Frederico Pires Vasconcelos

Skeletonized versus pedicled internal thoracic artery and risk of sternal wound infection after coronary bypass surgery: meta-analysis and meta-regression of 4817 patients

It is suggested that the internal thoracic artery (ITA) harvesting technique influences the incidence of sternal wound infection (SWI) after coronary artery bypass graft (CABG). To determine if there is any real difference between skeletonized vs pedicled ITA, we performed a meta-analysis to determine if there is any real difference between these two established techniques in terms of SWI. We performed a systematic review using MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles to search for studies that compared the incidence of SWI after CABG between skeletonized vs pedicled ITA until June 2012. The principal summary measures were odds ratio (OR) with 95% confidence interval (CI) and P values (statistically significant when <0.05). The ORs were combined across studies using the weighted DerSimonian-Laird random effects model and weighted Mantel-Haenszel fixed effects. Meta-analysis, sensitivity analysis and meta-regression were completed using the software Comprehensive Meta-Analysis version 2 (Biostat, Inc., Englewood, NJ, USA). Twenty-two studies involving 4817 patients (2424 skeletonized; 2393 pedicled) met the eligibility criteria. There was no evidence for important heterogeneity of effects among the studies. The overall OR (95% CI) of SWI showed a statistically significant difference in favour of skeletonized ITA (fixed effect model: OR 0.443, 95% CI 0.323-0.608, P < 0.001; random effect model: OR 0.443, 95% CI 0.323-0.608, P < 0.001). In the sensitivity analysis, the difference in favour of skeletonized ITA was also observed in subgroups such as diabetic, bilateral ITA and diabetic with bilateral ITA; we also observed that there was a difference in the type of study, since non-randomized studies together demonstrated the benefit of skeletonized ITA in comparison with pedicled ITA, but the randomized studies together did not show this difference (although close to statistical significance and with the tendency to favour the skeletonized group). In meta-regression, we observed a statistically significant coefficient for SWI and proportion of diabetic patients (coefficient -0.02, 95% CI -0.03 to -0.01, P = 0.016). In conclusion, skeletonized ITA appears to reduce the incidence of postoperative SWI in comparison with pedicled ITA after CABG, with this effect being modulated by the presence of diabetes.

Revascularização miocárdica em pacientes octogenários: estudo retrospectivo e comparativo entre pacientes operados com e sem circulação extracorpórea

OBJECTIVE: The purpose of the present study is to compare and analyze the benefits of this operation with and without cardiopulmonary bypass in octogenarian patients. METHOD: Retrospective data of the patients aged eighty years or more from December 1995 to December 2003 were analyzed. During this period 73 patients were submitted to coronary artery bypass grafting (CABG), 26 (35.6%) on-pump and 47 (64.4%) off-pump. A comparison was made of the demographic data, preoperative risks, concurrent morbid conditions, types of angina, postoperative complications and surgical outcomes between the on-pump and off-pump groups. The Student t-test was used to compare the groups and the level of significance was set at p-value < 0.05. RESULTS: Both groups showed a high preoperative risk, although the off-pump group presented less surgical mortality (11.5% vs 2.1%, p < 0.05). No strokes were observed in the patients operated on off-pump (11.5% vs 0.0%, p < 0.005). Atrial fibrillation (AF) in the immediate postoperative period was present less often in the off-pump group (30.8% vs 12.8%, p < 0.005). The postoperative mechanical ventilation time and the presence of respiratory failure were less in the off-pump group (p < 0.005). The presence of acute renal insufficiency (ARI) was 19.2% in the on-pump group and 0% in the off-pump group (p < 0.05). There was less need for transfusion of blood or blood derivatives in the off-pump group (69.2% vs 31.9%, p < 0.005). The mean sojourn in the intensive care unit (ICU) was shorter in the off-pump group (p < 0.05). The percentage of patients with no postoperative complications was higher in the off-pump group than in the on-pump group (89.4% vs 61.5%, p <0.001). CONCLUSIONS: The present study suggests that patients aged eighty years and over benefit when submitted to off-pump CABG and that this procedure is associated with low rates of postoperative complications such as stroke, AF, ARI and respiratory insufficiency, and with less time in the ICU, a shorter hospital sojourn, less use of blood derivatives and lower mortality. In octogenarian patients off-pump CABG surgery is a safe and effective technique, and may be the operation of choice when correctly indicated.

