Omar Asdrúbal Vilca Mejía

Fatores de risco pré-operatórios para mediastinite após cirurgia cardíaca: análise de 2768 pacientes

BACKGROUND Longitudinal median sternotomy is the most common surgical approach for access to heart disease treatment. The deep wound infections in postoperative period of cardiovascular surgery are a serious complication requiring high costs during treatment. Different studies have indicated some risk factors for the development of mediastinitis and preoperative variables are currently under investigation. OBJECTIVE The aim of this study is to identify the preoperative risk factors for postoperative development of mediastinitis in patients undergoing coronary artery bypass grafting and valve replacement. METHODS This observational study represents a cohort of 2768 consecutive operated patients. The period considered for analysis was from May 2007 to May 2009 and there were no exclusion criteria. Analysis was performed by univariate and multivariate logistic regression model of 38 preoperative variables. RESULTS Thirty-five (1.3%) patients developed mediastinitis and 19 (0.7%) associated with osteomyelitis. The patient age average was 59.9 ± 13.5 years and the EuroSCORE of 4.5 ± 3.6. Hospital mortality was 42.8%. The multivariate analysis identified three variables as independent predictors of postoperative mediastinitis: intra-aortic balloon pump (OR 5.41, 95% CI [1.83 -16.01], P = 0.002), hemodialysis (OR 4.87, 95% CI [1.41 to 16.86], P = 0.012) and extracardiac vascular intervention (OR 4.39, 95% CI [1.64 to 11.76], P = 0.003). CONCLUSION This study showed that necessity of preoperative hemodynamic support with intra-aortic balloon, hemodialysis, and extracardiac vascular intervention were risk factors for development of mediastinitis after cardiac surgery.INTRODUCAO: A esternotomia mediana longitudinal e a via de acesso mais utilizada no tratamento das doencas cardiacas. As infeccoes profundas da ferida operatoria no pos-operatorio das cirurgias cardiovasculares sao uma complicacao seria, com alto custo durante o tratamento. Diferentes estudos tem encontrado fatores de risco para o desenvolvimento de mediastinite e as variaveis pre-operatorias tem tido especial destaque. OBJETIVO: O objetivo deste estudo e identificar fatores de risco pre-operatorios para o desenvolvimento de mediastinite em pacientes submetidos a revascularizacao do miocardio e a substituicao valvar. METODOS: Este estudo observacional representa uma coorte de 2768 pacientes operados consecutivamente. O periodo considerado para analise foi de maio de 2007 a maio de 2009 e nao houve criterios de exclusao. Foi realizada analise univariada e multivariada pelo modelo de regressao logistica das 38 variaveis pre-operatorias eleitas. RESULTADOS: Nesta serie, 35 (1,3%) pacientes evoluiram com mediastinite e 19 (0,7%) com osteomielite associada. A idade media dos pacientes foi de 59,9 ± 13,5 anos e o EuroSCORE de 4,5 ± 3,6. A mortalidade hospitalar foi de 42,8%. Na analise multivariada, foram identificadas tres variaveis como preditoras independentes de mediastinite: balao intra-aortico (OR 5,41, 95% IC [1,83 -16,01], P=0,002), hemodialise (OR 4,87, 95% IC [1,41 - 16,86], P=0,012) e intervencao vascular extracardiaca (OR 4,39, 95% IC [1,64 - 11,76], P=0,003). CONCLUSAO: O presente estudo demonstrou que necessidade do suporte hemodinâmico pre-operatorio com balao intra-aortico, hemodialise e intervencao vascular extracardiaca sao fatores de risco para o desenvolvimento de mediastinite apos cirurgia cardiaca.

Os escores 2000 Bernstein-Parsonnet e EuroSCORE são similares na predição da mortalidade no Instituto do Coração-USP

OBJECTIVE: To evaluate the performance of 2000 Bernstein-Parsonnet (2000BP) and additive EuroSCORE (ES) for predicting surgical mortality at the Heart Institute, University of Sao Paulo. METHODS: A prospective observational design. Seven hundred and seventy four patients were operated for coronary artery bypass graft, valve or combined procedure between May and October, 2007, were analyzed. The mortality was estimated with the 2000BP and ES. The correlation between expected mortality and observed mortality was validated through calibration and discrimination test. RESULTS: The patients were stratified into five groups for the 2000BP and three for the ES. The Hosmer-Lemeshow test for 2000BP (P = 0.70) and for ES (P = 0.39) indicate a good calibration. The ROC curve for the 2000BP = 0.84 and for the ES = 0.81 confirms that the models are good predictors (P<0.001). CONCLUSION: Both models are similar and adequate in predicting surgical mortality at the InCor-USP.

