Atrial fibrillation after coronary artery bypass grafting and its relationship with hospital complications in São Paulo state

INTRODUCTION: Atrial fibrillation is the main complication in the postoperative period of cardiovascular surgery. Its genesis is multifactorial, so its rapid identification to mitigate the associated risks is essential. OBJECTIVE: To evaluate the incidence of atrial fibrillation in patients undergoing coronary artery bypass grafting (CABG) and its relationship with other complications in our setting. METHODS: This is a multicenter, observational study involving patients undergoing isolated CABG between 2017 and 2019 with data from the Registro Paulista de Cirurgia Cardiovascular (or REPLICCAR II). Variables were prospectively collected in REDCap following the definitions given by version 2.73 of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Data were collected with prior authorization from the local ethics committee and analyses performed in R software. RESULTS: A total of 3,803 patients were included, of these 605 had postoperative atrial fibrillation (POAF). In order to adjust the groups, propensity score matching was used. Such analyses resulted in 605 patients in each group (without POAF vs. with POAF). Among patients with POAF, the mean age was 67.56 years, with a prevalence of males (73.6%, 445 patients). Patients belonging to the group with POAF had a mortality rate of 9.26% (P=0.007), longer ventilation time (P<0.001), pneumonia (P<0.001), and sepsis (P<0.001). In multiple analysis, acute renal dysfunction (P=0.032) and longer intensive care unit stay (P<0,001) were associated with the presence of POAF. CONCLUSION: POAF in CABG is associated with longer intensive care unit and hospital stay, as well as renal dysfunction, pneumonia, and in-hospital mortality.

Atrial Fibrillation After Coronary Artery Bypass Grafting and Its Relationship with Hospital Complications in São Paulo State.

INTRODUCTION: Atrial fibrillation is the main complication in the postoperative period of cardiovascular surgery. Its genesis is multifactorial, so its rapid identification to mitigate the associated risks is essential. OBJECTIVE: To evaluate the incidence of atrial fibrillation in patients undergoing coronary artery bypass grafting (CABG) and its relationship with other complications in our setting. METHODS: This is a multicenter, observational study involving patients undergoing isolated CABG between 2017 and 2019 with data from the Registro Paulista de Cirurgia Cardiovascular (or REPLICCAR II). Variables were prospectively collected in REDCap following the definitions given by version 2.73 of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Data were collected with prior authorization from the local ethics committee and analyses performed in R software. RESULTS: A total of 3,803 patients were included, of these 605 had postoperative atrial fibrillation (POAF). In order to adjust the groups, propensity score matching was used. Such analyses resulted in 605 patients in each group (without POAF vs. with POAF). Among patients with POAF, the mean age was 67.56 years, with a prevalence of males (73.6%, 445 patients). Patients belonging to the group with POAF had a mortality rate of 9.26% (P=0.007), longer ventilation time (P<0.001), pneumonia (P<0.001), and sepsis (P<0.001). In multiple analysis, acute renal dysfunction (P=0.032) and longer intensive care unit stay (P<0,001) were associated with the presence of POAF. CONCLUSION: POAF in CABG is associated with longer intensive care unit and hospital stay, as well as renal dysfunction, pneumonia, and in-hospital mortality.

Thinking Outside the Box: The Interventional Surgeon.

Advances in treatment of structural heart disease have been disruptive to cardiovascular surgery, and there have been discussions about how to incorporate these technologies into the surgeons' therapeutic arsenal. Transcatheter procedures, complex redo interventions, and endovascular aortic approaches are already practiced by cardiovascular surgeons in Brazil. The expansion of these techniques, coupled with recent changes in the country's medical residency program in cardiovascular surgery, has led to an urgent need to acquire catheter-based skills. In this article, we discuss these aspects in the light of the reality of cardiovascular surgery training in Brazil.

Thinking outside the box: the interventional surgeon

Advances in treatment of structural heart disease have been disruptive to cardiovascular surgery, and there have been discussions about how to incorporate these technologies into the surgeons' therapeutic arsenal. Transcatheter procedures, complex redo interventions, and endovascular aortic approaches are already practiced by cardiovascular surgeons in Brazil. The expansion of these techniques, coupled with recent changes in the country's medical residency program in cardiovascular surgery, has led to an urgent need to acquire catheter-based skills. In this article, we discuss these aspects in the light of the reality of cardiovascular surgery training in Brazil.