Risk factors for low cardiac output syndrome after coronary artery bypass grafting surgery

OBJECTIVES Low cardiac output syndrome (LCOS) is a serious complication after cardiac surgery and is associated with significant morbidity and mortality. The aim of this study is to identify risk factors for LCOS in patients undergoing coronary artery bypass grafting (CABG) in the Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE (Recife, PE, Brazil). METHODS A historical prospective study comprising 605 consecutive patients operated between May 2007 and December 2010. We evaluated 12 preoperative and 7 intraoperative variables. We applied univariate and multivariate logistic regression analysis. RESULTS The incidence of LCOS was 14.7% (n = 89), with a lethality rate of 52.8% (n = 47). In multivariate analysis by logistic regression, four variables remained as independent risk factors: age > 60 years (OR 2.00, 95% CI 1.20 to 6.14, P = 0.009), on-pump CABG (OR 2.16, 95% CI 1.40 to 7.08, P = 0.006), emergency surgery (OR 4.71, 95% CI 1.34 to 26.55, P = 0.028), incomplete revascularization (OR 2.62, 95% CI 1.32 to 5.86, P = 0.003), and ejection fraction <50%. CONCLUSIONS This study identified the following independent risk factors for LCOS after CABG: age> 60 years of off-pump CABG, emergency surgery, incomplete CABG and ejection fraction <50%.

Patency of skeletonized versus pedicled internal thoracic artery in coronary bypass graft surgery: A systematic review, meta-analysis and meta-regression

BACKGROUND It is suggested that the skeletonization harvesting technique influences the patency rates of internal thoracic artery (ITA) after coronary artery bypass graft (CABG) surgery in comparison to conventional (pedicled) harvesting. We conducted a meta-analysis to determine whether there is any difference between skeletonized versus pedicled ITA in terms of patency after CABG. METHODS We performed a systematic-review using MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles to search for studies that performed angiographic evaluation within the first two years after CABG between these two groups until December 2013. The principal summary measures were odds ratio (OR) with 95% Confidence Interval (CI) and P values (statistically significant when <0.05). The ORs were combined across studies using weighted DerSimonian-Laird random effects model and weighted Mantel-Haenszel fixed effects. Meta-analysis, sensitivity analysis and meta-regression were completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, New Jersey). RESULTS Five studies involving 1764 evaluated conduits (1145 skeletonized; 619 pedicled) met the eligibility criteria. There was no evidence for important heterogeneity of effects among the studies. The overall OR (95% CI) for graft occlusion showed no statistical significant difference between groups (fixed effect model: OR 1.351, 95% CI 0.408 to 4.471, P = 0.801; random effect model: OR 1.351, 95% CI 0.408 to 4.471, P = 0.801). In sensitivity analysis, no difference regarding to left or right ITA was also observed. In meta-regression, we observed no statistically significant coefficients for graft occlusion and proportion of female, diabetics, renal failure, age, off-pump surgery or urgency, which means that the effect is not modulated by these factors. CONCLUSION In terms of patency, skeletonized ITA appears to be non-inferior in comparison to pedicled ITA after CABG.

Surgical results of coronary artery bypass grafting without cardiopulmonary bypass: analysis of 3,410 patients

