Aldemir Nogueira

Serum lactate as mortality and morbidity marker in infants after Jatene´s operation

OBJECTIVE To assess the morbidity and mortality after Jatenes operation using lactate as the main marker. METHODS We performed a historical cohort with infants admitted in a pediatric intensive care unit during 1995 to 2005 who underwent this surgery. We assessed the preoperative, immediate (IPD), third hour (3h), six hour (6h) and first day (POD1) serum lactate as well as other factors such as sepsis, increased bleeding, low cardiac output syndrome, renal insufficiency, pulmonary hypertension, cardiac arrythmias, chylothorax, myocardial ischemia, seizures, presence of other complication, and also information about length of PICU stay and death. RESULTS The mean age of 76 patients was 14.59± 19.09 days, birth weight 3.128± 0.48 kg Forty-four patients had the diagnosis of simple transposition of great arteries. The circulatory bypass time was 143.78± 28.77 minutes and aortic clamping time of 87.68± 22.3 minutes and LOS of 20.28 ± 15.62 days. Twenty four (31.58%) died during hospital stay. Lactate increased in IPD, returning to baseline at 24 hours. Patients who died raised and maintained IPD lactate higher. The 3h lactate best discriminated mortality with area under the curve of 0.68 (CI 0.54 to 0.83) P = 0.035. However, considering a cutoff point for lactate greater or equal to 5.8 mmol/dl in the 3-h PO, we obtained only 67% sensitivity and specificity of 64% for mortality. There is positive correlation between number of complications and lactate. The low cardiac output syndrome with an odds ratio (OR) of 7.67 (2.38-24), increased bleeding with OR 2.91 (1.07-7.94) and respiratory complication with OR 1.67 (1.35-2.05) are risk factors when combined. CONCLUSION After Jatenes operation, morbidity and mortality can be assessed with the serum lactate levels, suggesting increased values in the third hour is suggestive of a worse prognosis.

Silent Patent Ductus Arteriosus Aneurysm

Ductus arteriosus aneurysm, a rare and potentially fatal condition, has been reported as a complication after surgical ductus arteriosus closure. Its spontaneous appearance as a septic complication, which was common in the presurgical and preantibiotic era, has been rarely reported in the contemporary literature. Persistence of silent ductus arteriosus in healthy children and adults is a frequent condition that currently has an increasing diagnostic possibility due to the availability of more accurate investigative methods, especially echocardiography. We report the case of a 1-year-old child, in whom no previous heart disease was known, who developed a giant aneurysm of the ductus arteriosus during a staphylococcal infection. This complication appeared after craniotomy for emptying an accidental subdural hematoma. This report associates the persistence of ductus arteriosus with a complication considered rare, which has a rapidly fatal evolution.

Assessment of PIM-2 performance among surgical patients with heart disease and correlation of results with RACHS-1

Objective To assess the performance of the Pediatric Index of Mortality (PIM) 2 and the Risk Adjustment for Congenital Heart Surgery (RACHS) in the postoperative period of congenital heart disease patients. Methods Retrospective cross-sectional study. Data were collected from patient records to generate the scores and predictions using recommended techniques, demographic data and outcomes. The Mann-Whitney test, Hosmer-Lemeshow test, standardized mortality rate, area under the receiver operating characteristic (ROC) curve, chi square test, Poisson regression with robust variance and Spearmans test were used for statistical analysis. Results A total of 263 patients were evaluated, and 72 died (27.4%). These patients presented significantly higher PIM-2 values than survivors (p < 0.001). In the RACHS-1 classification, mortality was progressively higher according to the complexity of the procedure, with a 3.24-fold increase in the comparison between groups 6 and 2. The area under the ROC curve for PIM-2 was 0.81 (95%CI 0.75 - 0.87), while for RACHS-1, it was 0.70 (95%CI 0.63 - 0.77). The RACHS presented better calibration power in the sample analyzed. A significantly positive correlation was found between the results of both scores (rs = 0.532; p < 0.001). Conclusion RACHS presented good calibration power, and RACHS-1 and PIM-2 demonstrated good performance with regard to their discriminating capacities between survivors and non-survivors. Moreover, a positive correlation was found between the results of the two risk scores.

