Marco Antônio Goldani

Risk score elaboration for mediastinitis after coronary artery bypass grafting

INTRODUCTION The mediastinitis is a serious postoperative complication of cardiac surgery, with an incidence of 0.4 to 5% and mortality between 14 and 47%. Several models were proposed to assess risk of mediastinitis after cardiac surgery. However, most of these models do not evaluate the postoperative morbidity. OBJECTIVE This study aims to develop a score risk model to predict the risk of mediastinitis for patients undergoing coronary artery bypass grafting. METHODS The study sample included data from 2,809 adult patients undergoing coronary artery bypass grafting between January 1996 and December 2007 at Hospital São Lucas -PUCRS. Logistic regression was used to examine the relationship between risk factors and the development of mediastinitis. Data from 1,889 patients were used to develop the model and its performance was evaluated in the remaining data (n=920). The definitive model was created with the data analysis of 2,809 patients. RESULTS The rate of mediastinitis was 3.3%, with mortality of 26.6%. In the multivariate analysis, five variables remained independent predictors of the outcome: chronic obstructive pulmonary disease, obesity, surgical reintervention, blood transfusion and stable angina class IV or unstable. The area under the ROC curve was 0.72 (95% CI, 0.67-0.78) and P = 0.61. CONCLUSION The risk score was constructed for use in daily practice to calculate the rate of mediastinitis after coronary artery bypass grafting. The score includes routinely collected variables and is simple to use.

Predictors of mediastinitis after cardiac surgery

OBJECTIVE: Mediastinitis is a serious complication of open-heart surgery, with an incidence that varies from 0.4% to 5%, mortality from 10% to 47% and a high morbidity rate. OBJECTIVE: To identify preoperative and trans-operative risk factors of mediastinitis after open-heart surgery in our hospital. METHOD: This was a prospective study of 1298 patients submitted to the open-heart surgery in Sao Lucas hospital in the period from March 1997 to May 2000. Nine potential risk factors associated with mediastinitis were studied (obesity, diabetes mellitus, chronic obstructive pulmonary disease -COPD-, internal mammary artery, cardiopulmonary bypass time, smoking, gender, ejection fraction and previous heart surgery) using univariate analysis, where necessary followed by multivariate logistic regression. RESULTS: Of the 1298 studied patients, 62.6% were men and 18.3 suffered from diabetes. Thirty-eight patients (2.9%) presented with mediastinitis postoperatively, and six (15.8%) of these died. Four variables identified as risk factors by univariate analysis (p<0.05) and were after analysed by logistic regression. Three variables were identified as independent predictors of mediastinitis: obesity (p=0.008), COPD (p=0.007) and diabetes mellitus (p= 0.009), even when gender and age were analysed. The internal mammary artery graft was observed as risk predictor only when associated to the obesity. CONCLUSION: In our hospital, mediastinitis occurs most frequently in patients suffering from obesity, diabetes, and/or COPD and in the obese patients in which internal mammary artery was used.OBJECTIVE: Mediastinitis is a serious complication of open-heart surgery, with an incidence that varies from 0.4% to 5%, mortality from 10% to 47% and a high morbidity rate. OBJECTIVE: To identify preoperative and trans-operative risk factors of mediastinitis after open-heart surgery in our hospital. METHOD: This was a prospective study of 1298 patients submitted to the open-heart surgery in Sao Lucas hospital in the period from March 1997 to May 2000. Nine potential risk factors associated with mediastinitis were studied (obesity, diabetes mellitus, chronic obstructive pulmonary disease -COPD-, internal mammary artery, cardiopulmonary bypass time, smoking, gender, ejection fraction and previous heart surgery) using univariate analysis, where necessary followed by multivariate logistic regression. RESULTS: Of the 1298 studied patients, 62.6% were men and 18.3 suffered from diabetes. Thirty-eight patients (2.9%) presented with mediastinitis postoperatively, and six (15.8%) of these died. Four variables identified as risk factors by univariate analysis (p<0.05) and were after analysed by logistic regression. Three variables were identified as independent predictors of mediastinitis: obesity (p=0.008), COPD (p=0.007) and diabetes mellitus (p= 0.009), even when gender and age were analysed. The internal mammary artery graft was observed as risk predictor only when associated to the obesity. CONCLUSION: In our hospital, mediastinitis occurs most frequently in patients suffering from obesity, diabetes, and/or COPD and in the obese patients in which internal mammary artery was used.

