Alexandre Siciliano Colafranceschi

Predictors of permanent pacemaker requirement after transcatheter aortic valve implantation: insights from a Brazilian registry.

BACKGROUND The aim of this study is to evaluate the predictors of permanent pacemaker (PPM) implantation after TAVI. METHODS Between January 2008 and February 2012, 418 patients with severe aortic stenosis underwent TAVI and were enrolled in a Brazilian multicenter registry. After excluding patients who died during the procedure and those with a previous PPM, 353 patients were included in the analysis. RESULTS At 30 days, the overall incidence of PPM implantation was 25.2%. Patients requiring PPM were more likely to be older (82.73 vs. 81.10 years, p=0.07), have pre-dilation (68.42% vs. 60.07%, p=0.15), receive CoreValve (93.68% vs. 82.55%, p=0.008), and have baseline right bundle branch block (RBBB, 25.26% vs. 6.58%, p<0.001). On multivariable analysis, CoreValve vs. Sapien XT (OR, 4.24; 95% CI, 1.56-11.49; p=0.005), baseline RBBB (OR, 4.41; 95% CI, 2.20-8.82; p<0.001), and balloon pre-dilatation (OR, 1.75; 95% CI, 1.02-3.02; p=0.04) were independent predictors of PPM implantation. CONCLUSION PPM implantation occurred in approximately one-fourth of cases. Pre-existing RBBB, balloon pre-dilatation, and CoreValve use were independent predictors of PPM after TAVI. The type of prosthesis used and pre-balloon dilatation should be considered in TAVI candidates with baseline RBBB.

Age influences outcomes in 70-year or older patients undergoing isolated coronary artery bypass graft surgery

OBJECTIVE To analyze the results of isolated on-pump coronary artery bypass graft surgery (CABG) in patients >70 years-old in comparison to patients <70 years-old. METHODS Patients undergoing isolated CABG were selected for the study. The patients were grouped in G1 (age > 70 years-old) and G2 (age <70 years-old). The endpoints were in-hospital mortality, acute myocardial infarction (AMI), stroke, reexploration for bleeding, intra-aortic balloon for circulatory shock, respiratory complications, acute renal failure, mediastinitis, sepsis, atrial fibrillation, and complete atrioventricular block (CAVB). RESULTS 1,033 patients were included, 257 (24.8%) in G1 and 776 (75.2%) in G2. Patients in G1 were more likely to have in-hospital mortality than G2 (8.9% vs. 3.6%, respectively; P=0.001), while the incidence of AMI was similar (5.8% vs. 5.5%; P=0.87) than G2. More patients in G1 had re-exploration for bleeding (12.1% vs. 6.1%; P=0.003). G1 had more incidence of respiratory complications (21.4% vs. 9.1%; P<0.001), mediastinitis (5.1% vs. 1.9%; P=0.013), stroke (3.9% vs. 1.3%; P=0.016), acute renal failure (7.8% vs. 1.3%; P<0.001), sepsis (3.9% vs. 1.9%;P=0.003), atrial fibrillation (15.6% vs. 9.8%; P=0.016), and CAVB (3.5% vs. 1.2%; P=0.023) than G2. There was no significant difference in the use of intra-aortic balloon. In the forward stepwise multivariate logistic regression analysis age > 70-year-old was an independent predictive factor for higher in-hospital mortality (P=0.004), reexploration for bleeding (P=0.002), sepsis (P=0.002), respiratory complications (P<0.001), mediastinitis (P=0.016), stroke (P=0.029), acute renal failure (P<0.001), atrial fibrillation (P=0.021) and CAVB (P=0.031). CONCLUSION This study suggests that patients > 70 years-old were at increased risk of death and other complications in the CABGs postoperative period in comparison to younger patients.