Validation of the 2000 Bernstein-Parsonnet and EuroSCORE at the Heart Institute - USP

OBJECTIVE To validate the 2000 Bernstein Parsonnet (2000BP) and additive EuroSCORE (ES) to predict mortality in patients who underwent coronary bypass surgery and/or heart valve surgery at the Heart Institute, University of São Paulo (InCor/HC-FMUSP). METHODS A prospective observational design. We analyzed 3000 consecutive patients who underwent coronary bypass surgery and/or heart valve surgery, between May 2007 and July 2009 at the InCor/HC-FMUSP. Mortality was calculated with the 2000BP and ES models. The correlation between estimated mortality and observed mortality was validated by calibration and discrimination tests. RESULTS There were significant differences in the prevalence of risk factors between the study population, 2000BP and ES. Patients were stratified into five groups for 2000BP and three for the ES. In the validation of models, the ES showed good calibration (P = 0.596), however, the 2000BP (P = 0.047) proved inadequate. In discrimination, the area under the ROC curve proved to be good for models, ES (0.79) and 2000BP (0.80). CONCLUSION In the validation, 2000BP proved questionable and ES appropriate to predict mortality in patients who underwent coronary bypass surgery and/or heart valve surgery at the InCor/HC-FMUSP.

Previous percutaneous coronary intervention as risk factor for coronary artery bypass grafting

BACKGROUND Percutaneous coronary intervention (PCI) has increased as the initial revascularization strategy in chronic coronary artery disease. Consequently, more patients undergoing coronary artery bypass grafting (CABG) have history of coronary stent. OBJECTIVE Evaluate the impact of previous PCI on in-hospital mortality after CABG in patients with multivessel coronary artery disease. METHODS Between May/2007 and June/2009, 1099 consecutive patients underwent CABG on cardiopulmonary bypass. Patients with no PCI (n=938, 85.3%) were compared with patients with previous PCI (n=161, 14.6%). Logistic regression models and propensity score matching analysis were used to assess the risk-adjusted impact of previous PCI on in-hospital mortality. RESULTS Both groups were similar, except for the fact that patients with previous PCI were more likely to have unstable angina (16.1% x 9.9%, P=0.019). In-hospital mortality after CABG was higher in patients with previous PCI (9.3% x 5.1%, P=0.034) and it was comparable with EuroSCORE and 2000 Bernstein-Parsonnet risk score. Using multivariate logistic regression analysis, previous PCI emerged as an independent predictor of postoperative in-hospital mortality (odds ratio 1.94, 95% CI 1.02-3.68, P=0.044) as strong as diabetes (odds ratio 1.86, 95% CI 1.07-3.24, P=0.028). After computed propensity score matching based on preoperative risk factors, in-hospital mortality remained higher among patients with previous PCI (odds ratio 3.46, 95% CI 1.10-10.93, P=0.034). CONCLUSIONS Previous PCI in patients with multivessel coronary artery disease is an independent risk factor for in-hospital mortality after CABG.This fact must be considered when PCI is indicated as initial alternative in patients with more severe coronary artery disease.

EuroSCORE II and the importance of a local model, InsCor and the future SP-SCORE

Introduction The most widely used model for predicting mortality in cardiac surgery was recently remodeled, but the doubts regarding its methodology and development have been reported. Objective The aim of this study was to assess the performance of the EuroSCORE II to predict mortality in patients undergoing coronary artery bypass grafts or valve surgery at our institution. Methods One thousand consecutive patients operated on coronary artery bypass grafts or valve surgery, between October 2008 and July 2009, were analyzed. The outcome of interest was in-hospital mortality. Calibration was performed by correlation between observed and expected mortality by Hosmer Lemeshow. Discrimination was calculated by the area under the ROC curve. The performance of the EuroSCORE II was compared with the EuroSCORE and InsCor (local model). Results In calibration, the Hosmer Lemeshow test was inappropriate for the EuroSCORE II (P=0.0003) and good for the EuroSCORE (P=0.593) and InsCor (P=0.184). However, the discrimination, the area under the ROC curve for EuroSCORE II was 0.81 [95% CI (0.76 to 0.85), P<0.001], for the EuroSCORE was 0.81 [95% CI (0.77 to 0.86), P<0.001] and for InsCor was 0.79 [95% CI (0.74-0.83), P<0.001] showing up properly for all. Conclusion The EuroSCORE II became more complex and resemblance to the international literature poorly calibrated to predict mortality in patients undergoing coronary artery bypass grafts or valve surgery at our institution. These data emphasize the importance of the local model.

