Challenges of Congenital Heart Surgery in Brazil: It is Time to Designate Pediatric Congenital Heart Surgery Subspecialty.

Congenital heart disease (CHD) affects eight to ten out of every 1,000 births, resulting in approximately 23,057 new cases in Brazil in 2022. About one in four children with CHD requires surgery or other procedures in the first year of life, and it is expected that approximately 81% of these children with CHD will survive until at least 35 years of age. Professionals choosing to specialize in CHD surgery face numerous challenges, not only related to mastering surgical techniques and the complexity of the diseases but also to the lack of recognition by medical societies as a separate subspecialty. Furthermore, families face difficulties when access to services capable of providing treatment for these children. To address these challenges, it is essential to have specialized hospitals, qualified professionals, updated technologies, sustainable industry, appropriate financing, quality assessment systems, and knowledge generation. The path to excellence involves specialization across all involved parties. As we reflect on the importance of Pediatric Cardiovascular Surgery and Congenital Heart Diseases establishing themselves as a subspecialty of Cardiovascular Surgery, it is essential to look beyond our borders to countries like the United States of America and United Kingdom, where this evolution is already a reality. This autonomy has led to significant advancements in research, education, and patient care outcomes, establishing a care model. By following this path in Brazil, we not only align our practice with the highest international standards but also demonstrate our maturity and the ability to meet the specific needs of patients with CHD and those with acquired childhood heart disease.

Esophageal Perforation by Fish Bone Ingestion Causing Purulent Pericarditis.

A previously healthy 38-year-old woman presented with new-onset sudden chest pain radiating to the back, associated with cough, dyspnea, nausea, vomiting, and gastric fullness after eating a bony fish. A diagnosis of gastroesophageal reflux disease was made. After a week of progressive worsening of her symptoms, she was referred to the specialist hospital. There, computed tomography imaging strongly suggested that a likely fishbone had penetrated the esophagus into the mediastinal structures; it seemed to have produced a pneumopericardium. Other tests suggested diffuse changes in ventricular repolarization, pericardial thickening, and diastolic restriction. Exploratory thoracotomy confirmed esophageal-pericardial perforation by the fishbone and purulent pericarditis. Despite appropriate surgical repair, the patient died on fifth postoperative day from an asystolic cardiac arrest that was refractory to repeated attempts to resuscitate her.

Challenges of Congenital Heart Surgery in Brazil: It is Time to Designate Pediatric Congenital Heart Surgery Subspecialty

ABSTRACT Congenital heart disease (CHD) affects eight to ten out of every 1,000 births, resulting in approximately 23,057 new cases in Brazil in 2022. About one in four children with CHD requires surgery or other procedures in the first year of life, and it is expected that approximately 81% of these children with CHD will survive until at least 35 years of age. Professionals choosing to specialize in CHD surgery face numerous challenges, not only related to mastering surgical techniques and the complexity of the diseases but also to the lack of recognition by medical societies as a separate subspecialty. Furthermore, families face difficulties when access to services capable of providing treatment for these children. To address these challenges, it is essential to have specialized hospitals, qualified professionals, updated technologies, sustainable industry, appropriate financing, quality assessment systems, and knowledge generation. The path to excellence involves specialization across all involved parties. As we reflect on the importance of Pediatric Cardiovascular Surgery and Congenital Heart Diseases establishing themselves as a subspecialty of Cardiovascular Surgery, it is essential to look beyond our borders to countries like the United States of America and United Kingdom, where this evolution is already a reality. This autonomy has led to significant advancements in research, education, and patient care outcomes, establishing a care model. By following this path in Brazil, we not only align our practice with the highest international standards but also demonstrate our maturity and the ability to meet the specific needs of patients with CHD and those with acquired childhood heart disease.