Análise do impacto dos níveis de hemoglobina glicada no pós-operatório de cirurgia de revascularização miocárdica em centro de referência / Analysis of the impact of glycated hemoglobin levels in the postoperative period of myocardial revascularization surgery in a reference center

INTRODUÇÃO: A prevalência de diabetes mellitus em pacientes com doença arterial coronariana (DAC) é elevada, constituindo um fator de risco significativo para complicações após cirurgia de revascularização miocárdica (CRM). OBJETIVO: Avaliar a associação dos níveis de hemoglobina glicada (HbA1c) com complicações pós-operatórias em pacientes submetidos à CRM. MÉTODOS: Estudo observacional e retrospectivo de pacientes submetidos à CRM isolada no período de 1 ano (julho de 2016 a julho de 2017). Os pacientes foram divididos em três grupos de acordo com os valores de hemoglobina glicada (HbA1c < 6,5%; HbA1c ≥ 6,5% e < 7,5%; HbA1c ≥ 7,5%) para análise e comparações múltiplas entre as variáveis préoperatórias e complicações. Subanálise entre pacientes diabéticos e não diabéticos também foi realizada. Neste estudo, o software R (versão 4.2.3) foi utilizado e aplicou-se P < 0,05 para significância estatística. RESULTADOS: Foram incluídos 383 pacientes, com média de 62,5 anos de idade (P = 0,308) e prevalência do sexo masculino (276, 72%; P = 0,019). HbA1c < 6,5% foi identificada em 192 (50,1%) pacientes e ≥ 7,5% em 115 (30%) pacientes. Entre as complicações pós-operatórias, acidente vascular cerebral (P = 0,036), sepse (P = 0,034) e mortalidade intra-hospitalar (P = 0,018) estiveram associados a maiores níveis de HbA1c. Na análise comparativa entre pacientes diabéticos e não diabéticos, ajustados pelos valores de HbA1c, mortalidade por todas as causas foi significativa (P = 0,007). CONCLUSÃO: Níveis de HbA1c elevados estão associados a maiores taxas de sepse e acidente vascular cerebral, bem como mortalidade intra-hospitalar, portanto, um pior prognóstico. A análise dos valores pré-operatórios de HbA1c permite à equipe cirúrgica estratificar pacientes de maior risco e permitir um controle dos níveis glicêmicos de forma adequada, mitigando complicações.

Bentall-De Bono Reoperation Associated With Pseudoaneurysm and Infectious Endocarditis

Abstract We present the case of a 55-year-old patient who underwent the Bentall-De Bono procedure with mechanical prosthesis in 2005 and was admitted to the emergency department in July 2020 with mixed shock. Complementary exams showed an abscess involving the prosthetic tube, two thirds of the aortic valve circumference and the left ventricle, with a neocavity of about 45 mm in diameter from the aortic sinus to the ascending aorta. The patient underwent surgical repair, with a new procedure using the Bentall-De Bono technique, now associated with coronary artery bypass grafting with a great saphenous vein graft between the aorta and the anterior descending artery. Culture of samples collected intraoperatively showed Staphylococcus epidermidis. The patient received antibiotic therapy for 30 days, evolving favorably, and is under regular outpatient follow-up.

Cardiac Surgery Training in Brazil - What Are We Discussing in Our Journal?

INTRODUCTION: Cardiovascular surgery has undergone numerous changes over the last decades. Transcatheter technologies, endovascular procedures, hybrids, and minimally invasive surgery have undoubtedly advanced as a therapy for patients. Thus, the discussion about the training of residents in the face of new technologies in the specialty is in check. In this article, it is proposed a review to discuss the challenges in this scenario as well as the current training in cardiovascular surgery in Brazil. METHODS: A comprehensive review was performed in the Brazilian Journal of Cardiovascular Surgery. All editions from 1986 to 2022 were included. The research was carried out using the search engine on the journal's website (https://www.bjcvs.org) and an individual analysis of the titles and abstracts of each article published. RESULTS: All the studies are summarized in the appropriate table with a discussion along this review. CONCLUSION: Most articles that discuss training in cardiovascular surgery in the national context are editorials and expert points of view with no observational studies evaluating the residency programs.

