Fernando Antoniali

O impacto de mudanças nas medidas de prevenção e no tratamento de infecções incisionais em cirurgia de revascularização do miocárdio

Objective: To assess the impact of new preventive measures of surgical site infections after coronary artery bypass graft (CABG) surgery. Method: A retrospective study of 468 patients who underwent CABG surgery with cardiopulmonary bypass was performed. These patients were distributed into two groups: Group A (n=224) and Group B (n=244), respectively before and after a new protocol. The two groups were compared by statistical analysis to determine differences in risk factors, the incidence of sternotomy surgical site infections (superficial and deep), recurrent infections and hospital readmission. Results: There was a greater use of internal thoracic artery grafts (p=0.003) and a shorter time of mechanical ventilation (p=0.001) in Group B. Surgical site infections occurred in 44 patients of Group A (19.6%); 33 superficial (14.7%) and 11 deep (4.9%) while in Group B only 13 patients had this complication (5.3%); 10 superficial (4.1%) and 3 deep (1.2%) surgical site infections. Significant improvements were seen in the total number of surgical site infections (p<0.001), of superficial infections (p<0.001) and of deep infections (p=0.037). There were 36.3% and 7.7% of recurrent infections in Groups A and B, respectively (p=0.102). Hospital readmissions due to surgical site infections were 21 in Group A and 3 in Group B (p<0.001). Conclusion: The new preventive measures and treatment for surgical site infections after CABG surgery in this series of patients significantly reduced the incidence of sternotomy surgical site infections and hospital readmissions related to this complication.

The economic effect of extracorporeal membrane oxygenation to support adults with severe respiratory failure in Brazil: a hypothetical analysis.

Objective: To analyze the cost-utility of using extracorporeal oxygenation for patients with severe acute respiratory distress syndrome in Brazil. Methods: A decision tree was constructed using databases from previously published studies. Costs were taken from the average price paid by the Brazilian Unified Health System ( Sistema Unico de Saude; SUS) over three months in 2011. Using the data of 10,000,000 simulated patients with predetermined outcomes and costs, an analysis was performed of the ratio between cost increase and years of life gained, adjusted for quality (cost-utility), with survival rates of 40 and 60% for patients using extracorporeal membrane oxygenation. Results: The decision tree resulted in 16 outcomes with different life support techniques. With survival rates of 40 and 60%, respectively, the increased costs were R

Proporção entre os segmentos do anel da valva tricúspide normal: um parâmetro para realização da anuloplastia valvar

=-301.00/-14.00, with a Part of a document submitted to the Brazilian Network for Health Technology Assessment (Rede Brasileira de Avaliacao de Tecnologias em Saude), Ministry of Health. ABSTRACT

Importance of the area of fibrosis at midterm evolution of patients submitted to ventricular reconstruction

Objective: The purpose of this study was to determine the proportions among the segments of the human tricuspid valve annulus. Methods: A descriptive autopsy study was made of 30 human hearts without fixation, within six hours of death, without congenital or acquired lesions and without tricuspid regurgitation. Tricuspid valve insufficiency was excluded by the infusion of pressurized water in the right ventricle with the pulmonary valve closed. Digital images of the tricuspid ring in its anatomical position and after flattening were analyzed by specific software. The mean measurements and ratios were compared in the two different situations. Results: The mean measurements of the perimeter, septal and antero-posterior segments of the tricuspid ring in the anatomical position were: 105 mm (± 12.7), 30.6 mm (± 3.7) and 74 mm (± 9.4), respectively. When flattened, the mean measurement of the perimeter was 117.5 mm (± 13.3) and the sizes of the septal, anterior and posterior segments were 32 mm (± 3.7), 46.3 mm (± 8.3) and 39.1 mm (± 8.5), respectively. The mean ratio between the antero-posterior and septal segments was 2.43 (± 0.212) in the anatomical position and when flattened it was 2.67 (± 0.304). Statistical differences were observed in the measurements of the perimeter (p<0.0001), septal segment (p=0.003) and antero-posterior segment (p<0.0001) in both situations. Statistical differences also occurred in the ratios between the antero-posterior and septal segments (p=0.0005). Conclusions: The proportion between the septal and antero-posterior segments of the normal human tricuspid valve is 1:2.43. Flattening the tricuspid ring to measure the segments, changes the values and the ratios between them.

