Fábio Gonçalves de Rueda

Risk factors for mediastinitis after coronary artery bypass grafting surgery

OBJECTIVE Mediastinitis is a serious complication of median sternotomy and is associated to significant morbidity and mortality. The aim of this study is to identify risk factors for mediastinitis in patients undergoing coronary artery bypass grafting (CABG), without the use of bilateral internal thoracic artery (ITA), at the Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE. METHODS A retrospective study of 500 consecutive patients operated on between May 2007 and April 2010. Ten preoperative variables, seven intraoperative variables and seven postoperative variables possibly involved in the development of postoperative mediastinitis were evaluated. Univariate and multivariate logistic regression analyses were performed. RESULTS The incidence of mediastinitis was 5.6% (n=28), with a lethality rate of 32.1% (n=9). In multivariate analysis using logistic regression, five variables remained as independent risk factors: obesity (OR 2.60, 95% CI 1.11 to 6.68), diabetes (OR 2.71, 95% CI 1.18 to 6.65), smoking (OR 2.10, 95% CI 1.12 to 4.67), use of pedicled internal thoracic artery (OR 5.17, 95% CI 1.45 to 18.42) and on-pump CABG (OR 2.26, 95% CI 1.14 to 5.85). CONCLUSION This study identified the following independent risk factors for mediastinitis after CABG: obesity, diabetes, smoking, use of pedicled ITA and on-pump CABG.

Estudo comparativo entre cirurgia de revascularização miocárdica com e sem circulação extracorpórea em mulheres

AbstractBackground: It has been well documented that womenhave higher morbidity and mortality rates than menfollowing coronary artery bypass graft (CABG) surgery. Inview of this evidence, it is necessary to know if there isbenefit to off-pump CABG surgery in women in comparisonto on-pump CABG. Objectives: Compare outcomes between off-pump CABGand on-pump CABG in women. Methods: Retrospective study. Our investigation analyzescomparatively clinical profile, thirteen procedurecomplications and mortality of a population of 941consecutive women undergoing CABG surgery (549 off-pumpand 392 on-pump) at two hospitals for the period January2000 to December 2005. Results: Mortality rate for women undergoing off-pumpCABG surgery is lower than for women undergoing on-pumpsurgery, however, not statistically significant (3.1% vs 5.3%; P =0.134). The complication rates analyzed (hemorrhagicshock, neurologic, respiratory, acute renal failure, adultrespiratory distress syndrome, septicemia, pneumonia, atrialfibrillation) were lower (significant statistically difference)for women off-pump than women on-pump, with theexception of low cardiac output and wound infection.

Skeletonized left internal thoracic artery is associated with lower rates of mediastinitis in diabetic patients

BACKGROUND Mediastinitis is a serious complication of median sternotomy and is associated to significant morbidity and mortality. Diabetes is a feared risk factor for mediastinitis and viewed with caution by cardiovascular surgeons. OBJECTIVE To identify risk factors for mediastinitis in diabetics undergoing CABG surgery with use of unilateral ITA in the Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE. METHODS Retrospective study of 157 diabetics operated between May 2007 and April 2010. Nine preoperative variables, five intraoperative variables and seven postoperative variables possibly involved in the development of postoperative mediastinitis were evaluated. Univariate and multivariate logistic regression analyses were applied. RESULTS The incidence of mediastinitis was 7% (n=11), with a lethality rate of 36.1% (n=4). Variables associated with increased risk of mediastinitis were: use of pedicled ITA (OR 8.25, 95% CI 2.03 to 66.10, P=0.016), postoperative renal complications (OR 5.10, 95% CI 1.03 to 25.62, P=0.049) and re-operation (OR 7.45, 95% CI 1.24 to 42.17, P=0.023). In multivariate analysis using backward logistic regression, only one variable remained as independent risk factor: use of pedicled ITA (OR 7.64, 95% CI 1.95 to 61.6, P=0.048), in comparison to skeletonized ITA. CONCLUSIONS We suggest that diabetics should be considered for strategies to minimize risk of infection. In diabetics that undergo unilateral ITA, the problem seems to be related to how ITA is harvested. Diabetics should always be considered for use of skeletonized ITA.

