Ricardo de Carvalho Lima

Pulmonary Valve Replacement After Operative Repair of Tetralogy of Fallot: Meta-Analysis and Meta-Regression of 3,118 Patients From 48 Studies

Because the real benefit of pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot who develop pulmonary insufficiency remains unclear, it is necessary to analyze the evidence published around the world. We performed a systematic review of studies that reported data about the effect of PVR in patients with repaired tetralogy of Fallot that developed pulmonary insufficiency, until December 2012. The variables chosen to represent the benefit were both right ventricular (RV) and left ventricular measures, QRS duration, and functional class. The principal summary measures were difference in means with 95% confidence interval and p values (considered statistically significant when p < 0.05). The differences in means were combined across studies with the weighted DerSimonian-Laird random effects model. Meta-analysis, sensitivity analysis, and meta-regression were completed with the software Comprehensive Meta-Analysis (version 2, Biostat, Inc., Englewood, New Jersey). Forty-eight studies involving 3,118 patients met the eligibility criteria. The pooled 30-day mortality was 0.87% (47 studies; 27 of 3,100 patients); the pooled 5-year mortality was 2.2% (24 studies; 49 of 2,231 patients); the pooled 5-year re-PVR was 4.9% (15 studies; 88 of 1,798 patients). The results of this meta-analysis demonstrate that after PVR: 1) the RV experiences improvement of its volumes and function; 2) the left ventricle experiences improvement of its function; 3) QRS duration decreases; 4) symptoms improve; 5) pre-operative RV geometry modulates the effect of PVR; and 6) there is important heterogeneity of the effects among the studies, and few publication biases. In conclusion, PVR seems to be a positive approach in the analyzed scenario.

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.

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.

Cirurgia de revascularização completa do miocárdio sem circulação extracorpórea: uma realidade

From January/95 to December/96 our surgical team (ICORP - Fortaleza - Ceara), has performed coronary artery surgery without cardiopulmonary bypass (CPB) as a routine. During this period, 385 operations were sequencially performed, 86 per cent of them (333) without CPB. The purpose of this study is to evaluate the results of these 333 patients regarding hospitalization time, age, gender, number of grafts, functional status and morbimortality. All patients were submitted to previous coronary arteriography. All coronaies were by-passed, including the circumflex marginal artery. The age of these patients ranged from 35 to 86 years with a mean age of 61. The average time of hospitalization was 7 days; 625 grafts were placed varying from 1 to 4 with an average of 1.9 by patient. The incidence of procedure related with complications was 2 per cent (7 patients). Ten patients died in the early postoperative course. Considering the data obtained herein we conclude that this procedure can be used in the great majority of patients that undergo coronary artery surgery.

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.

EuroSCORE and mortality in coronary artery bypass graft surgery at Pernambuco Cardiologic Emergency Medical Services [Pronto Socorro Cardiológico de Pernambuco]

OBJECTIVE The aim of this study is to evaluate the applicability of EuroSCORE in patients undergoing coronary artery bypass graft (CABG) surgery at the Division of Cardiovascular Surgery of Pernambuco Cardiologic Emergency Medical Services--PROCAPE. METHODS A retrospective study involving 500 patients operated between May 2007 and April 2010. The registers contained all the information used to calculate the EuroSCORE. The outcome of interest was death. Univariate analysis and multivariate analysis by backward logistic regression were applied to assess the association between each variable in the EuroSCORE and deaths. The following parameters were calculated: sensitivity, specificity, positive predictive value, and negative predictive value. The power of concordance between the predicted mortality by the EuroSCORE and the observed mortality was measured using the Kappa coefficient. The accuracy of the model was evaluated by the ROC (receiver operating characteristic) curve. RESULTS The incidence of death was 13%. In multivariate analysis, nine variables remained independent predictors of death: chronic obstructive pulmonary disease, creatinine >2,3mg/dL, active endocarditis, preoperative critical state, unstable angina, ejection fraction 30% to 50%, acute myocardial infarction < 90 days, emergency surgery and additional surgery. The score had a sensitivity of 88.4%, specificity of 79.3%, positive predictive value of 40.7%, negative predictive value of 97.7% and 80.6% concordance. The accuracy measured by the area under the ROC curve was 0.892 (95% CI 0.862-0.922). CONCLUSIONS The EuroSCORE proved to be a simple and objective index, revealing a satisfactory discriminator of postoperative evolution in patients undergoing CABG surgery at our institution.

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.

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.