Benefício da revascularização do miocárdio em pacientes com disfunção ventricular e músculo viável: remodelamento ventricular reverso e prognóstico

BACKGROUND Although it is acknowledged that the ventricular reconstruction surgery (VRS) can promote reverse remodeling, new studies are necessary to define the influence of the left ventricular (LV) area of fibrosis. OBJECTIVE To evaluate whether the extension of the area of fibrosis of the LV is important in the LV functional recovery after the surgery and correlate it with clinical factors. METHODS Prospective analysis of 82 patients with ventricular dysfunction submitted to VRS. We analyzed the importance of the clinical characteristics and the amount of fibrosis was assessed, measured by cardiac magnetic resonance (CMR) as small, medium and large. RESULTS All patients were followed for 36 months, with a mortality of 6%. The amount of medium fibrosis was 25.8% +/- 13.6%. There was improvement in the left ventricular ejection fraction (LVEF), from 36.9% +/- 6.8% to 48.2% +/- 8.2% (p < 0.001). There was an inverse association between the amount of fibrosis and the increase in LVEF (r = -0.83, p < 0.0001). There was a decrease in the LV end-systolic volume of 43.3 +/- 8.2 ml/m(2) (p < 0.001). There was an improvement in heart failure symptoms, except in patients with large areas of fibrosis (p = 0.45). The independent predictors for events were: fibrotic area (p = 0.01), age (p = 0.01), LV end-systolic volume (p = 0.03) and LVEF (p = 0.02). The event-free follow-up was different in relation to the area of fibrosis (p < 0.01). CONCLUSION In patients with ventricular dysfunction, the extension of the area of fibrosis was an independent predictor of the LV functional recovery after the VRS. The combination of cardiac MRI and clinical parameters can help in the indication for VRS.FUNDAMENTO: Si bien se reconoce que la cirugia de reconstruccion ventricular (CRV) promueve remodelacion reversa, son necesarios nuevos estudios para definir la influencia del area de fibrosis del ventriculo izquierdo (VE). OBJETIVO: Evaluar si la extension del area de fibrosis del VI es importante en la recuperacion funcional ventricular tras la CRV y correlacionarlo con factores clinicos. METODO: Analisis prospectivo de 82 pacientes con disfuncion ventricular sometidos a CRV. Se analizo la importancia de las caracteristicas clinicas y se evaluaron las areas de fibrosis, medidas por resonancia magnetica y ponderadas como pequena, mediana y grande. RESULTADOS: Se realizo un seguimiento de 36 meses a todos los pacientes, con mortalidad del 6%. La cantidad de fibrosis promedio fue del 25,8% ± 13,6%. Existio una mejora de la fraccion de eyeccion del VI (FEVI), del 36,9% ± 6,8% al 48,2% ± 8,2% (p < 0,001). Existio relacion inversa entre la cantidad de fibrosis y el incremento de la FEVI (r = -0,83, p < 0,0001). Hubo una disminucion del volumen de fin de sistole del VI de 43,3 ± 8,2ml/m² (p < 0,001). Se produjo una mejoria en los sintomas de insuficiencia cardiaca, excepto en los pacientes con gran area de fibrosis (p = 0,45). Los predictores independientes para eventos fueron: area de fibrosis (p = 0,01), edad (p = 0,01), volumen de fin de sistole del VI (p = 0,03) y fraccion de eyeccion (p = 0,02). El seguimiento libre de eventos fue diferente en relacion con el area de fibrosis (p < 0,01). CONCLUSION: En pacientes con disfuncion ventricular, la extension del area de fibrosis fue un predictor independiente de la recuperacion funcional del VI luego de la CRV. La combinacion de RMC y parametros clinicos puede auxiliar en la indicacion de CRV.

There is one more thing to be done: ECMO!.