Postoperative mediastinitis in cardiovascular surgery. Analysis of 1038 consecutive surgeries

OBJETIVO: Relatar a incidencia de mediastinite no pos-operatorio de cirurgia cardiovascular. METODOS: Foram analisados os prontuarios de 1038 pacientes submetidos a cirurgia cardiovascular entre maio/ 2007 e junho/2009. Todas as operacoes foram realizadas na Divisao de Cirurgia Cardiovascular do Pronto Socorro Cardiologico de Pernambuco - PROCAPE. RESULTADOS: A mediastinite ocorreu, em media, 13 dias apos a cirurgia, num total de 25 (2,4%) casos, com taxa de letalidade 32,0% (n=8). Varios fatores de risco foram identificados: 56% diabeticos, 56% tabagistas, 20% obesos, 16% portadores de doenca pulmonar obstrutiva cronica e 8% com insuficiencia renal cronica. A maioria (n=21; 84,0%) dos casos foi observada em pacientes submetidos a revascularizacao do miocardio, sendo esta associada a maior risco de desenvolvimento da infeccao (IC 3.44-8.30, P=0,0001). Observou-se alto indice de complicacoes: insuficiencia respiratoria (44%), acidente vascular cerebral (16%), choque cardiogenico (12%), insuficiencia renal aguda (28%), infeccao pulmonar (36%), falencia de multiplos orgaos (16%) e deiscencia de esterno (48%). A cultura do exsudato foi positiva em 84% dos casos, sendo o Staphylococcus aureus o patogeno mais observado (28,8%). CONCLUSOES: A mediastinite continua como complicacao cirurgica bastante grave e de dificil manuseio no pos-operatorio de cirurgia cardiovascular. A doenca permanece como de baixa incidencia, entretanto, ainda com alta letalidade. A cirurgia de revascularizacao esta associada a maior risco de desenvolvimento da infeccao.Objective: To report the incidence of postoperative mediastinitis in cardiovascular surgery. Methods: The medical records of all 1038 patients who underwent cardiovascular surgical procedures between May/ 2007 and June/2009 were reviewed. All operations were performed at the Division of Cardiovascular Surgery of Cardiac Emergency Hospital of Pernambuco – PROCAPE. Results: On average, complication occurred within 13 days after operation; in a total of 25 lethal cases (2.4%), deaths occurred in eight (32%). Several risk factors for mediastinitis were identified as follows: 56% diabetes, 56% smoking, 20% obesity, 16% chronic obstructive pulmonary disease, and 8% end-stage renal disease. Mediastinitis was reported in 21 (84%) patients submitted to coronary artery bypass grafting and it was related to a major risk for development of infection (IC 3.44-8.30, P=0.0001). High rates of complications were observed: respiratory failure (44%), stroke (16%), cardiogenic shock (12%), acute renal failure (28%), pulmonary infection (36%), multiple organs failure (16%), and sternal dehiscence (48%). Bacterial cultures of exudates were positive in 84% of patients; Staphylococcus aureus was the most frequently pathogen (28.8%) detected. Conclusion: Mediastinitis remains as a severe surgical complication and difficult to manage in postoperative cardiovascular surgery. The disease has low incidence rate but high lethality. Coronary bypass was associated to a major risk for development of infection.

Validation of MagedanzSCORE as a predictor of mediastinitis after coronary artery bypass graft surgery

OBJECTIVE The aim of this study is to evaluate the applicability of a new score for predicting mediastinitis - MagedanzSCORE - in patients undergoing coronary artery bypass graft (CABG) surgery in the Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE. METHODS Retrospective study involving 500 patients operated between May/2007 and April/2010. The registers contained all the information used to calculate the MagedanzSCORE. The outcome of interest was mediastinitis. We calculated sensitivity, specificity, positive predictive value, negative predictive value, concordance and accuracy. The accuracy of the model was evaluated by ROC (receiver operating characteristic) curve. RESULTS The incidence of mediastinitis was 5.6%, with a lethality rate of 32.1%. In univariate analysis, the five variables of the MagedanzSCORE were predictors of postoperative mediastinitis: chronic obstructive pulmonary disease (OR 6.42; 95.0% CI 2.76-14.96; P<0.001), obesity (OR 3.06; 95.0% CI 1.32-7.09; P=0.009), surgical reintervention (OR 82.40; 95.0% CI 30.40-223.30; P<0.001), multiple transfusion (OR 3.33; 95.0% CI 1.52-7.29; P=0.003) and stable angina class IV or unstable (OR 2.59; 95.0% CI 1.19-7.64; P=0.016) according to Canadian Cardiovascular Society. The score had a sensitivity of 96.4%, specificity of 90.0%, positive predictive value of 36.5%, negative predictive value of 99.8% and 90.4% concordance. The accuracy measured by the area under the ROC curve was 96.2% (95.0% CI 94.5%-97.9%). CONCLUSIONS The MagedanzSCORE proved to be a simple and objective index, revealing a satisfactory predictor of development of postoperative mediastinitis in patients undergoing CABG surgery at our institution.