Indicadores de qualidade assistencial na cirurgia de revascularização miocárdica isolada em centro cardiológico terciário

BACKGROUND: Quality indicators (QI) for cardiac surgery are important instruments for measuring healthcare quality in hospital centers and allow comparison with high-quality healthcare centers. OBJECTIVE: To evaluate QIs in isolated myocardial revascularization procedures (CABG) performed at a tertiary cardiology center. METHODS: One hundred and forty-four consecutive patients who had undergone isolated CABG were evaluated between October 2005 and March 2007. One hundred and eight patients were men (75%), the mean age was 65±11, and the EuroSCORE was 4±3. The following QIs were measured: time elapsed between the surgery date-setting appointment and the actual day of the CABG (TDC); surgery cancellation rate (SCR) due to problems in hospital infrastructure; length of hospital stay (LOS); operative mortality (OM) and rate of readmission (RHR) for infection in the surgical wound. RESULTS: The TDC (n=98) was 4±3 days (median: 4 days) and the SCR was zero. The OM recorded of 4.9% (95% confidence interval [CI] = 2.2 - 9.87%) was lower than the expected OM of 5.1% (95% CI = 1.4% to 14.37%), but with no statistical significance (p=0.65). The area under the ROC curve of the EuroSCORE for the OM was 0.702 (95% CI = 0.485 - 0.919). LOS was 11±9 days. The area under the ROC curve of the EuroSCORE for the LOS was 0.764 (95% CI = 0.675 - 0.852). The RHR recorded was 2.1%. CONCLUSION: The measurement of the QIs showed that, in a medical center with a low annual volume of CABG, the results were compatible with the risk profile of the population involved.

Tratamento cirúrgico de fibrilação atrial utilizando ablação com radiofrequência bipolar em doença mitral reumática

OBJECTIVE: To analyze the effectiveness of surgical treatment of atrial fibrillation (AF) using bipolar radiofrequency ablation during mitral valve procedures of rheumatic etiology in heart surgery. METHODS: We retrospectively reviewed medical registries of 53 patients submitted to atrial ablation with bipolar radiofrequency energy during mitral valve surgery. Thirty four (64%) patients were women and the age varied from 27 to 72 years old (average: 49.3 ± 10.7 years). Aortic and/or tricuspid procedures were also present in 36 (68%) patients. Average time of reported atrial fibrillation was 41 months (from 3 to 192 months). Type of AF was classified as: paroxysmal in 8 patients, persistent in 3, permanent in 42. Left atrium had an average size of 52.9 ± 8.5 mm. The surgeries in these series were: 47 mitral valve replacements and 6 mitral valve repairs. Eletrocardiografic follow up was 83% complete in 14 months. Data from 24h Holter were explored. RESULTS: Seven (13%) perioperative deaths were observed and survival after 14 months was 87%. Observed heart rhythm after 1 year of surgery was sinus rhythm in 25 (66%) patients, AF in 7 (18%), flutter in 7 (13%), junctional in 1 (3%). CONCLUSION: Bipolar radiofrequency ablation in patients submitted to mitral valve surgery of rheumatic etiology is effective in converting to sinus rhythm in 68% of patients after 14 months.

Sumário de atualização da II Diretriz Brasileira de Insuficiência Cardíaca Aguda 2009/2011

In the past two years we observed several changes in the diagnostic and therapeutic approach of patients with acute heart failure (acute HF), which led us to the need of performing a summary update of the II Brazilian Guidelines on Acute Heart Failure 2009. In the diagnostic evaluation, the diagnostic flowchart was simplified and the role of clinical assessment and echocardiography was enhanced. In the clinical-hemodynamic evaluation on admission, the hemodynamic echocardiography gained prominence as an aid to define this condition in patients with acute HF in the emergency room. In the prognostic evaluation, the role of biomarkers was better established and the criteria and prognostic value of the cardiorenal syndrome was better defined. The therapeutic approach flowcharts were revised, and are now simpler and more objective. Among the advances in drug therapy, the safety and importance of the maintenance or introduction of beta-blockers in the admission treatment are highlighted. Anticoagulation, according to new evidence, gained a wider range of indications. The presentation hemodynamic models of acute pulmonary edema were well established, with their different therapeutic approaches, as well as new levels of indication and evidence. In the surgical treatment of acute HF, CABG, the approach to mechanical lesions and heart transplantation were reviewed and updated. This update strengthens the II Brazilian Guidelines on Acute Heart Failure to keep it updated and refreshed. All clinical cardiologists who deal with patients with acute HF will find, in the guidelines and its summary, important tools to help them with the clinical practice for better diagnosis and treatment of their patients.

