Abstract Woven coronary disease is a rare pathology with unknown etiology. Although initially considered benign, recent publications report myocardial ischemia caused by the affected vessel. Since most patients are asymptomatic, long-term follow-up to understand its behavior is mandatory. We report a multivessel woven disease case with documented ischemia that was submitted to coronary artery bypass grafting and remained asymptomatic for two years of follow-up.

Abstract Since the beginning of the coronavirus disease (COVID-19) pandemic, in March 2020, the number of people infected with COVID-19 worldwide increases continuously. Brazil is being followed with great concern in the international media, as it can, very soon, be the epicenter of the pandemic. Initial surgical data suggest that patients who acquire COVID-19 in the perioperative period are prone to a higher morbidity and mortality, however, evidence in cardiac surgery is still scarce. This article aims to aggregate to the growing evidence suggesting that perioperative infection with severe acute respiratory syndrome coronavirus 2 contributes to a more morbid evolution of the case.

Resumo Fundamento: O desafio atual da cirurgia cardiovascular (CCV) é melhorar resultados em pacientes cada vez mais graves. Nesse sentido, Programas de Melhoria Contínua da Qualidade (PMCQ) tem impactado os resultados. Objetivo: Avaliar a evolução da incidência e mortalidade das CCV, assim como os resultados atuais do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor). Métodos: Análise dos resultados das CCV realizadas no InCor entre jan-1984 e jun-2019. Foram observadas as tendências dos volumes cirúrgicos e da mortalidade em 5 períodos 1º (1984-1989), 2º (1990-1999), 3º (2000-2007), 4º (2008-2015) e 5º (2016-2019). O PMCQ foi estabelecido entre 2015-2016. A análise incluiu o total de cirurgias e a evolução dos procedimentos mais frequentes. Resultados: Foram realizadas 105.599 CCV, com uma média anual de 2.964 procedimentos e mortalidade de 5,63%. Comparando o 4º com o 5º período, o volume global médio de cirurgias foi de 2.943 para 3.139 (p = 0,368), cirurgias de revascularização miocárdica (CRM) de 638 para 597 (p = 0,214), valvas cardíacas de 372 para 465 (p = 0,201) e cardiopatias congênitas de 530 para 615 (p = 0,125). A mortalidade média global passou de 7,8% para 5% (p < 0,0001), nas cirurgias de revascularização miocárdica de 5,8% para 3,1% (p < 0,0001), nas cirurgias valvares de 14% para 7,5% (p < 0,0001) e nas cirurgias de cardiopatias congênitas de 12,1% para 9,6% (p < 0,0001). Conclusão: Embora haja uma tendência recente ao aumento dos volumes cirúrgicos, houve uma diminuição significativa da mortalidade cirúrgica nos grupos analisados. Após o estabelecimento do PMCQ, as taxas de mortalidade se aproximaram a dos padrões internacionais.

Abstract Background: The current challenge of cardiovascular surgery (CVS) is to improve the outcomes in increasingly severe patients. In this respect, continuous quality improvement (CQI) programs have had an impact on outcomes. Objective: To assess the evolution of the incidence and mortality due to CVS, as well as the current outcomes of the Hospital das Clínicas Heart Institute of the University of São Paulo Medical School (InCor-HCFMUSP). Methods: An outcome analysis of CVSs performed at the InCor, between January 1984 and June 2019. We observed the surgical volume and mortality rates in 5 time periods: 1st (1984-1989), 2nd (1990-1999), 3rd (2000-2007), 4th (2008-2015) and 5th (2016-2019). The CQI program was implemented between 2015 and 2016. The analysis included the total number of surgeries and the evolution of the most frequent procedures. Results: A total of 105,599 CCVs were performed, with an annual mean of 2,964 procedures and mortality of 5,63%. When comparing the 4th and the 5th periods, the average global volume of surgeries was increased from 2,943 to 3,139 (p = 0.368), bypass graft (CABG), from 638 to 597 (p = 0.214), heart valve surgery, from 372 to 465 (p = 0.201), and congenital heart disease surgery, from 530 to 615 (p = 0.125). The average global mortality went from 7.8% to 5% (p < 0.0001); in CABG surgery, from 5.8% to 3.1% (p < 0.0001); in heart valve surgery, from 14% to 7.5% (p < 0.0001) and in congenital heart disease surgery, from 12.1% to 9.6% (p < 0.0001). Conclusion: In spite of a recent trend towards increased surgical volume, there was a significant decrease in operative mortality in the groups studied. After the implementation of the CQI program, the mortality rates were closer to international standards.