OBJETIVO: Nos ultimos anos, tem-se observado um grande avanco na cirurgia de revascularizacao miocardica sem circulacao extracorporea (RMSCEC). Esse desenvolvimento deveu-se a combinacao dos avancos da tecnica cirurgica e ao desenvolvimento de instrumentos que possibilitam a realizacao deste procedimento nas mais variadas situacoes. Este e um estudo retrospectivo, que visa avaliar nossa experiencia com este procedimento nos ultimos 11,5 anos. Os autores enfatizam o rapido progresso do metodo nos ultimos anos, suas indicacoes, contra-indicacoes e resultados. METODO: No periodo de agosto de 1991 e dezembro de 2002, 3.410 pacientes consecutivos, portadores de angina do peito, foram submetidos a cirurgia de revascularizacao miocardica sem circulacao extracorporea. A idade variou de 13 a 93 anos (63 12,0 anos), sendo 58% dos pacientes do sexo masculino. A angina foi classificada segundo a Canadian Cardiovascular Society, sendo 6,1% na classe I, 6,8% na classe II, 46,3% na classe III e 40,8% na classe IV. RESULTADOS: A mortalidade intra-operatoria foi baixa (0,4%). A mortalidade hospitalar (trinta dias de pos-operatorio) foi de 2,58%. A mortalidade e morbidade, no grupo dos pacientes octogenarios, foram extremamente baixas em relacao aos pacientes operados com circulacao extracorporea (2,2% x 12,6%) (p<0,001). As complicacoes pos-operatorias que nao resultaram em obito foram de 7,6%. No ultimo ano, nao observamos diferenca entre o numero de condutos nos pacientes operados com e sem CEC [com CEC 2,81,2 e sem CEC 2,80,8 (NS)]. Infarto agudo do miocardio foi a complicacao nao fatal mais frequente, observada em 2,8% dos pacientes. O tempo medio de permanencia na UTI foi de 22,3 horas. CONCLUSOES: A RMSCEC, usada como tecnica de revascularizacao em pacientes multiarteriais, e um procedimento reproduzivel e apresenta resultados semelhantes aos obtidos com a operacao convencional com CEC. Nesta serie foi possivel revascularizar o miocardio sem circulacao extracorporea em mais de 95% dos pacientes, tornando assim, a principio, todos os pacientes, com indicacao de revascularizacao miocardica, potenciais candidatos a operacao de RMSCEC.

Prophylactic intra-aortic balloon pump in high-risk patients undergoing coronary artery bypass surgery: a meta-analysis of randomized controlled trials.

ObjectivesThe aim of this study was to assess the efficacy of a prophylactic intra-aortic balloon pump (IABP) in high-risk patients undergoing coronary artery bypass graft surgery. MethodsMEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar, and reference lists of relevant articles were searched. We included only randomized controlled trials. Assessments for eligibility, relevance, and study validity and data extraction were performed in duplicate using prespecified criteria. Meta-analysis was carried out using fixed-effect and random-effect models. ResultsSeven publications fulfilled our eligibility criteria. There was no important statistical heterogeneity or publication bias among included studies. In total, 177 patients received prophylactic IABP and 168 did not. Overall relative risk (RR) for hospital mortality in patients treated with prophylactic IABP was 0.255 [95% confidence interval (CI), 0.122–0.533; P<0.001; same results for both effect models]. Pooled RR for postoperative low cardiac output syndrome was 0.206 (95% CI, 0.109–0.389; P<0.001) for the fixed-effect model and 0.219 (95% CI, 0.095–0.504; P<0.001) for the random-effect model. Patients treated with prophylactic IABP presented an overall difference in means for length of intensive care unit stay and hospital stay, which was lower than that in the control group (P<0.001 for both effect models). Only 7.4% (13/177) of patients who received prophylactic IABP developed complications at an insertion site, with no IABP-related death. ConclusionThis meta-analysis supports the use of prophylactic IABP in high-risk patients to reduce hospital mortality.

Five-year outcomes following PCI with DES versus CABG for unprotected LM coronary lesions: meta-analysis and meta-regression of 2914 patients

OBJECTIVE To compare the safety and efficacy at long-term follow-up of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. METHODS MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at 5-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Five studies (1 randomized controlled trial and 4 observational studies) were identified and included a total of 2914 patients (1300 for CABG and 1614 for PCI with DES). RESULTS At 5-year follow-up, there was no significant difference between the CABG and PCI-DES groups in the risk for death (odds ratio [OR] 1.159, P=0.168 for random effect) or the composite endpoint of death, myocardial infarction, or stroke (OR 1.214, P=0.083). The risk for target vessel revascularization (TVR) was significantly lower in the CABG group compared to the PCI-DES group (OR 0.212, P<0.001). The risk of major adverse cardiac and cerebrovascular events (MACCE) was significantly lower in the CABG group compared to the PCI-DES group (OR 0.526, P<0.001). It was observed no publication bias about outcomes and considerably heterogeneity effect about MACCE. CONCLUSION CABG surgery remains the best option of treatment for patients with ULMCA disease, with less need of TVR and MACCE rates at long-term follow-up.