Assessment of pain and quality of life in patients undergoing cardiac surgery: a cohort study

SUMMARY OBJECTIVE: This study aimed to evaluate postoperative pain and quality of life in patients undergoing median sternotomy. METHODS: A cohort study was carried out on a sample of 30 patients who underwent elective cardiac surgery by longitudinal median sternotomy. Patients were interviewed at Intensive Care Unit discharge and hospital discharge, when the Visual Numeric Scale and the Brief Pain Inventory were applied, and 2 weeks after hospital discharge, when the World Health Organization Quality of Life-Bref questionnaire was administered. The normality of the results was analyzed by the Shapiro-Wilk test, and Wilcoxon Rank Sum and McNemar tests were utilized for the analysis of numerical and categorical variables. For correlation between numerical variables, Spearman's linear correlation test was applied. To compare numerical variables, Mann-Whitney U and Kruskal-Wallis tests were applied. Differences between groups were considered significant when the p-value was <0.05. RESULTS: Between Intensive Care Unit and hospital discharge, there was a reduction in median pain intensity assessed by the Visual Numeric Scale from 5.0 to 2.0 (p<0.001), as well as in eight Brief Pain Inventory parameters: worst pain intensity in the last 24 h (p=0.001), analgesic relief (p=0.035), and pain felt right now (p=0.009); and in interference in daily activities (p<0.001), mood (p=0.017), ability to walk (p<0.001), relationship with other people (p=0.005), and sleep (p=0.006). Higher pain intensity at Intensive Care Unit discharge was associated with worse performance in the psychological domain of quality of life at out-of-hospital follow-up. CONCLUSION: Proper management of post-sternotomy pain in the Intensive Care Unit may imply better quality of life at out-of-hospital follow-up.

Assessment of pain and quality of life in patients undergoing cardiac surgery: a cohort study.

OBJECTIVE: This study aimed to evaluate postoperative pain and quality of life in patients undergoing median sternotomy. METHODS: A cohort study was carried out on a sample of 30 patients who underwent elective cardiac surgery by longitudinal median sternotomy. Patients were interviewed at Intensive Care Unit discharge and hospital discharge, when the Visual Numeric Scale and the Brief Pain Inventory were applied, and 2 weeks after hospital discharge, when the World Health Organization Quality of Life-Bref questionnaire was administered. The normality of the results was analyzed by the Shapiro-Wilk test, and Wilcoxon Rank Sum and McNemar tests were utilized for the analysis of numerical and categorical variables. For correlation between numerical variables, Spearman's linear correlation test was applied. To compare numerical variables, Mann-Whitney U and Kruskal-Wallis tests were applied. Differences between groups were considered significant when the p-value was <0.05. RESULTS: Between Intensive Care Unit and hospital discharge, there was a reduction in median pain intensity assessed by the Visual Numeric Scale from 5.0 to 2.0 (p<0.001), as well as in eight Brief Pain Inventory parameters: worst pain intensity in the last 24 h (p=0.001), analgesic relief (p=0.035), and pain felt right now (p=0.009); and in interference in daily activities (p<0.001), mood (p=0.017), ability to walk (p<0.001), relationship with other people (p=0.005), and sleep (p=0.006). Higher pain intensity at Intensive Care Unit discharge was associated with worse performance in the psychological domain of quality of life at out-of-hospital follow-up. CONCLUSION: Proper management of post-sternotomy pain in the Intensive Care Unit may imply better quality of life at out-of-hospital follow-up.

Early Mobilization Prescription in Patients Undergoing Cardiac Surgery: Systematic Review