A score proposal to evaluate surgical risk in patients submitted to myocardial revascularization surgery

INTRODUCTION Scores to predict surgical risk in patients submitted to myocardial revascularization surgery are broadly used. OBJECTIVE To develop a score capable to predict mortality in patients submitted to myocardial revascularization surgery. METHODS From January 1996 to December 2007, data were collected from 2809 patients submitted to myocardial revascularization surgery at PUC-RS São Lucas Hospital. In 2/3 of the sample (n = 1875), the score was developed, after uni and mutivariated analyses. In the remaining 1/3 (n = 934) the score was validated. The final score was developed with the total sample, using the same variables (n = 2809). The accuracy of the model was tested using the area under the ROC curve. RESULTS The mean age was 61.3 ± 10.1 years and 34% were women. The risk factors identified as independent predictors of surgical mortality and used for score development (parentheses) were: age > 60 years (2), female (2), extracardiac vasculopathy (2), heart failure functional class III and IV (3), ejection fraction<45% (2), atrial fibrillation (2), chronic obstructive pulmonary disease (3), aortic stenosis (3), creatinine 1.5-2.4 (2), creatinine > 2.5 or dialysis (4), emergency/urgency surgery (16). The area obtained under the ROC curve was 0.86 (CI 0.81-0.9). CONCLUSION The score developed, using clinical variables easy to obtain (age, sex, extracardiac vasculopathy, functional class, ejection fraction, atrial fibrillation, chronic obstructive pulmonary disease, aortic stenosis, creatinine and emergency/urgency surgery) showed capability to predict mortality in patients submitted to myocardial revascularization surgery in our Hospital.

The use of inhibitors of angiotensin-converting enzyme and its relation to events in the postoperative period of CABG

BACKGROUND Angiotensin-converting enzyme (ACE) inhibitors reduce the chance of death, myocardial infarction (MI) and cerebrovascular accident (CVA) in patients with coronary disease. However there is no consensus as to its indication in patients undergoing coronary artery bypass grafting (CABG). OBJECTIVE To assess the relationship between preoperative use of ACE inhibitors and clinical outcomes after CABG. METHODS Retrospective cohort study. We included data from 3,139 consecutive patients undergoing isolated CABG in Brazilian tertiary care hospital between January 1996 and December 2009. Follow-up was until discharge or death. Clinical outcomes after surgery were analyzed between users and nonusers of ACE inhibitors preoperatively. RESULTS Fifty-two percent (n=1,635) of patients received ACE inhibitors preoperatively. The use of ACE inhibitors was an independent predictor of need for inotropic support (OR 1.24, 95% CI 1.01 to 1.47, P = 0.01), acute renal failure (OR 1.23, 95% CI 1.01 to 1.73, P = 0.04) and progression to atrial fibrillation (OR 1.32, 95% CI 1.02 to 1.7, P = 0.03) postoperatively. The mortality rate among patients receiving or not preoperative ACE inhibitors was similar (10.3% vs. 9.4%, P = 0.436), as well as the incidence of myocardial infarction and stroke (15.6% vs. 15.0%, P = 0.694 and 3.4% vs. 3.5%, P = 0.963, respectively). CONCLUSION The use of preoperative ACE inhibitors was associated with increased need for inotropic support and higher incidence of acute renal failure and postoperative atrial fibrillation, not associated with increased rates of myocardial infarction, stroke or death.

Proposta de escore de risco pré-operatório para pacientes candidatos à cirurgia cardíaca valvar