[Evolution of cardiovascular surgery at the Instituto do Coração: analysis of 71,305 surgeries].

BACKGROUND: Cardiovascular surgery has been undergoing transformations due to the advancement of percutaneous techniques, clinical treatment and primary prevention. OBJECTIVE: Evaluation of incidence and mortality of heart surgeries performed at the Instituto do Coracao (InCor-HCFMUSP). METHODS: Using database from the Instituto do Coracao, analysis was carried out on cardiovascular surgeries performed between 1984 and 2007, taking into consideration trends of main procedures and of mortality rates. RESULTS: In 24 years, 71,305 heart surgeries were performed, with an annual average of 2971 procedures. The number of coronary artery bypass graft surgeries, which in the 1980s had an average of 856/year, is currently around 1.106/year. Heart valve procedures increased from 400 to 597 surgeries per year, growing 36.7%, when compared to the 1990s. Repair of congenital heart disease also had a significant increase of 50.8% in relation to the last decade. Global mortality average rate, which at baseline was 7.5%, is currently at 7.0% and 4.9% among elective procedures. In coronary artery bypass graft surgery, current average mortality rate is 4.8% and 8.5% in valve surgery. Repair of congenital heart disease accounts for 5.3%. CONCLUSION: Cardiovascular surgery continues increasing. The coronary artery bypass graft is still the most commonly performed surgery. However, profile of procedures has been undergoing changes with the largest increase of approach to cardiac valves and congenital heart disease. Mortality rates are higher when compared to international rates, reflecting the high complexity presented in tertiary service of national reference.BACKGROUND Cardiovascular surgery has been undergoing transformations due to the advancement of percutaneous techniques, clinical treatment and primary prevention. OBJECTIVE Evaluation of incidence and mortality of heart surgeries performed at the Instituto do Coração (InCor-HCFMUSP). METHODS Using database from the Instituto do Coração, analysis was carried out on cardiovascular surgeries performed between 1984 and 2007, taking into consideration trends of main procedures and of mortality rates. RESULTS In 24 years, 71,305 heart surgeries were performed, with an annual average of 2971 procedures. The number of coronary artery bypass graft surgeries, which in the 1980s had an average of 856/year, is currently around 1.106/year. Heart valve procedures increased from 400 to 597 surgeries per year, growing 36.7%, when compared to the 1990s. Repair of congenital heart disease also had a significant increase of 50.8% in relation to the last decade. Global mortality average rate, which at baseline was 7.5%, is currently at 7.0% and 4.9% among elective procedures. In coronary artery bypass graft surgery, current average mortality rate is 4.8% and 8.5% in valve surgery. Repair of congenital heart disease accounts for 5.3%. CONCLUSION Cardiovascular surgery continues increasing. The coronary artery bypass graft is still the most commonly performed surgery. However, profile of procedures has been undergoing changes with the largest increase of approach to cardiac valves and congenital heart disease. Mortality rates are higher when compared to international rates, reflecting the high complexity presented in tertiary service of national reference.

Analysis of aortic root surgery with composite mechanical aortic valve conduit and valve-sparing reconstruction.

OBJECTIVE Comparative analysis of early and late results of aortic root reconstruction with aortic valve sparing operations and the composite mechanical valve conduit replacement. METHODS From November 2002 to September 2009, 164 consecutive patients with mean age 54 ± 15 years, 115 male, underwent the aortic root reconstruction (125 mechanical valve conduit replacements and 39 valve sparing operations). Sixteen percent of patients had Marfan syndrome and 4.3% had bicuspid aortic valve. One hundred and forty-four patients (88%) were followed for a mean period of 41.1 ± 20.8 months. RESULTS The hospital mortality was 4.9%, 5.6% in operations with valved conduits and 2.6% in the valve sparing procedures (P <0.05). There was no difference neither in survival (95% CI = 86% - 96%, P= 0.1) nor in reoperation-free survival (95% CI = 85% - 90%, P = 0.29). The survival free of complications such as bleeding, thromboembolism and endocarditis were favorable to the valve sparing operations, respectively (95% CI = 70% - 95%, P = 0.001), (95% CI = 82% - 95% P = 0.03) and (95% CI = 81% - 95%, P = 0.03). Multivariate analysis showed that creatinine greater than 1.4 mg/dl, Cabrol operation and renal dialysis were predictors of mortality, respectively, with occurrence chance of 6 (95% CI = 1.8 - 19.5, P = 0.003), 12 (95% CI = 3 - 49.7, P = 0.0004) and 16 (95% CI = 3.6 - 71.3, P = 0.0002). CONCLUSIONS The aortic root reconstruction has a low early and late mortality, high survival free of complications and low need for reoperation. During the late follow-up, valve sparing aortic root reconstructions presented fewer incidences of bleeding, thromboembolic events and endocarditis.

