heart surgery in Brazil - the bypass registry analysis

Abstract Objective: To analyze the profile and outcomes of patients who underwent valve heart surgery in Brazil, using information retrieved from the Brazilian Registry of Cardiovascular Surgeries in Adults (BYPASS Registry) database. Methods: This is a multicenter cohort study, evaluating 920 patients submitted to heart valve surgery. Demographics and postoperative clinical outcomes were assessed and compared to estimate mortality risk using the European System for Cardiac Operative Risk Evaluation (EuroSCORE). Results: Isolated aortic valve replacement was the most frequently performed surgery (34%), followed by isolated mitral valve replacement (24.9%). Valve repair was performed in 21% of mitral procedures. Minimally invasive access was performed in 1.6% and the most frequent postoperative complications were arrhythmias (22.6%), infections (5.7%), and low-output syndrome (5.1%). Operations covered by the public health system accounted for 80.8% and the hospital mortality rate was 7.3%. Conclusion: The most frequent isolated valve surgery in Brazil is the aortic valve replacement by conventional open access and the rheumatic disease is still the main etiology for valve surgery. The BYPASS Registry has a fundamental role to provide information on the profile of patients with valve heart disease in our country in order to delineate adequate strategies for health promotion and resource allocation for cardiac surgery.

Metabolic Crosstalk between the Heart and Fat

It is now recognized that the heart can behave as a true endocrine organ, which can modulate the function of other tissues. Emerging evidence has shown that visceral fat is one such distant organ the heart communicates with. In fact, it appears that bi-directional crosstalk between adipose tissue and the myocardium is crucial to maintenance of normal function in both organs. In particular, factors secreted from the heart are now known to influence the metabolic activity of adipose tissue and other organs, as well as modulate the release of metabolic substrates and signaling molecules from the periphery. This review summarizes current knowledge regarding primary cardiokines and adipokines involved in heart-fat crosstalk, as well as implications of their dysregulation for cardiovascular health.