ABSTRACT Introduction: Early mobilization of patients in the postoperative period of cardiac surgery who are hospitalized in the intensive care unit (ICU) is a practice that has a positive impact. Methods: This is a systematic review of studies published until September 2020 in the Medical Literature Analysis and Retrieval System Online (or MEDLINE®), Embase, Physiotherapy Evidence Database (or PEDro), Scientific Electronic Library Online (or SciELO), and Latin American and Caribbean Health Sciences Literature (or LILACS) databases. Randomized clinical trials describing mobilization protocols performed early in ICU patients after cardiac surgery were included. Results: According to the eligibility criteria, only 14 of the 1,128 articles found were included in the analysis. Early mobilization protocols were initiated in the immediate postoperative period or first postoperative day. The resources and technics used were progressive mobilization, cycle ergometer, early bed activities, walking protocols, resistance exercise, and virtual reality. Intensity of the mobilization activities was determined using the Borg scale and heart rate. Conclusion: Early mobilization protocols are generalist (not individual), and low-intensity exercises are used, through progressive mobilization, with two daily physical therapy sessions, during 10 to 30 minutes.

Surviving the Struggle of COVID-19: Practical Recommendations for Pediatric/Adult Cardiology and Cardiac Surgical Programs in Resource-Limited Settings: a Review.

INTRODUCTION: The primary aim of this systematic review is to provide perioperative strategies to help restore or preserve cardiovascular services under threat from financial and personnel constraints imposed by the coronavirus disease 2019 (COVID-19) pandemic. METHODS: The Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane Central Register of Controlled Trials/CCTR, and Google Scholar were systematically searched using the search terms "(cardiac OR cardiology OR cardiothoracic OR surgery) AND (COVID-19 or coronavirus OR SARS-CoV-2 OR 2019-nCoV OR 2019 novel coronavirus OR pandemic)". Additionally, the webpages of relevant medical societies, including the World Federation Society of Anesthesiologists, the Cardiothoracic Surgery Network, and the Society of Thoracic Surgeons, were screened for relevant information. RESULTS: Whereas cardiac surgery and cardiology practices were reduced by 50-75% during the pandemic, mortality of patients with COVID-19 increased significantly. Healthcare workers are among those at high risk of infection with COVID-19. CONCLUSION: Hospitals must provide maximum protective equipment and training on how to use it to healthcare workers for their mutual protection. Triage management of patients - which accounts for patient's clinical status and risk-factor profile relatable to which services are available during the COVID-19 pandemic - is recommended. A strict reorganization of the hospital resources including preoperative, intraoperative, and postoperative detailed protective measures is necessary to reduce probability of vector contamination, to protect patients and the cardiovascular teams, and to permit safe resumption of cardiological and cardiac surgical activity.

Early Mobilization Prescription in Patients Undergoing Cardiac Surgery: Systematic Review.

INTRODUCTION: Early mobilization of patients in the postoperative period of cardiac surgery who are hospitalized in the intensive care unit (ICU) is a practice that has a positive impact. METHODS: This is a systematic review of studies published until September 2020 in the Medical Literature Analysis and Retrieval System Online (or MEDLINE®), Embase, Physiotherapy Evidence Database (or PEDro), Scientific Electronic Library Online (or SciELO), and Latin American and Caribbean Health Sciences Literature (or LILACS) databases. Randomized clinical trials describing mobilization protocols performed early in ICU patients after cardiac surgery were included. RESULTS: According to the eligibility criteria, only 14 of the 1,128 articles found were included in the analysis. Early mobilization protocols were initiated in the immediate postoperative period or first postoperative day. The resources and technics used were progressive mobilization, cycle ergometer, early bed activities, walking protocols, resistance exercise, and virtual reality. Intensity of the mobilization activities was determined using the Borg scale and heart rate. CONCLUSION: Early mobilization protocols are generalist (not individual), and low-intensity exercises are used, through progressive mobilization, with two daily physical therapy sessions, during 10 to 30 minutes.