OBJECTIVES: To evaluate the integration of both viability and clinical parameters on the improvement in systolic performance, symptoms and prognosis, with post-revascularization reverse remodeling. METHOD: One hundred and fifteen patients underwent thallium-201 imaging before myocardial revascularization. Left ventricular ejection fraction, left ventricular end-systolic volume index and left ventricular end-diastolic volume index were determined before and at each 6 months post-revascularization for 3 years. RESULTS: Patients with > 4 viable segments on thallium-201 imaging demonstrated an improvement in left ventricular ejection fraction from 34±6 to 44±4%, p<0.001), left ventricular end-systolic volume decreased from 78.3±11 to 57±17 mL/m2, p<0.001; left end-diastolic volume decreased from 113±31 to 91±22 ml/m2, p<0.001). Patients with < 4 viable segments failed to demonstrate an improvement of the left ventricle ejection fraction, 33.4±4 vs. 35.1±5% (p=0.19), and exhibited ongoing left ventricle end-systolic remodeling, 72±23 vs. 73±12 mL/m2 (p= 0.81), and the left ventricle end-diastolic volume increased from 112±24 to 118±16 mL/m2 (p=0.34), without improvement in NYHA class, and worse long-term prognosis (event; log rank test, p=0.0053). The multivariable analysis demonstrated clinical variables related to the unfavorable evolution showed diabetes, more than one myocardial infarction, and time interval between myocardial infarction and surgery were associated with worse prognosis. CONCLUSION: The benefits of myocardium revascularization in patients with viable muscle, as well as an improvement in the left ventricular ejection fraction, provide reverse remodeling, improvement in functional class and favorable long-term prognosis.

Importancia del área de fibrosis en la evolución a mediano plazo de pacientes sometidos a reconstrucción ventricular

1Coordinator of the Pediatric Cardiac Surgery at PUC-Campinas and the Cardio Surgical Clinic ECMO group of Campinas linked to ELSO, Campinas, SP, Brazil. E-mail: ferantoniali@uol.com.br “ – Unfortunately, it is not possible to get out of cardiopulmonary bypass. We have already tried several times and it is not working. We will have to let the patient die! I will talk to the family...” This is an extremely distressing situation for all the team involved in a cardiac surgery. Everyone who has been present in a moment like this and have the humility to recognize certainly will not deny how difficult it is to make the decision: turn off the pump and allow the patient to die. Especially, if the surgery is going on for several hours and there were many attempts to wean from cardiopulmonary bypass (CPB). Especially, if the patient is a child and the parents are outside waiting anxiously for a successful surgical repair. However, for the most part of these patients, we can say that there is one more thing to be done. We cannot use this claim for all the patients with cardiac and respiratory failure after a heart surgery but for the most part of them, we can! For sure! Despite some of these patients can get out of the operating room with high doses of vasoactive drugs or high parameters of mechanical ventilation, the circulatory failure and severe hypoxia will culminate with important acidosis, multiple organ failure and the patient will die a few days later. The post-cardiotomy ECMO (Extracorporeal Membrane Oxygenation) is the best option to support these patients. Nevertheless, it is necessary to use a real post-cardiotomy ECMO because keeping the patient on CPB in the ICU will not work. If we are talking about ECMO, the numbers from the ELSO registry (Extracorporeal Life Support Organization) must be highlighted. The last ELSO international report was on July 2015 and there were 69.114 ECMO patients in the registry with an overall survival of 59%[1]. Inside of this big group of patients, 10.183 cases were neonates and infants under 16 years old with congenital heart problems and they were supported with a cardiac ECMO. The majority of them received the support because of cardiac failure after CPB or during the first postoperative day. In this post-cardiotomy ECMO group, the mean survival was 42.7%. Using these information from ELSO, at least we should say that it is mandatory remember about ECMO as a possibility of treatment for a patient with cardiac failure after CPB. However, it is not a widespread knowledge in our country and some people don’t understand it. There is no doubt that the treatment with ECMO is increasing in Brazil but we still have to expand the information about it and improve the quality of this therapeutic technique in our country. Another important action would be the incorporation of this technology on the treatment of our patients from the public health system (SUS). In order to spread information about ECMO, the First Latin American ELSO Conference was performed in Brazil on December 2014. There were over 500 health professionals present with the majority of Brazilians and this event was the first scientific meeting of the Latin American chapter of ELSO that was created in 2012 following examples as the Euro ELSO and Asian-Pacific ELSO. The registrants discussed different issues about cardiopulmonary support with more than 20 international speakers, including Dr. Robert Bartlett, called “The Father of ECMO” who, on the opening ceremony, talked about the experimental studies of his group in the 1960’s and also about the first ECMO survival patients in the 1970’s. Fortunately, ECMO is not an experimental therapy anymore and the fact of more than 69 thousands of patients had been treated until now can prove it.