Cardiac Surgery Training in Brazil - What Are We Discussing in Our Journal?

ABSTRACT Introduction: Cardiovascular surgery has undergone numerous changes over the last decades. Transcatheter technologies, endovascular procedures, hybrids, and minimally invasive surgery have undoubtedly advanced as a therapy for patients. Thus, the discussion about the training of residents in the face of new technologies in the specialty is in check. In this article, it is proposed a review to discuss the challenges in this scenario as well as the current training in cardiovascular surgery in Brazil. Methods: A comprehensive review was performed in the Brazilian Journal of Cardiovascular Surgery. All editions from 1986 to 2022 were included. The research was carried out using the search engine on the journal's website (https://www.bjcvs.org) and an individual analysis of the titles and abstracts of each article published. Results: All the studies are summarized in the appropriate table with a discussion along this review. Conclusion: Most articles that discuss training in cardiovascular surgery in the national context are editorials and expert points of view with no observational studies evaluating the residency programs.

Cardiac surgery training in Brazil ­ what are we discussing in our journal ?

ABSTRACT INTRODUCTION: Cardiovascular surgery has undergone numerous changes over the last decades. Transcatheter technologies, endovascular procedures, hybrids, and minimally invasive surgery have undoubtedly advanced as a therapy for patients. Thus, the discussion about the training of residents in the face of new technologies in the specialty is in check. In this article, it is proposed a review to discuss the challenges in this scenario as well as the current training in cardiovascular surgery in Brazil. METHODS: A comprehensive review was performed in the Brazilian Journal of Cardiovascular Surgery. All editions from 1986 to 2022 were included. The research was carried out using the search engine on the journal's website (https://www.bjcvs.org) and an individual analysis of the titles and abstracts of each article published. RESULTS: All the studies are summarized in the appropriate table with a discussion along this review. CONCLUSION: Most articles that discuss training in cardiovascular surgery in the national context are editorials and expert points of view with no observational studies evaluating the residency programs. KEYWORDS: Cardiovascular Surgery. Internship and Residency. Mentoring. Minimally Invasive Surgical Procedures. Patients. Research. Review

Fibrilação atrial após cirurgia de revascularização miocárdica e sua relação com complicações hospitalares: análise do registro paulista de cirurgia cardiovascular (REPLICCAR II) / Atrial fibrillation after coronary artery bypass grafting and its relationship with hospital complications: analysis of the cardiovascular surgery registry in São Paulo (REPLICCAR II)

INTRODUÇÃO: A fibrilação atrial constitui a principal complicação no pós-operatório de cirurgia cardiovascular. Sua gênese é multifatorial, portanto, sua rápida identifi cação é fundamental para mitigar os riscos associados. OBJETIVO: Avaliar a incidência de fi brilação atrial em pacientes submetidos à cirurgia de revascularização miocárdica (CRM) e sua relação com outras complicações no nosso cenário. MÉTODOS: Análise retrospectiva de pacientes submetidos à CRM isolada entre 2017 e 2019, pertencentes ao Registro Paulista de Cirurgia Cardiovascular (REPLICCAR II). As variáveis foram coletadas prospectivamente no REDCap seguindo as defi nições dadas pela versão 2.73 do STS Adult Cardiac Surgery Database. Os dados foram coletados com autorização prévia do Comitê de Ética local e as análises, realizadas no software R. RESULTADOS: Foram incluídos 3.803 pacientes, dos quais 605 apresentaram fi brilação atrial no pós-operatório (FAPO). De forma a ajustar os grupos, foi utilizado propensity score matching entre as seguintes variáveis (insufi ciência renal crônica/ aguda; classifi cação NYHA; diabetes mellitus; doença arterial periférica; ex-tabagista/tabagista; gênero; infarto agudo do miocárdio; necessidade de balão intra-aórtico; status cirúrgico; transfusão de hemoderivados no intraoperatório). Tais análises resultaram em 605 pacientes em cada grupo (sem FAPO vs. com FAPO). Entre os pacientes com FAPO, a média de idade foi de 67,56 anos, com prevalência do sexo masculino (445 pacientes, 73,6%). Não houve diferença estatística entre comorbidades (hipertensão arterial sistêmica, diabetes mellitus e dislipidemia), fração de ejeção, classe funcional ou risco cirúrgico (EuroSCORE). Pacientes pertencentes ao grupo com FAPO apresentaram mortalidade de 9,26% (P = 0,007), maior tempo de ventilação prolongada (P < 0,001), readmissão na unidade de terapia intensiva (P < 0,001), pneumonia (P < 0,001) e sepse (P < 0,001). Na análise múltipla, os tempos de ventilação mecânica (P = 0,044) e permanência na UTI (P < 0,001), bem como disfunção renal aguda (P = 0,032), estiveram associados à presença de FAPO. CONCLUSÃO: A fi brilação atrial no pós-operatório de CRM está associada com maior tempo de UTI e de internação, assim como com disfunção renal, pneumonia e mortalidade hospitalar.