BACKGROUND To establish a risk score for heart surgery allows the assessment of preoperative risk, informing the patient and defining care during the intervention. OBJECTIVE To assess preoperative risk factors for death in cardiac valve surgery and construct a simple risk model (score) for in-hospital mortality of patients candidate to surgery at Hospital São Lucas of Pontifícia Universidade Católica do Rio Grande do Sul (HSL-PUCRS). METHODS The study sample included 1,086 adult patients that underwent cardiac valve surgery between January 1996 and December 2007 at HSL-PUCRS. Logistic regression was used to identify risk and in-hospital mortality factors. The model was developed in 699 patients and its performance was tested in the remaining data (n = 387). The final model was created using the total study sample (n = 1,086). RESULTS Global mortality was 11.8%: 8.8% of elective cases and 63.8% of emergency cases. At the multivariate analysis, 9 variables remained independent predictors for the outcome: advanced age, surgical priority, female sex, ejection fraction < 45%, concomitant myocardial revascularization (CABG), pulmonary hypertension, NYHA functional class III or IV, creatinine levels (1.5 to 2.49 mg/dl and > 2.5 mg/dl or undergoing dialysis). The area under the ROC curve was 0.83 (95% CI: 0.78-0.86). The risk model showed good capacity for observed/predicted mortality: the Hosmer-Lemeshow test was x(2) = 5.61; p = 0.691 and r = 0.98 (Pearsons coefficient). CONCLUSION The variables predictive of in-hospital mortality allowed the construction of a simplified risk score for daily practice, which classifies the patient as having low, moderate, high, very high and extremely high preoperative risk.FUNDAMENTO: Estabelecer escore de risco para cirurgias cardiacas permite avaliar risco pre-operatorio, informar o paciente e definir cuidados durante a intervencao. OBJETIVO: Pesquisar fatores de risco pre-operatorios para obito em cirurgia cardiaca valvar e construir um modelo de risco simples (escore) para mortalidade hospitalar para os pacientes candidatos a cirurgia no Hospital Sao Lucas da Pontificia Universidade Catolica do Rio Grande do Sul (HSL-PUCRS). METODOS: A amostra do estudo inclui 1.086 pacientes adultos que realizaram cirurgia cardiaca valvar entre Janeiro de 1996 a Dezembro de 2007 no HSL-PUCRS. Regressao logistica foi usada para identificar fatores de risco e mortalidade hospitalar. O modelo foi desenvolvido em 699 pacientes e seu desempenho foi testado nos dados restantes (n = 387). O modelo final foi criado com a analise da amostra total (n = 1.086). RESULTADOS: A mortalidade global foi 11,8%: 8,8% casos eletivos e 63,8% cirurgia de emergencia. Na analise multivariada, 9 variaveis permaneceram preditores independentes para o desfecho: idade avancada, prioridade cirurgica, sexo feminino, fracao de ejecao 2,5 mg/dl ou dialise). A area sob a curva ROC foi 0,83 (IC: 95%, 0,78 - 0,86). O modelo de risco mostrou boa habilidade para mortalidade observada/prevista: teste Hosmer-Lemeshow foi x2 = 5,61; p = 0,691 e r = 0,98 (coeficiente de Pearson). CONCLUSAO: As variaveis preditoras de mortalidade hospitalar permitiram construir um escore de risco simplificado para a pratica diaria, que classifica o paciente de baixo, medio, elevado, muito elevado e extremamente elevado risco pre-operatorio.

Atrioventricular block in the postoperative period of heart valve surgery: incidence, risk factors and hospital evolution

INTRODUCTION Disturbances of the cardiac conduction system are potential complications after cardiac valve surgery. OBJECTIVES This study was designed to investigate the association between perioperative factors and atrio-ventricular block, the need for temporary cardiac artificial pacing and, if necessary, permanent pacemaker implantation after cardiac valve surgery. METHODS Retrospective analysis of the Cardiac Surgery Database - Hospital São Lucas/PUCRS. The data are collected prospectively and analyzed retrospectively. RESULTS Between January 1996 and December 2008 were included 1102 valve surgical procedures: 718 aortic valves (65.2%), 407 (36.9%) mitral valve and 190 (17.2%) coronar artery bypass grafting combined with valve repair and 23 (2.1%) aortic and mitral combined surgery. 187 patients (17%) showed clinical and electrocardiographic pattern of atrio-ventricular block requiring artificial temporary pacing. Of these, 14 patients (7.5%) required permanent pacemaker implantation (1.27% of the total valve surgery patients). Multivariate analysis showed association of the incidence of atrio-ventricular block and temporary pacing with mitral valve surgery (OR 1,76; CI 95% 1.08-2.37; P = 0.002), implantation of bioprosthetic devices (OR 1.59; CI 95% 1.02-3.91; P = 0,039), age over 60 years (OR 1.99; CI 95% 1.352.85; P < 0.001), prior use of anti-arrhythmic drugs (OR 1.86; CI 95% 1.04-3.14; P = 0.026) and previous use of b-blocker (OR 1.76; CI 95% 1.25-2.54; P = 0.002). Remarkably the presence of atrio-ventricular block did not significantly show association with increased mortality, but significantly prolonged (P < 0.0001) hospital length-of-stay and, therefore, hospital costs. CONCLUSIONS Our study presents a group of predictive factors referring to a specific patient profile by which high risk of atrio-ventricular block and the need of temporary cardiac pacing after cardiac valve surgery it is determined.