Uso da radiofrequência bipolar para o tratamento da fibrilação atrial durante cirurgia cardíaca

FUNDAMENTO: O tratamento da fibrilacao atrial com dispositivo de ablacao de tecidos por radiofrequencia bipolar em concomitância a cirurgia cardiaca tem se mostrado metodo eficaz no tratamento desta arritmia. OBJETIVO: Descrever a experiencia inicial do Instituto Nacional de Cardiologia no tratamento cirurgico da fibrilacao atrial com uso de dispositivo de radiofrequencia bipolar em pacientes submetidos a cirurgia cardiaca, relatando o resultado de acompanhamento pos-operatorio de um ano. METODOS: Entre janeiro de 2008 e marco de 2009, 47 pacientes (36 mulheres) consecutivos, com idade media de 53,7 ± 10,6 anos, apresentando fibrilacao atrial por um periodo medio de 34,6 meses (3 a 192 meses) foram submetidos a ablacao cirurgica desta arritmia, por radiofrequencia bipolar, durante o procedimento que motivou a indicacao da cirurgia. Oito apresentavam fibrilacao atrial intermitente e 39, continua. Oitenta e um por cento foram submetidos a cirurgia valvar como procedimento principal. Esta e uma analise retrospectiva, observacional, com avaliacao de um ano de pos-operatorio das variaveis clinicas e de Holter 24 h. RESULTADOS: Dos 47 pacientes, 40 sobreviveram um ano. Desses, 33 foram submetidos a Holter 24 h, em um intervalo medio de 401 dias apos a cirurgia. Encontrou-se a seguinte distribuicao de ritmos: 24 (73%) sinusal, 5 (15%) fibrilacao atrial, tres (9%) Flutter atrial e um (3%) ritmo juncional. Foram observados dois acidentes vasculares encefalicos, sendo um associado a arritmia supraventricular. CONCLUSAO: A ablacao cirurgica de fibrilacao atrial com dispositivo de radiofrequencia bipolar concomitante a cirurgia cardiaca e metodo eficaz para o tratamento desta arritmia.BACKGROUND Atrial fibrillation with tissue ablation device through bipolar radiofrequency in conjunction with cardiac surgery has proven to be an effective method to treat this arrhythmia. OBJECTIVE Describe the initial experience of the Instituto Nacional de Cardiologia in the surgical treatment of atrial fibrillation using bipolar radiofrequency device in patients undergoing cardiac surgery, reporting the results of postoperative follow-up of one year. METHODS Between January 2008 and March 2009, 47 consecutive patients (36 women), with mean age of 53.7 ± 10.6 years, with atrial fibrillation for a mean period of 34.6 months (3-192 months) underwent surgical ablation of this arrhythmia, through bipolar radiofrequency during the procedure which led to the indication of surgery. Eight of them showed intermittent atrial fibrillation and 39, continued. Eighty-one percent underwent valve surgery as the main procedure. This is a one-year postoperative retrospective, observational evaluation of clinical variables and 24-h Holter. RESULTS Out of the 47 patients, 40 survived one year. Out of these, 33 underwent 24 h Holter, at an average interval of 401 days after the surgery. The following rhythm distribution was found: 24 (73.0%) sinus, five (15.0%) atrial fibrillation, three (9.0%) atrial Flutter and one (3.0%) junctional rhythm. Two cerebrovascular accidents were observed, one of which was associated with supraventricular arrhythmia. CONCLUSION Surgical ablation of atrial fibrillation with bipolar radiofrequency device concomitant with cardiac surgery is an effective method for treating this arrhythmia.

Assistência circulatória com oxigenação por membrana extracorpórea (ECMO) no adulto: um conceito falido ou esquecido?