Surviving the Struggle of COVID-19: Practical Recommendations for Pediatric/Adult Cardiology and Cardiac Surgical Programs in Resource-Limited Settings: a Review

ABSTRACT Introduction: The primary aim of this systematic review is to provide perioperative strategies to help restore or preserve cardiovascular services under threat from financial and personnel constraints imposed by the coronavirus disease 2019 (COVID-19) pandemic. Methods: The Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane Central Register of Controlled Trials/CCTR, and Google Scholar were systematically searched using the search terms "(cardiac OR cardiology OR cardiothoracic OR surgery) AND (COVID-19 or coronavirus OR SARS-CoV-2 OR 2019-nCoV OR 2019 novel coronavirus OR pandemic)". Additionally, the webpages of relevant medical societies, including the World Federation Society of Anesthesiologists, the Cardiothoracic Surgery Network, and the Society of Thoracic Surgeons, were screened for relevant information. Results: Whereas cardiac surgery and cardiology practices were reduced by 50-75% during the pandemic, mortality of patients with COVID-19 increased significantly. Healthcare workers are among those at high risk of infection with COVID-19. Conclusion: Hospitals must provide maximum protective equipment and training on how to use it to healthcare workers for their mutual protection. Triage management of patients — which accounts for patient's clinical status and risk-factor profile relatable to which services are available during the COVID-19 pandemic — is recommended. A strict reorganization of the hospital resources including preoperative, intraoperative, and postoperative detailed protective measures is necessary to reduce probability of vector contamination, to protect patients and the cardiovascular teams, and to permit safe resumption of cardiological and cardiac surgical activity.

Applicability of the Disruptions in Surgery Index in the Cardiovascular Management Scenarios - A Marker for Developing Functionally Efficient Teams.

INTRODUCTION: To support the development of practices and guidelines that might help to reduce adverse events related to human factors, we aimed to study the response and perception by members of a cardiovascular surgery team of various error-driven or adverse features that might arise in the operating room (OR). METHODS: A previously validated Disruptions in Surgery Index (DiSI) questionnaire was completed by individuals working together in a cardiovascular surgical unit. Results were submitted to reliability analysis by calculating the Cronbach's alpha coefficient. Non-parametric Kruskal-Wallis test and Dunn's post-test were performed to estimate differences in perceptions of adverse events or outcomes between the groups (surgeons, nurses, anesthesiologists, and technicians). P<0.05 was considered statistically significant. RESULTS: Cronbach's alpha reliability coefficients showed consistency within the recommended range for all disruption types assessed in DiSI: an individual's skill (0.85), OR environment (0.88), communication (0.81), situational awareness (0.92), patient-related disruption (0.89), team cohesion (0.83), and organizational disruption (0.83). Nurses (27.4%) demonstrated significantly higher perception of disruptions than surgeons (25.4%), anesthetists (23.3%), and technicians (23.0%) (P=0.005). Study participants were more observant of their colleagues' disruptive behaviors than their own (P=0.0001). CONCLUSION: Our results revealed that there is a tendency among participants to hold a positive self-perception position. DiSI appears to be a reliable and useful tool to assess surgical disruptions in cardiovascular OR teams, identifying negative features that might imperil teamwork and safety in the OR. And human factors training interventions are available to develop team skills and improve safety and efficiency in the cardiovascular OR.

Applicability of the Disruptions in Surgery Index in the Cardiovascular Management Scenarios - A Marker for Developing Functionally Efficient Teams

Abstract Introduction: To support the development of practices and guidelines that might help to reduce adverse events related to human factors, we aimed to study the response and perception by members of a cardiovascular surgery team of various error-driven or adverse features that might arise in the operating room (OR). Methods: A previously validated Disruptions in Surgery Index (DiSI) questionnaire was completed by individuals working together in a cardiovascular surgical unit. Results were submitted to reliability analysis by calculating the Cronbach's alpha coefficient. Non-parametric Kruskal-Wallis test and Dunn's post-test were performed to estimate differences in perceptions of adverse events or outcomes between the groups (surgeons, nurses, anesthesiologists, and technicians). P<0.05 was considered statistically significant. Results: Cronbach's alpha reliability coefficients showed consistency within the recommended range for all disruption types assessed in DiSI: an individual's skill (0.85), OR environment (0.88), communication (0.81), situational awareness (0.92), patient-related disruption (0.89), team cohesion (0.83), and organizational disruption (0.83). Nurses (27.4%) demonstrated significantly higher perception of disruptions than surgeons (25.4%), anesthetists (23.3%), and technicians (23.0%) (P=0.005). Study participants were more observant of their colleagues' disruptive behaviors than their own (P=0.0001). Conclusion: Our results revealed that there is a tendency among participants to hold a positive self-perception position. DiSI appears to be a reliable and useful tool to assess surgical disruptions in cardiovascular OR teams, identifying negative features that might imperil teamwork and safety in the OR. And human factors training interventions are available to develop team skills and improve safety and efficiency in the cardiovascular OR.