Mediastinite no pós-operatório de cirurgia cardiovascular: análise de 1038 cirurgias consecutivas

OBJETIVO: Relatar a incidencia de mediastinite no pos-operatorio de cirurgia cardiovascular. METODOS: Foram analisados os prontuarios de 1038 pacientes submetidos a cirurgia cardiovascular entre maio/ 2007 e junho/2009. Todas as operacoes foram realizadas na Divisao de Cirurgia Cardiovascular do Pronto Socorro Cardiologico de Pernambuco - PROCAPE. RESULTADOS: A mediastinite ocorreu, em media, 13 dias apos a cirurgia, num total de 25 (2,4%) casos, com taxa de letalidade 32,0% (n=8). Varios fatores de risco foram identificados: 56% diabeticos, 56% tabagistas, 20% obesos, 16% portadores de doenca pulmonar obstrutiva cronica e 8% com insuficiencia renal cronica. A maioria (n=21; 84,0%) dos casos foi observada em pacientes submetidos a revascularizacao do miocardio, sendo esta associada a maior risco de desenvolvimento da infeccao (IC 3.44-8.30, P=0,0001). Observou-se alto indice de complicacoes: insuficiencia respiratoria (44%), acidente vascular cerebral (16%), choque cardiogenico (12%), insuficiencia renal aguda (28%), infeccao pulmonar (36%), falencia de multiplos orgaos (16%) e deiscencia de esterno (48%). A cultura do exsudato foi positiva em 84% dos casos, sendo o Staphylococcus aureus o patogeno mais observado (28,8%). CONCLUSOES: A mediastinite continua como complicacao cirurgica bastante grave e de dificil manuseio no pos-operatorio de cirurgia cardiovascular. A doenca permanece como de baixa incidencia, entretanto, ainda com alta letalidade. A cirurgia de revascularizacao esta associada a maior risco de desenvolvimento da infeccao.Objective: To report the incidence of postoperative mediastinitis in cardiovascular surgery. Methods: The medical records of all 1038 patients who underwent cardiovascular surgical procedures between May/ 2007 and June/2009 were reviewed. All operations were performed at the Division of Cardiovascular Surgery of Cardiac Emergency Hospital of Pernambuco – PROCAPE. Results: On average, complication occurred within 13 days after operation; in a total of 25 lethal cases (2.4%), deaths occurred in eight (32%). Several risk factors for mediastinitis were identified as follows: 56% diabetes, 56% smoking, 20% obesity, 16% chronic obstructive pulmonary disease, and 8% end-stage renal disease. Mediastinitis was reported in 21 (84%) patients submitted to coronary artery bypass grafting and it was related to a major risk for development of infection (IC 3.44-8.30, P=0.0001). High rates of complications were observed: respiratory failure (44%), stroke (16%), cardiogenic shock (12%), acute renal failure (28%), pulmonary infection (36%), multiple organs failure (16%), and sternal dehiscence (48%). Bacterial cultures of exudates were positive in 84% of patients; Staphylococcus aureus was the most frequently pathogen (28.8%) detected. Conclusion: Mediastinitis remains as a severe surgical complication and difficult to manage in postoperative cardiovascular surgery. The disease has low incidence rate but high lethality. Coronary bypass was associated to a major risk for development of infection.

Predictors of transfusion of packed red blood cells in coronary artery bypass grafting surgery