Left ventricular reconstruction benefits patients with ischemic cardiomyopathy and non-viable myocardium

BACKGROUND Although it is acknowledged that the ventricular reconstruction surgery (VRS) can promote reverse remodeling, new studies are necessary to define the influence of the left ventricular (LV) area of fibrosis. OBJECTIVE To evaluate whether the extension of the area of fibrosis of the LV is important in the LV functional recovery after the surgery and correlate it with clinical factors. METHODS Prospective analysis of 82 patients with ventricular dysfunction submitted to VRS. We analyzed the importance of the clinical characteristics and the amount of fibrosis was assessed, measured by cardiac magnetic resonance (CMR) as small, medium and large. RESULTS All patients were followed for 36 months, with a mortality of 6%. The amount of medium fibrosis was 25.8% +/- 13.6%. There was improvement in the left ventricular ejection fraction (LVEF), from 36.9% +/- 6.8% to 48.2% +/- 8.2% (p < 0.001). There was an inverse association between the amount of fibrosis and the increase in LVEF (r = -0.83, p < 0.0001). There was a decrease in the LV end-systolic volume of 43.3 +/- 8.2 ml/m(2) (p < 0.001). There was an improvement in heart failure symptoms, except in patients with large areas of fibrosis (p = 0.45). The independent predictors for events were: fibrotic area (p = 0.01), age (p = 0.01), LV end-systolic volume (p = 0.03) and LVEF (p = 0.02). The event-free follow-up was different in relation to the area of fibrosis (p < 0.01). CONCLUSION In patients with ventricular dysfunction, the extension of the area of fibrosis was an independent predictor of the LV functional recovery after the VRS. The combination of cardiac MRI and clinical parameters can help in the indication for VRS.FUNDAMENTO: Si bien se reconoce que la cirugia de reconstruccion ventricular (CRV) promueve remodelacion reversa, son necesarios nuevos estudios para definir la influencia del area de fibrosis del ventriculo izquierdo (VE). OBJETIVO: Evaluar si la extension del area de fibrosis del VI es importante en la recuperacion funcional ventricular tras la CRV y correlacionarlo con factores clinicos. METODO: Analisis prospectivo de 82 pacientes con disfuncion ventricular sometidos a CRV. Se analizo la importancia de las caracteristicas clinicas y se evaluaron las areas de fibrosis, medidas por resonancia magnetica y ponderadas como pequena, mediana y grande. RESULTADOS: Se realizo un seguimiento de 36 meses a todos los pacientes, con mortalidad del 6%. La cantidad de fibrosis promedio fue del 25,8% ± 13,6%. Existio una mejora de la fraccion de eyeccion del VI (FEVI), del 36,9% ± 6,8% al 48,2% ± 8,2% (p < 0,001). Existio relacion inversa entre la cantidad de fibrosis y el incremento de la FEVI (r = -0,83, p < 0,0001). Hubo una disminucion del volumen de fin de sistole del VI de 43,3 ± 8,2ml/m² (p < 0,001). Se produjo una mejoria en los sintomas de insuficiencia cardiaca, excepto en los pacientes con gran area de fibrosis (p = 0,45). Los predictores independientes para eventos fueron: area de fibrosis (p = 0,01), edad (p = 0,01), volumen de fin de sistole del VI (p = 0,03) y fraccion de eyeccion (p = 0,02). El seguimiento libre de eventos fue diferente en relacion con el area de fibrosis (p < 0,01). CONCLUSION: En pacientes con disfuncion ventricular, la extension del area de fibrosis fue un predictor independiente de la recuperacion funcional del VI luego de la CRV. La combinacion de RMC y parametros clinicos puede auxiliar en la indicacion de CRV.