Evolução da cirurgia cardiovascular no Instituto do Coração: análise de 71.305 operações

BACKGROUND: Cardiovascular surgery has been undergoing transformations due to the advancement of percutaneous techniques, clinical treatment and primary prevention. OBJECTIVE: Evaluation of incidence and mortality of heart surgeries performed at the Instituto do Coracao (InCor-HCFMUSP). METHODS: Using database from the Instituto do Coracao, analysis was carried out on cardiovascular surgeries performed between 1984 and 2007, taking into consideration trends of main procedures and of mortality rates. RESULTS: In 24 years, 71,305 heart surgeries were performed, with an annual average of 2971 procedures. The number of coronary artery bypass graft surgeries, which in the 1980s had an average of 856/year, is currently around 1.106/year. Heart valve procedures increased from 400 to 597 surgeries per year, growing 36.7%, when compared to the 1990s. Repair of congenital heart disease also had a significant increase of 50.8% in relation to the last decade. Global mortality average rate, which at baseline was 7.5%, is currently at 7.0% and 4.9% among elective procedures. In coronary artery bypass graft surgery, current average mortality rate is 4.8% and 8.5% in valve surgery. Repair of congenital heart disease accounts for 5.3%. CONCLUSION: Cardiovascular surgery continues increasing. The coronary artery bypass graft is still the most commonly performed surgery. However, profile of procedures has been undergoing changes with the largest increase of approach to cardiac valves and congenital heart disease. Mortality rates are higher when compared to international rates, reflecting the high complexity presented in tertiary service of national reference.BACKGROUND Cardiovascular surgery has been undergoing transformations due to the advancement of percutaneous techniques, clinical treatment and primary prevention. OBJECTIVE Evaluation of incidence and mortality of heart surgeries performed at the Instituto do Coração (InCor-HCFMUSP). METHODS Using database from the Instituto do Coração, analysis was carried out on cardiovascular surgeries performed between 1984 and 2007, taking into consideration trends of main procedures and of mortality rates. RESULTS In 24 years, 71,305 heart surgeries were performed, with an annual average of 2971 procedures. The number of coronary artery bypass graft surgeries, which in the 1980s had an average of 856/year, is currently around 1.106/year. Heart valve procedures increased from 400 to 597 surgeries per year, growing 36.7%, when compared to the 1990s. Repair of congenital heart disease also had a significant increase of 50.8% in relation to the last decade. Global mortality average rate, which at baseline was 7.5%, is currently at 7.0% and 4.9% among elective procedures. In coronary artery bypass graft surgery, current average mortality rate is 4.8% and 8.5% in valve surgery. Repair of congenital heart disease accounts for 5.3%. CONCLUSION Cardiovascular surgery continues increasing. The coronary artery bypass graft is still the most commonly performed surgery. However, profile of procedures has been undergoing changes with the largest increase of approach to cardiac valves and congenital heart disease. Mortality rates are higher when compared to international rates, reflecting the high complexity presented in tertiary service of national reference.

Cirurgia de revascularização miocárdica na fase aguda do infarto: análise dos fatores preditores de mortalidade intra-hospitalar