Predictors of stroke in patients undergoing cardiac surgery

Objective To determine the risk factors related to the development of stroke in patients undergoing cardiac surgery. Methods A historical cohort study. We included 4626 patients aged > 18 years who underwent coronary artery bypass surgery, heart valve replacement surgery alone or heart valve surgery combined with coronary artery bypass grafting between January 1996 and December 2011. The relationship between risk predictors and stroke was assessed by logistic regression model with a significance level of 0.05. Results The incidence of stroke was 3% in the overall sample. After logistic regression, the following risk predictors for stroke were found: age 50-65 years (OR=2.11 - 95% CI 1.05-4.23 - P=0.036) and age >66 years (OR=3.22 - 95% CI 1.6-6.47 - P=0.001), urgent and emergency surgery (OR=2.03 - 95% CI 1.20-3.45 - P=0.008), aortic valve disease (OR=2.32 - 95% CI 1.18-4.56 - P=0.014), history of atrial fibrillation (OR=1.88 - 95% CI 1.05-3.34 - P=0.032), peripheral artery disease (OR=1.81 - 95% CI 1.13-2.92 - P=0.014), history of cerebrovascular disease (OR=3.42 - 95% CI 2.19-5.35 - P<0.001) and cardiopulmonary bypass time > 110 minutes (OR=1.71 - 95% CI 1.16-2.53 - P=0.007). Mortality was 31.9% in the stroke group and 8.5% in the control group (OR=5.06 - 95% CI 3.5-7.33 - P<0.001). Conclusion The study identified the following risk predictors for stroke after cardiac surgery: age, urgent and emergency surgery, aortic valve disease, history of atrial fibrillation, peripheral artery disease, history of cerebrovascular disease and cardiopulmonary bypass time > 110 minutes.

Proposed preoperative risk score for patients candidate to cardiac valve surgery

BACKGROUND To establish a risk score for heart surgery allows the assessment of preoperative risk, informing the patient and defining care during the intervention. OBJECTIVE To assess preoperative risk factors for death in cardiac valve surgery and construct a simple risk model (score) for in-hospital mortality of patients candidate to surgery at Hospital São Lucas of Pontifícia Universidade Católica do Rio Grande do Sul (HSL-PUCRS). METHODS The study sample included 1,086 adult patients that underwent cardiac valve surgery between January 1996 and December 2007 at HSL-PUCRS. Logistic regression was used to identify risk and in-hospital mortality factors. The model was developed in 699 patients and its performance was tested in the remaining data (n = 387). The final model was created using the total study sample (n = 1,086). RESULTS Global mortality was 11.8%: 8.8% of elective cases and 63.8% of emergency cases. At the multivariate analysis, 9 variables remained independent predictors for the outcome: advanced age, surgical priority, female sex, ejection fraction < 45%, concomitant myocardial revascularization (CABG), pulmonary hypertension, NYHA functional class III or IV, creatinine levels (1.5 to 2.49 mg/dl and > 2.5 mg/dl or undergoing dialysis). The area under the ROC curve was 0.83 (95% CI: 0.78-0.86). The risk model showed good capacity for observed/predicted mortality: the Hosmer-Lemeshow test was x(2) = 5.61; p = 0.691 and r = 0.98 (Pearsons coefficient). CONCLUSION The variables predictive of in-hospital mortality allowed the construction of a simplified risk score for daily practice, which classifies the patient as having low, moderate, high, very high and extremely high preoperative risk.FUNDAMENTO: Estabelecer escore de risco para cirurgias cardiacas permite avaliar risco pre-operatorio, informar o paciente e definir cuidados durante a intervencao. OBJETIVO: Pesquisar fatores de risco pre-operatorios para obito em cirurgia cardiaca valvar e construir um modelo de risco simples (escore) para mortalidade hospitalar para os pacientes candidatos a cirurgia no Hospital Sao Lucas da Pontificia Universidade Catolica do Rio Grande do Sul (HSL-PUCRS). METODOS: A amostra do estudo inclui 1.086 pacientes adultos que realizaram cirurgia cardiaca valvar entre Janeiro de 1996 a Dezembro de 2007 no HSL-PUCRS. Regressao logistica foi usada para identificar fatores de risco e mortalidade hospitalar. O modelo foi desenvolvido em 699 pacientes e seu desempenho foi testado nos dados restantes (n = 387). O modelo final foi criado com a analise da amostra total (n = 1.086). RESULTADOS: A mortalidade global foi 11,8%: 8,8% casos eletivos e 63,8% cirurgia de emergencia. Na analise multivariada, 9 variaveis permaneceram preditores independentes para o desfecho: idade avancada, prioridade cirurgica, sexo feminino, fracao de ejecao 2,5 mg/dl ou dialise). A area sob a curva ROC foi 0,83 (IC: 95%, 0,78 - 0,86). O modelo de risco mostrou boa habilidade para mortalidade observada/prevista: teste Hosmer-Lemeshow foi x2 = 5,61; p = 0,691 e r = 0,98 (coeficiente de Pearson). CONCLUSAO: As variaveis preditoras de mortalidade hospitalar permitiram construir um escore de risco simplificado para a pratica diaria, que classifica o paciente de baixo, medio, elevado, muito elevado e extremamente elevado risco pre-operatorio.