Meta-analysis of 5674 patients treated with percutaneous coronary intervention and drug-eluting stents or coronary artery bypass graft surgery for unprotected left main coronary artery stenosis

OBJECTIVES To compare the safety and efficacy of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. METHODS MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at the 1-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Sixteen studies (three randomized controlled trials and 13 observational studies) were identified and included a total of 5674 patients (2331 for PCI with DES and 3343 for CABG). RESULTS At the 1-year follow-up, there was no significant difference between the CABG and DES groups in the risk for death (odds ratio [OR] 0.691, P = 0.051) or the composite endpoint of death, myocardial infarction or stroke (OR 0.832, P = 0.258). The risk for target vessel revascularization (TVR) was significantly higher in the PCI group compared with the CABG group (OR 3.597, P < 0.001). The risk of major adverse cardiac and cerebrovascular events (MACCE) was significantly higher in the PCI group compared with the CABG group (OR 1.607, P < 0.001). A publication bias was observed regarding the outcome of death and also a considerable heterogeneity effect on the composite endpoint of death, myocardial infarction or stroke and MACCE. CONCLUSIONS CABG surgery remains the best option of treatment for patients with ULMCA disease, with less need of TVR and lower MACCE rates.

GuaragnaSCORE satisfactorily predicts outcomes in heart valve surgery in a Brazilian hospital

OBJECTIVE The aim of this study is to evaluate the applicability of GuaragnaSCORE for predicting mortality in patients undergoing heart valve surgery in the Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, PE, Brazil. METHODS Retrospective study involving 491 consecutive patients operated between May/2007 and December/2010. The registers contained all the information used to calculate the score. The outcome of interest was death. Association of model factors with death (univariate analysis and multivariate logistic regression analysis), association of risk score classes with death and accuracy of the model by the area under the ROC (receiver operating characteristic) curve were calculated. RESULTS The incidence of death was 15.1%. The nine variables of the score were predictive of perioperative death in both univariate and multivariate analysis. We observed that the higher the risk class of the patient (low, medium, high, very high, extremely high), the greater is the incidence of postoperative AF (0%; 7.2%; 25.5%; 38.5%; 52.4%), showing that the model seems to be a good predictor of risk of postoperative death, in a statistically significant association (P <0.001). The score presented a good accuracy, since the discrimination power of the model in this study according to the ROC curve was 78.1%. CONCLUSIONS The Brazilian score proved to be a simple and objective index, revealing a satisfactory predictor of perioperative mortality in patients undergoing heart valve surgery at our institution.

Complete versus partial preservation of mitral valve apparatus during mitral valve replacement: meta-analysis and meta-regression of 1535 patients

OBJECTIVES To determine if there is any real difference between complete preservation (CP) and partial preservation (PP) of the mitral valve apparatus during mitral valve replacement (MVR) in terms of hard outcomes. METHODS MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that compared outcomes [30-day mortality, postoperative low cardiac output syndrome (LCOS), 5-year mortality or left ventricle ejection fraction (LVEF) before and after surgery] between MVR-CP vs MVR-PP during MVR until July 2012. The principal summary measures were odds ratios (ORs) with 95% confidence interval (CI)--for categorical variables (30-day mortality, postoperative LCOS, 5-year mortality); difference means and standard error (SE)--for continuous variables (LVEF before and after surgery) and P values (that will be considered statistically significant when <0.05). The ORs were combined across studies using DerSimonian-Laird random effects weighted model. The same procedure was executed for continuous variables, taking into consideration the difference in means. RESULTS Eight studies (2 randomized and 6 non-randomized) were identified and included a total of 1535 patients (597 for MVR-CP and 938 for MVR-PP). There was no significant difference between MVR-CP or MVR-PP groups in the risk for 30-day mortality (OR 0.870; 95% CI 0.50-1.52; P = 0.63) or postoperative LCOS (OR 0.35; 95% CI 0.11-1.08 and P = 0.07) or 5-year mortality (OR 0.70; 95% CI 0.43-1.14; P = 0.15). Taking into consideration LVEF, neither MVR-CP nor MVR-CP demonstrated a statistically significant improvement in LVEF before and after surgery, and both strategies were not different from each other. No publication bias was observed. CONCLUSIONS We found evidence that argues against any superiority between both techniques of preservation (complete or partial) of mitral valve apparatus during MVR.