OBJECTIVE Coronary artery bypass grafting (CABG) during the acute phase of infarction (AMI) is associated with increased operative risk. The aim of this study was to determine predictors of in-hospital mortality in patients undergoing CABG in AMI. METHODS During three years, all patients undergoing CABG in AMI were retrospectively analyzed of the institutional database. Sixty variables per patient were evaluated: 49 preoperative variables from the 2000 Bernstein-Parsonnet and EuroSCORE models, 4 preoperative variables not considered in these models (time between AMI and CABG, maximum CKMB, Troponin maximum and ST-segment elevation) and 7 intraoperative variables [(cardiopulmonary bypass (CPB), CPB time, type of cardioplegia, endarterectomy, number of grafts, use of internal thoracic artery and complete revascularization]. Univariate and multivariate analysis for the outcome of in hospital mortality were performed. RESULTS The mean time between AMI and CABG was 3.8 ± 3 days. The overall mortality was 19%. In the multivariate analysis: age > 65 years OR [16.5 (CI 1.8 to 152), P= 0.013]; CPB > 108 minutes [OR 40 (CI 2.7 to 578), P= 0.007], creatinine> 2 mg/dl [OR 35.5 (CI 1.7 to 740), P= 0.021] and systolic pulmonary pressure > 60 mmHg [OR 31 (CI 1.6 to 591), P= 0.022] were predictors of in-hospital mortality. CONCLUSION Conventional preoperative variables such as age > 65 years, creatinine > 2 mg/dl and systolic pulmonary pressure > 60 mmHg were predictive of in-hospital mortality in patients underwent CABG in AMI.OBJETIVO: A cirurgia de revascularizacao miocardica (CRM) na fase aguda do infarto do miocardio (IAM) esta associada a aumento do risco operatorio. O objetivo do estudo foi determinar fatores preditores de mortalidade intra-hospitalar nos pacientes submetidos a CRM no IAM. METODOS: Durante tres anos, todos os pacientes submetidos a CRM no IAM foram analisados retrospectivamente, utilizando o banco de dados institucional. Sessenta variaveis por paciente foram avaliadas: 49 variaveis pre-operatorias provenientes dos escores 2000 Bernstein-Parsonnet e EuroSCORE; 4 variaveis pre-operatorias nao consideradas por esses escores (tempo entre o IAM e a CRM, valor maximo de CKMB, valor maximo de troponina e supradesnivelamento do segmento ST) e 7 variaveis intraoperatorias [uso de circulacao extracorporea (CEC), tempo de CEC, tipo de cardioplegia, endarterectomia, numero de enxertos, uso da arteria toracica interna e revascularizacao completa]. Analise univariada e multivariada para o desfecho mortalidade intra-hospitalar foram realizadas. RESULTADOS: O tempo medio entre o IAM e a CRM foi de 3,8 ± 3 dias. A mortalidade global foi 19%. Na analise multivariada: idade > 65 anos [OR 16,5 (IC 1,8-152), P=0,013]~˜ CEC >108 minutos [OR 40 (IC 2,7-578), P=0,007], creatinina > 2 mg/dl [OR 35,5 (IC 1,7-740), P=0,021] e pressao pulmonar sistolica > 60 mmHg [OR 31(IC 1,6-591), P=0,022] foram preditores de mortalidade intra-hospitalar. CONCLUSAO: Variaveis pre-operatorias classicas como idade > 65 anos, creatinina > 2 mg/dl e pressao pulmonar sistolica > 60 mmHg foram preditoras de mortalidade intra-hospitalar nos pacientes operados de revascularizacao miocardica na fase aguda do infarto.

Mortality impact of thoracic aortic disease in São Paulo state from 1998 to 2007

Background The epidemiological characteristics of thoracic aortic diseases (TAD) in the State of São Paulo and in Brazil, as well as their impact on the survival of these patients have yet to be analyzed. Objectives To evaluate the mortality impact of TAD and characterize it epidemiologically. Methods Retrospective analysis of data from the public health system for the TAD registry codes of hospitalizations, procedures and deaths, from the International Code of Diseases (ICD-10), registered at the Ministry of Health of São Paulo State from January 1998 to December 2007. Results They were 9.465 TAD deaths, 5.500 men (58.1%) and 3.965 women (41.9%); 6.721 dissections (71%) and 2.744. aneurysms. In 86.3% of cases the diagnosis was attained during autopsy. There were 6.109 hospitalizations, of which 67.9% were males; 21.2% of them died (69% men), with similar proportions of dissection and aneurysm between sexes, respectively 54% and 46%, but with different mortality. Men with TAD die more often than women (OR = 1.5). The age distribution for deaths and hospitalizations was similar with predominance in the 6th decade. They were 3.572 surgeries (58% of hospitalizations) with 20.3% mortality (patients kept in clinical treatment showed 22.6% mortality; p = 0.047). The number of hospitalizations, surgeries, deaths of in-patients and general deaths by TAD were progressively greater than the increase in population over time. Conclusions Specific actions for the early identification of these patients, as well as the viability of their care should be implemented to reduce the apparent progressive mortality from TAD seen among our population.