Acute effects of aerobic exercise on the blood pressure of patients after coronary artery bypass grafting.

BACKGROUND: Coronary artery bypass grafting a frequent surgical procedure to treat coronary heart disease, uses the patient's own veins or arteries to bypass narrowed areas and restore blood flow to heart muscle. Cardiac rehabilitation follows this procedure and includes psychological and nutritional support along with the regular practice of physical exercises. OBJECTIVE: The aim of this study was to investigate the acute effects of the aerobic exercise on the blood pressure of patients after coronary artery bypass grafting. METHODS: After 30 days of surgical procedure, 14 patients were assigned to the aerobic exercise group (exercise on the cycle ergometer for 35 minutes), while 8 patients were assigned to the control group (absolute rest for 35 minutes). Blood pressure was measured by a digital automatic device before and after 24 hours of the experiment in both groups. RESULTS: Systolic (P = 0.639) and diastolic (P = 0.103) blood pressures were similar between CG and AEG at baseline. Regarding intragroup differences, no significant changes were observed after 24 hours for SBP in the CG (P = 0.999) and AEG (P = 0.244). On the other hand, significant changes were found for DBP after 24 hours for the CG (P = 0.007) and AEG (P = 0.015). When CG and AEG were compared after 24 hours, no significant differences were found for SBP (P = 0.999) and DBP (P = 0.054). CONCLUSIONS: We found decreased diastolic blood pressure in the aerobic exercise group when the results for pre-training and post-training were compared. However, to support our findings further research is needed, preferably using randomized controlled trials.

Acute Response to Aerobic Exercise on Autonomic Cardiac Control of Patients in Phase III of a Cardiovascular Rehabilitation Program Following Coronary Artery Bypass Grafting.

OBJECTIVE: The aim of the present study was to investigate the acute response to aerobic exercise on autonomic cardiac control of patients undergoing coronary artery bypass grafting (CABG). METHODS: The study sample consisted of eight patients (age: 58.6±7.7 years; body mass index: 26.7±3.5 kg.m2) who underwent a successful CABG (no complications during surgery and/or in the following weeks). To assess heart rate variability (HRV), participants remained in a supine position with a 30-degree head elevation for 20 minutes. Electrocardiographic signal (protocol with three derivations) was collected from 600 Hz sample rate to obtain beat-to-beat intervals (R-R interval). This assessment was performed before, after one hour and after 24 hours of the exercise session. All patients underwent a 35 minutes aerobic exercise session (AES) (low-moderate intensity) on the cycle ergometer. RESULTS: Significant differences were found in the time domain, with positive changes in root mean square of successive RR interval differences (rMSSD) (ms) (parasympathetic component) (one [P=0.017] and 24 hours [P=0.007] post-session). In the frequency domain, we found a significant difference in high frequency (HF) (ms2) (parasympathetic component) (one hour [P=0.048] post-session). The low frequency (LF)/HF ratio (sympathetic and parasympathetic components with a predominance of the sympathetic component) reached statistical significance only 24 hours (P=0.018) post-session. Additionally, the largest effect size was observed only for the LF/HF ratio at one (d=-0.8) and 24 hours (d=-1.3) after one AES. CONCLUSION: The practice of (acute) aerobic exercise improved autonomic cardiac control in patients undergoing CABG.