Alta dose de amiodarona em curto período reduz incidência de fibrilação atrial e flutter atrial no pós-operatório de cirurgia de revascularização miocárdica

OBJECTIVE To investigate whether oral amiodarone administered before surgery for a short period in high dose would reduce the incidence of postoperative atrial fibrillation or atrial flutter and reduces the length of hospital stay. METHODS In the double-blind, randomized study, 93 patients were given either oral amiodarone (46 patients) or placebo (47 patients). Therapy consisted of 600 mg of amiodarone three times a day, started at minimum 30 hours and at maximum 56 hours before surgery. RESULTS Postoperative atrial fibrillation or atrial flutter occurred in 8 of 46 patients in the amiodarone group (17.4%) and 19 of the 47 patients in the placebo group (40.4%) (p=0.027). The mean dose of amiodarone was 2.8 g. Patients in the amiodarone group were hospitalized for 8.9+/-3.1 days and patients in the placebo group were hospitalized for 11.4+/-8.7 days (p=0.07). The hospital length were significantly prolonged in patients who developed atrial arrhythmias after surgery, despite the treatment received.(p<0.001). CONCLUSION This new alternative way of using amiodarone in high dose and in a short-term period before surgery reduce the incidence of postoperative atrial fibrillation or atrial flutter in coronary artery bypass graft surgery.

Bloqueio atrioventricular no pós-operatório de cirurgia cardíaca valvar: incidence, risk factors and hospital evolution

INTRODUCTION Disturbances of the cardiac conduction system are potential complications after cardiac valve surgery. OBJECTIVES This study was designed to investigate the association between perioperative factors and atrio-ventricular block, the need for temporary cardiac artificial pacing and, if necessary, permanent pacemaker implantation after cardiac valve surgery. METHODS Retrospective analysis of the Cardiac Surgery Database - Hospital São Lucas/PUCRS. The data are collected prospectively and analyzed retrospectively. RESULTS Between January 1996 and December 2008 were included 1102 valve surgical procedures: 718 aortic valves (65.2%), 407 (36.9%) mitral valve and 190 (17.2%) coronar artery bypass grafting combined with valve repair and 23 (2.1%) aortic and mitral combined surgery. 187 patients (17%) showed clinical and electrocardiographic pattern of atrio-ventricular block requiring artificial temporary pacing. Of these, 14 patients (7.5%) required permanent pacemaker implantation (1.27% of the total valve surgery patients). Multivariate analysis showed association of the incidence of atrio-ventricular block and temporary pacing with mitral valve surgery (OR 1,76; CI 95% 1.08-2.37; P = 0.002), implantation of bioprosthetic devices (OR 1.59; CI 95% 1.02-3.91; P = 0,039), age over 60 years (OR 1.99; CI 95% 1.352.85; P < 0.001), prior use of anti-arrhythmic drugs (OR 1.86; CI 95% 1.04-3.14; P = 0.026) and previous use of b-blocker (OR 1.76; CI 95% 1.25-2.54; P = 0.002). Remarkably the presence of atrio-ventricular block did not significantly show association with increased mortality, but significantly prolonged (P < 0.0001) hospital length-of-stay and, therefore, hospital costs. CONCLUSIONS Our study presents a group of predictive factors referring to a specific patient profile by which high risk of atrio-ventricular block and the need of temporary cardiac pacing after cardiac valve surgery it is determined.