A dívida com a saúde da nação: o caso das cardiopatias congênitas

1. President of the Brazilian Society of Cardiovascular Surgery, Sao Paulo, SP, Brazil. Accepting the quality of healthcare provided to Brazilians has become untenable, not only to the population as a whole, but especially to patients and their loved ones as well as doctors and other related professionals. The situation becomes worse when it compromises children with congenital heart diseases, stripping them of their basic rights to proper care and the chance of remaining alive. The article by Pinto Jr. about the difficulties of caring for children with congenital heart diseases, published in this issue of the Brazilian Journal of Cardiovascular Surgery, is particularly timely as it does a great job of showcasing part of the reality faced by all of us in our daily routine [1]. Epidemiological data show a painful reality, in which 65% of the 23000 children diagnosed with congenital heart disease needing surgical treatment born annually in Brazil do not have access to the procedures requested. The largest discrepancies are found in the North and Northeast of the country (93.5% and 77.4%, respectively); the smallest, in the South and MidWest (46.4% and 57.4%, respectively). These children grow up with the natural progression of the disease. Consequently, they face high mortality rates and restrictions in their quality of life, both preventable considering more than 70% of them could be cured if treated appropriately. Resources dedicated to the treatment of congenital heart diseases are insufficient and, most of the time, are re-allocated to other departments whose productivity results are more visible thereby impressing authorities [2,3]. With a growing concern about this omission, the Brazilian Society of Cardiovascular Surgery (BSCVS) has made every effort to find solutions for this deficit. A group of specialists was gathered to tackle the problem by formulating several proposals for a definitive solution, which were then referred to the Brazilian Society of Cardiology (BSC) to be discussed.1. President of the Brazilian Society of Cardiovascular Surgery, São Paulo, SP, Brazil. Accepting the quality of healthcare provided to Brazilians has become untenable, not only to the population as a whole, but especially to patients and their loved ones as well as doctors and other related professionals. The situation becomes worse when it compromises children with congenital heart diseases, stripping them of their basic rights to proper care and the chance of remaining alive. The article by Pinto Jr. about the difficulties of caring for children with congenital heart diseases, published in this issue of the Brazilian Journal of Cardiovascular Surgery, is particularly timely as it does a great job of showcasing part of the reality faced by all of us in our daily routine [1]. Epidemiological data show a painful reality, in which 65% of the 23000 children diagnosed with congenital heart disease needing surgical treatment born annually in Brazil do not have access to the procedures requested. The largest discrepancies are found in the North and Northeast of the country (93.5% and 77.4%, respectively); the smallest, in the South and MidWest (46.4% and 57.4%, respectively). These children grow up with the natural progression of the disease. Consequently, they face high mortality rates and restrictions in their quality of life, both preventable considering more than 70% of them could be cured if treated appropriately. Resources dedicated to the treatment of congenital heart diseases are insufficient and, most of the time, are re-allocated to other departments whose productivity results are more visible thereby impressing authorities [2,3]. With a growing concern about this omission, the Brazilian Society of Cardiovascular Surgery (BSCVS) has made every effort to find solutions for this deficit. A group of specialists was gathered to tackle the problem by formulating several proposals for a definitive solution, which were then referred to the Brazilian Society of Cardiology (BSC) to be discussed.

Tratamento cirúrgico da insuficiência aórtica nos aneurismas e dissecções da aorta ascendente pela técnica de Tirone David

Aneurismas da aorta ascendente (AAA) e disseccoes agudas da aorta (DAA) sao defeitos que cursam com insuficiencia valvar aortica (IAo) na maioria dos pacientes, geralmente causada por varios mecanismos. Em 30% a 50% dos casos, os folhetos aorticos sao morfologicamente normais, possibilitando a reconstrucao atraves do reimplante da valva e das arterias coronarias em um tubo corrugado de Dacron e pericardio bovino. Descrita por Tirone David, esta tecnica evita a protese valvular e, provavelmente, nos casos de AAA, corrige definitivamente os mecanismos envolvidos. No periodo de novembro de 1994 a dezembro de 1995 operamos 11 pacientes, que foram assim divididos: Grupo I: DAA, 5 pacientes, todos com o Tipo 1 de DeBakey, sendo 4 agudos e 1 cronico; Grupo II: AAA, 6 pacientes, a maioria com idade acima de 50 anos. No Grupo I empregamos hipotermia profunda, parada circulatoria total e perfusao cerebral retrograda. No Grupo II usamos hipotermia moderada a 28oC. Em ambos a protecao miocardica foi realizada atraves de infusao anterograda intermitente e isotermica de solucao cardioplegica sanguinea associada a solucao salina gelada no pericardio. Dois (18,2%) pacientes faleceram na fase hospitalar e 1 (9%) tardiamente, todos do Grupo I, e 8 vem sendo acompanhados, com tempo maximo de 13 meses de seguimento. Todos os pacientes sobreviventes (9/11) foram submetidos a estudo ecocardiografico antes da alta e nenhum apresentou disfuncao valvar aortica. Em dezembro de 1995, todos que sobreviviam (8/11) foram reavaliados por ecocardiografia e os resultados sao mostrados neste trabalho. Concluimos que o reimplante da valva aortica descrito por David e um metodo efetivo de tratamento da IAo associada aos AAA e DAA. Mesmo sendo pequeno o numero de pacientes e o seguimento desta serie, acreditamos que a tentativa de evitar o implante de proteses valvulares e encorajadora para ambos, cirurgiao e paciente, em um seleto numero de casos.