Objectives: Finding predictors of blood transfusion may facilitate the most efficient approach for the use of blood bank services in coronary artery bypass grafting procedures. The aim of this retrospective study is to identify preoperative and intraoperative patient characteristics predicting the need for blood transfusion during or after CABG in our local cardiac surgical service. Methods: 435 patients undergoing isolated first-time CABG were reviewed for their preoperative and intraoperative variables and analyzed postoperative data. Patients were 255 males and 180 females, with mean age 62.01 ± 10.13 years. Regression logistic analysis was used for identifying the strongest perioperative predictors of blood transfusion. Results: Blood transfusion was used in 263 patients (60.5%). The mean number of transfused blood products units per patient was 2.27 ± 3.07 (0-23) units. The total number of transfused units of blood products was 983. Univariate analysis identified age >65 years, weight <70 Kg, body mass index <25 Kg/m2, hemoglobin ≤ ≤ ≤ ≤ ≤13mg/dL, hematocrit ≤ 40% and ejection fraction <50%, use of cardiopulmonary bypass (CPB), not using an internal thoracic artery as a bypass, and multiple bypasses as significant predictors. The strongest predictors using multivariate analysis were hematocrit ≤ ≤ ≤ ≤ ≤ 40% (OR 2.58; CI 1.62-4.15; P<0.001), CPB use (OR 2.00; CI 1.27-3.17; P=0.003) and multiple bypasses (OR 2.31; CI 1.31-4.08; P=0.036). Conclusions: The identification of these risk factors leads to better identification of patients with a grater probability of using blood, allocation blood bank resources and costeffectiveness use of blood products.OBJECTIVES Finding predictors of blood transfusion may facilitate the most efficient approach for the use of blood bank services in coronary artery bypass grafting procedures. The aim of this retrospective study is to identify preoperative and intraoperative patient characteristics predicting the need for blood transfusion during or after CABG in our local cardiac surgical service. METHODS 435 patients undergoing isolated first-time CABG were reviewed for their preoperative and intraoperative variables and analyzed postoperative data. Patients were 255 males and 180 females, with mean age 62.01 ± 10.13 years. Regression logistic analysis was used for identifying the strongest perioperative predictors of blood transfusion. RESULTS Blood transfusion was used in 263 patients (60.5%). The mean number of transfused blood products units per patient was 2.27 ± 3.07 (0-23) units. The total number of transfused units of blood products was 983. Univariate analysis identified age >65 years, weight <70 Kg, body mass index <25 Kg/m2, hemoglobin <13mg/dL, hematocrit < 40% and ejection fraction <50%, use of cardiopulmonary bypass (CPB), not using an internal thoracic artery as a bypass, and multiple bypasses as significant predictors. The strongest predictors using multivariate analysis were hematocrit < 40% (OR 2.58; CI 1.62-4.15; P<0.001), CPB use (OR 2.00; CI 1.27-3.17; P=0.003) and multiple bypasses (OR 2.31; CI 1.31-4.08; P=0.036). CONCLUSIONS The identification of these risk factors leads to better identification of patients with a greater probability of using blood, allocation blood bank resources and cost-effectiveness use of blood products.

Clinical and surgical profile of patients operated for postinfarction interventricular septal rupture

OBJECTIVES To study clinical features, complications and in-hospital outcomes of patients operated for postinfarction ventricular septal rupture. METHODS A retrospective study involving 21 patients between January/1996 and June/2009. All operations were performed at the Division of Cardiovascular Surgery of Complexo Hospitalar HUOC/PROCAPE. RESULTS Mean age of patients was 62.81 years (± 8.21), 61.9% (n = 13) were male. Rupture occurred on average 4.8 days after infarction. Cardiogenic shock was observed in 57.1% (n = 12), being risk factor for death (100% with shock vs. 22.2% without shock; P<0.001). Survivors had a higher mean ejection fraction compared to deaths (66.29% ± 4.61% versus 42.71% ± 4.79%, P <0.001). All were classified as high risk by the EuroSCORE, and the survivors had lower average score compared to deaths (6.57 ± 0.53 versus 10.93 ± 2.23; P <0.001). The majority (76.2%, n = 16) of the patients needed to use vasoactive drugs and 57.1% (n = 12) considered hemodynamically unstable. Need for vasoactive drugs was a risk factor for death (81.3% with vasoactive drugs versus 20% without vasoactive drugs, P = 0.025). Hemodynamic instability was also a risk factor for death (100% in the unstable group versus 22.2% in the stable group; P <0.001). The rate of in-hospital mortality was 66.7% (n = 14). CONCLUSIONS The need for vasoactive drugs, hemodynamic instability and cardiogenic shock were associated with higher rates of mortality. Patients who had adverse outcomes had less ventricular function and higher score in the EuroSCORE. Mortality remains high.

Mortalidade perioperatória em diabéticos submetidos à cirurgia de revascularização miocárdica

OBJECTIVE To investigate the risk factors for in-hospital death in diabetic patients undergoing isolated Coronary Artery Bypass Grafting (CABG). METHODS We conducted a retrospective study with 305 consecutive diabetic patients undergoing CABG in the Division of Cardiovascular Surgery of our institution from April 2004 to April 2010. Univariate analysis for categorical variables was performed with the chi-square or Fishers exact test, as appropriate. Potential risk factors with p <0.05 in the univariate analysis were included in the multivariate analysis, which was performed by backward logistic regression. Values of p <0.05 were considered statistically significant. RESULTS The study population had a mean age of 61.44 years (± 9.81) and 65.6% (n=200) were male. The in-hospital mortality rate was 11.8% (n=36). The following independent risk factors for death were identified: on-pump CABG (OR 6.15, 95% CI 1.57 to 24.03, P=0.009) and low cardiac output in the postoperative period (OR 34.17, 95% CI 10.46 to 111.62, P <0.001). The use of internal thoracic artery (ITA) was an independent protective factor for death (OR 0.27, 95% CI 0.08 to 0.093, P=0.038). CONCLUSION This study identified the following independent risk factors for death after CABG: on-pump CABG and low cardiac output syndrome. The use of ITA was an independent protective factor.