Acute pericarditis and pericardial effusion after Covid-19 infection

INTRODUCTION: COVID-19 infection has a wide spectrum of clinical presentations, including cardiovascular, including myocarditis and pericarditis. The prevalence and events associated with this condition still remain under analysis, as well as the repercussion of such complications after the viral infection. CASE DESCRIPTION: 74-year-old female patient, former smoker, bilateral carotid stenosis without hemodynamic repercussions, rheumatoid arthritis and diagnosis of viral pneumonia due to COVID-19 in January 2022. She was admitted, in March 2022, to a referral center in cardiovascular diseases, with a clinical picture of chest pain that worsened during inspiration with 2 months of evolution. Laboratory measurements of troponin and D-dimer within normal limits. Admission electrocardiogram suggestive of pericarditis. Transthoracic echocardiogram (TTECT) revealed preserved biventricular function and pericardial effusion with a greater depth of 11.0 mm. Despite the optimized clinical treatment for the pericarditis, the patient evolved with clinical worsening and rapid evolution of the pericardial effusion initially evident, with a 30.0 mm blade and signs of hemodynamic repercussion, requiring urgent drainage. On the 1st postoperative day in the intensive care unit, the patient evolved with severe acute biventricular dysfunction and need for vasoactive drugs, without response to the established clinical measures, progressing to death. CONCLUSION: The prevalence of underlying pericarditis and pericardial effusion in patients with COVID-19, as well as its clinical significance remains the subject of clinical research. Thus, knowing risk factors and the pathophysiology of cardiovascular complications related to COVID-19 are sine qua non conditions for understanding the clinical presentation, prognosis and therapeutic management.

Takotsubo syndrome after mitral valve surgery

INTRODUCTION: Takotsubo Syndrome is a recurrent diagnosis, however, it's rarely seen post cardiac surgery. The disease usually occurs after physical or emotional stress, most prevalent in post-menopausal women. The clinical features may present similar to acute coronary syndrome, with chest pain and electrocardiogram (ECG) alterations, but with this diagnosis being excluded after the absence of obstructive lesions in coronary angiography and encountering typical echocardiogram findings, such as compensatory apical akinesia and basal compensatory hypercontractility. CASE DESCRIPTION: A 56-year-old woman with a history of rheumatoid arthritis, active smoking and percutaneous mitral valvuloplasty in 2007, presents with functional class II dyspnea and transthoracic echocardiogram (TTECO) showing important mitral regurgitation. Patient was submitted to mitral valve replacement surgery with an mechanical prosthesis on March 2022, without complications. In the immediate postoperative care, the patient evolved with cardiogenic shock, requiring vasoactive drugs. The ECG presented with T-wave inversion of precordial leads and TTECO revealed hypercontractility of the basal segments and akinesia of medium-apical segments, with left ventricular ejection (LVEF) of 20%. During hospitalization the patient gradually improved from cardiogenic shock, with normalization of LVEF to 64%. CONCLUSION: Takotsubo Cardiomyopathy is a reversible condition, characterised by transient ventricular dysfunction, with rare cases described in the context of postoperative care due to valve surgery. The surgical intervention can be considered as a trigger for the development of this syndrome.