FUNDAMENTO: A oxigenacao por membrana extracorporea (ECMO) em recem-nascidos e criancas tem resultados excelentes. A experiencia em adultos e mais modesta e os resultados imediatos sao inferiores. Entretanto, a sobrevida em cinco anos de pacientes que sobrevivem a esse metodo e bastante promissora. Nao ha relato na literatura brasileira de experiencias com esse sistema nesse contexto. OBJETIVO: Relatar a experiencia com o uso da oxigenacao por membrana extracorporea no adulto que se apresenta em choque cardiogenico agudo e refratario. METODOS: Analise retrospectiva de prontuarios medicos de pacientes submetidos a implante do sistema de oxigenacao por membrana extracorporea para a assistencia circulatoria no choque cardiogenico agudo e refratario. RESULTADOS: Onze pacientes (63,5 anos; 45,5% homens) foram considerados para analise no periodo de 2005 a 2007. O tempo medio de suporte circulatorio foi de 77 horas (10-240h) e cinco pacientes estavam vivos em 30 dias (45,5%). Dois pacientes foram subsequentemente submetidos a implante de assistencia circulatoria prolongada apos um periodo de ressuscitacao em ECMO, um dos quais foi submetido ao transplante cardiaco. As causas de morte durante a assistencia com ECMO (seis pacientes) incluiram falencia multiorgânica (66,6%) ou sangramento refratario (33,4%). CONCLUSAO: O sistema ECMO e uma opcao de assistencia circulatoria temporaria para pacientes adultos com falencia cardiaca aguda refrataria, podendo ser utilizado como ponte para a recuperacao ou com o intuito de selecionar candidatos a assistencia circulatoria prolongada (ponte para a ponte).

Surgical treatment of right atrial myxoma complicated with pulmonary embolism

Myxomas are the most common type of cardiac benign tumors and most of them are located in the left atrium, followed by the right atrium. Myxomas in the right atrium may rarely embolize to the pulmonary arterial vasculature. Here, we present a case report of a patient with right atrial myxoma and massive embolism to the pulmonary arteries treated surgically with right atrial mass removal and pulmonary embolectomy. The right atrium mass presented with prolapse through the tricuspid valve causing a stenotic physiology. The left pulmonary artery was completed occluded and the right pulmonary artery was partially obstructed. Surgical tactics included a brief hypothermic circulatory arrest. The patient had an uneventful recovery and was asymptomatic after 6 months of follow-up.

Videothoracoscopy for isolated atrial fibrillation ablation through bipolar radiofrequency

BACKGROUND The prevalence of atrial fibrillation, expenses with the healthcare system and the associated high morbidity and mortality have justified the search for new therapeutic approaches. OBJECTIVE To evaluate the reproducibility of the surgical technique, its safety and the initial outcome of the video-assisted surgery for the isolated atrial fibrillation ablation with bipolar radiofrequency. METHODS Ten patients (90% men) with symptomatic atrial fibrillation (50% paroxystic type) that was refractory to drug therapy, with no heart disease that required concomitant surgical treatment, were submitted to arrhythmia ablation guided by thoracoscopy from May 2007 to May 2008. Clinical, laboratory and image variables were prospectively collected before, during surgery and at the postoperative follow-up. RESULTS The surgery was carried out as planned in all patients. There was no intra-thoracic structure iatrogenic lesion or deaths. At the mean 6-month follow-up, 80% of the patients were free of atrial fibrillation. There was a significant improvement in the symptoms of New York Heart Association Functional Class heart failure (2.4 + or - 0.5 to 1.6 + or - 0.7; p = 0.011). There was no evidence of pulmonary vein stenosis at the angiotomography in this series. CONCLUSION The video-assisted surgery for the treatment of atrial fibrillation is reproducible and safe. There is a heart failure symptom evolution improvement after the surgery.FUNDAMENTO: A prevalencia da fibrilacao atrial, os gastos com o sistema de saude e a elevada morbidade e mortalidade associadas a ela, tem justificado a procura por novas abordagens terapeuticas. OBJETIVO: Avaliar a reprodutibilidade da tecnica cirurgica, a seguranca e os resultados inicias da cirurgia video-assistida para a ablacao da fibrilacao atrial isolada com radiofrequencia bipolar. METODOS: Dez pacientes (90% homens) com fibrilacao atrial (50% paroxistica) sintomatica e refrataria a terapia medicamentosa, sem doenca cardiaca que requeresse cirurgia concomitante, foram submetidos a ablacao da arritmia guiada por toracoscopia, no periodo de maio de 2007 a maio de 2008. Variaveis clinicas, laboratoriais e de imagem foram prospectivamente coletadas antes, durante e no seguimento pos-operatorio. RESULTADOS: A cirurgia foi realizada conforme o planejado em todos os pacientes. Nao houve lesao iatrogenica de estruturas intratoracicas ou obitos. No seguimento medio de seis meses, 80% dos pacientes estao livres de fibrilacao atrial. Houve melhora significativa dos sintomas de insuficiencia cardiaca classe funcional New York Heart Association (2,4 ± 0,5 para 1,6 ± 0,7; p = 0,011). Nao houve evidencia de estenose de veias pulmonares a angiotomografia, nesta serie. CONCLUSAO: A cirurgia video-assistida para o tratamento da fibrilacao atrial e reprodutivel e segura. Ha melhora evolutiva dos sintomas de insuficiencia cardiaca apos a cirurgia.

Cirurgia vídeo-assistida para a ablação da fibrilação atrial isolada por radiofrequência bipolar

BACKGROUND The prevalence of atrial fibrillation, expenses with the healthcare system and the associated high morbidity and mortality have justified the search for new therapeutic approaches. OBJECTIVE To evaluate the reproducibility of the surgical technique, its safety and the initial outcome of the video-assisted surgery for the isolated atrial fibrillation ablation with bipolar radiofrequency. METHODS Ten patients (90% men) with symptomatic atrial fibrillation (50% paroxystic type) that was refractory to drug therapy, with no heart disease that required concomitant surgical treatment, were submitted to arrhythmia ablation guided by thoracoscopy from May 2007 to May 2008. Clinical, laboratory and image variables were prospectively collected before, during surgery and at the postoperative follow-up. RESULTS The surgery was carried out as planned in all patients. There was no intra-thoracic structure iatrogenic lesion or deaths. At the mean 6-month follow-up, 80% of the patients were free of atrial fibrillation. There was a significant improvement in the symptoms of New York Heart Association Functional Class heart failure (2.4 + or - 0.5 to 1.6 + or - 0.7; p = 0.011). There was no evidence of pulmonary vein stenosis at the angiotomography in this series. CONCLUSION The video-assisted surgery for the treatment of atrial fibrillation is reproducible and safe. There is a heart failure symptom evolution improvement after the surgery.FUNDAMENTO: A prevalencia da fibrilacao atrial, os gastos com o sistema de saude e a elevada morbidade e mortalidade associadas a ela, tem justificado a procura por novas abordagens terapeuticas. OBJETIVO: Avaliar a reprodutibilidade da tecnica cirurgica, a seguranca e os resultados inicias da cirurgia video-assistida para a ablacao da fibrilacao atrial isolada com radiofrequencia bipolar. METODOS: Dez pacientes (90% homens) com fibrilacao atrial (50% paroxistica) sintomatica e refrataria a terapia medicamentosa, sem doenca cardiaca que requeresse cirurgia concomitante, foram submetidos a ablacao da arritmia guiada por toracoscopia, no periodo de maio de 2007 a maio de 2008. Variaveis clinicas, laboratoriais e de imagem foram prospectivamente coletadas antes, durante e no seguimento pos-operatorio. RESULTADOS: A cirurgia foi realizada conforme o planejado em todos os pacientes. Nao houve lesao iatrogenica de estruturas intratoracicas ou obitos. No seguimento medio de seis meses, 80% dos pacientes estao livres de fibrilacao atrial. Houve melhora significativa dos sintomas de insuficiencia cardiaca classe funcional New York Heart Association (2,4 ± 0,5 para 1,6 ± 0,7; p = 0,011). Nao houve evidencia de estenose de veias pulmonares a angiotomografia, nesta serie. CONCLUSAO: A cirurgia video-assistida para o tratamento da fibrilacao atrial e reprodutivel e segura. Ha melhora evolutiva dos sintomas de insuficiencia cardiaca apos a cirurgia.