Arterite de Takayasu: aneurisma de aorta ascendente e doença coronária em jovem de 19 anos / Takayasu's arteritis: ascending aortic aneurysm and coronary artery disease in a 19-year-old

INTRODUÇÃO: A Arterite de Takayasu constitui doença de múltipla apresentação, podendo acometer diversos sistemas. Acomete principalmente mulheres nas primeiras décadas de vida. MÉTODOS: Trata-se de um relato de caso acerca de paciente jovem com diagnóstico de arterite de takayasu que evoluiu com aneurisma de aorta ascendente e doença arterial coronariana. RESULTADOS: Reportamos um caso de paciente com 19 anos de idade com AT, admitida em serviço de referência em Cirurgia Cardiovascular com diagnóstico de aneurisma de aorta ascendente e doença arterial coronariana grave em artéria coronária direita (CD) e tronco de coronária esquerda (TCE), sendo submetida à implante de enxerto de Dacron supra-coronariano em aorta ascendente (e revascularização miocárdica (CRM) com dupla artéria torácica interna. Evoluiu de forma satisfatória no pós-operatório, seguindo em acompanhamento clínico em nosso serviço. CONCLUSÃO: A apresentação dos pacientes com arterite de takayasu é diversa, em associação com DAC, tornam o seguimento dos pacientes mandatário em centro especializado.

Tendências em cirurgia de revascularização miocárdica isolada ­ análise de 19 anos em centro de referência / Trends in isolated myocardial revascularization surgery - 19-year analysis in a reference center

INTRODUÇÃO: Com a evolução das técnicas operatórias, melhoria da terapêutica medicamentosa assim como da abordagem percutânea, o perfil de pacientes submetidos a cirurgia de revascularização miocárdica isolada (CRM) tem se modificado ao longo dos anos. A avaliação desta mudança pode resultar em compreensão dos atuais resultados de morbidade e mortalidade hospitalar. MÉTODOS: Estudo observacional, transversal e retrospectivo. Foram avaliados pacientes (p) submetidos à CRM entre 1999 e 2017 sendo divididos em três grupos temporais, 1999-2005 (3627p), 2006-2011 (3426 p) e 2012-2017 (2773p) a fim de comparar o perfil epidemiológico, evolução clínica e complicações associadas ao procedimento cirúrgico. RESULTADOS: No período analisado, 9826 p foram submetidos CRM; nos três períodos a idade média pouco se modificou, 62,1 vs 62,4 vs 62,8 anos (a), porém observou-se queda significativa no percentual de p jovens, idade < 50 a, 13,8% vs 11% vs 9,5%, e discreta diminuição de p acima de 70 a, 25,1% vs, 24,3% e 24,8% (p< 0,001) e diabetes melito, 36,6% vs 43,8% vs 47,9% (p < 0,001). Elevou-se o percentual de não tabagistas, 45% vs 47,3% vs 48,5% (p=0,004). Entre os vasos acometidos, houve diminuição importante no percentual de uniarteriais, 7,3% vs 5,3% e 3,1% e biarteriais, 22,9% vs 21,8% vs 18,1%, com aumento de triarteriais, 49,4% vs 51,4% vs 55,1%, assim como de lesões de tronco de coronária esquerda, 20,2% vs 21,4% vs 23%(p<0,001). Não houve aumento significativo no percentual de p com disfunção ventricular grave, 10,3% vs 10% vs 9,5%. O uso de enxertos com artéria torácica interna (ATI) esquerda foi crescente,86,8% vs 94,7% vs 96,2%, assim como a utilização de enxertos com ATI direita e esquerda, 4,3% vs 7,9% vs 9%, p<0,001. Entre as complicações pós operatórias observou-se diminuição da necessidade ventilação mecânica prolongada (> 48h), 4,9% vs 5,9% vs 3,8% (p<0,001). A mortalidade hospitalar foi 4,5% vs 5,6% vs 4,8% (p=0,07). CONCLUSÃO: Na presente análise foi possível observar aumento na gravidade do perfil dos pacientes submetidos a CRM, com maior número de pacientes hipertensos, diabéticos, triarteriais e com lesão de tronco de coronária. Enxertos com ATIE e dupla artéria torácica foram progressivamente mais utilizados. A taxa de mortalidade não se modificou significantemente no período analisado.