Abstract Currently there is a progressive increase in the prevalence of diabetes in a referred for cardiovascular surgery. Benefits of glycemic management (< 180 mg/dL) in diabetic patients compared to patients without diabetes in perioperative cardiac surgery. The purpose of this study is to present recommendations based on international evidence and adapted to our clinical practice for the perioperative management of hyperglycemia in adult patients with and without diabetes undergoing cardiovascular surgery. This update is based on the latest current literature derived from articles and guidelines regarding perioperative management of diabetic patients to cardiovascular surgery.

Abstract Introduction: Advances in modern medicine have led to people living longer and healthier lives. Frailty is an emerging concept in medicine yet to be explored as a risk factor in cardiac surgery. When it comes to CABG surgery, randomized controlled clinical trials have primarily focused on low-risk (ROOBY, CORONARY), elevated-risk (GOPCABE) or high-risk patients (BBS), but not on frail patients. Therefore, we believe that off-pump CABG could be an important technique in patients with limited functional capacity to respond to surgical stress. In this study, the authors introduce the new national, multicenter, randomized, controlled trial "FRAGILE", to be developed in the main cardiac surgery centers of Brazil, to clarify the potential benefit of off-pump CABG in frail patients. Methods: FRAGILE is a two-arm, parallel-group, multicentre, individually randomized (1:1) controlled trial which will enroll 630 patients with blinded outcome assessment (at 30 days, 6 months, 1 year, 2 years and 3 years), which aims to compare adverse cardiac and cerebrovascular events after off-pump versus on-pump CABG in pre-frail and frail patients. Primary outcomes will be all-cause mortality, acute myocardial infarction, cardiac arrest with successful resuscitation, low cardiac output syndrome/cardiogenic shock, stroke, and coronary reintervention. Secondary outcomes will be major adverse cardiac and cerebrovascular events, operative time, mechanical ventilation time, hyperdynamic shock, new onset of atrial fibrillation, renal replacement therapy, reoperation for bleeding, pneumonia, length of stay in intensive care unit, length of stay in hospital, number of units of blood transfused, graft patency, rate of complete revascularization, neurobehavioral outcomes after cardiac surgery, quality of life after cardiac surgery and costs. Discussion: FRAGILE trial will determine whether off-pump CABG is superior to conventional on-pump CABG in the surgical treatment of pre-frail and frail patients. Trial registration: ClinicalTrials.gov, ID: NCT02338947. Registered on August 29th 2014; last updated on March 21st 2016.

ResumoFundamento:Escores de risco para cirurgia cardíaca não podem continuar sendo neglicenciados.Objetivo:Avaliar o desempenho do Age, Creatinine and Ejection Fraction Score (ACEF Score) na predição de mortalidade dos pacientes submetidos à cirurgia de revascularização miocárdica e/ou valvar eletiva, e compará-lo a outros escores.Métodos:Estudo de coorte prospectivo no banco de um centro terciário brasileiro. Foram avaliados 2.565 pacientes operados de maneira eletiva entre maio de 2007 e julho de 2009. Para uma análise mais detalhada, o desempenho do ACEF Score foi comparado ao do InsCor e ao do EuroSCORE por meio de testes de correlação, calibração e discriminação.Resultados:Os pacientes foram estratificados em leve, moderado e grave para todos os modelos. A calibração foi inadequada para o ACEF Score (p = 0,046) e adequada para o InsCor (p = 0,460) e o EuroSCORE (p = 0,750). Na discriminação, a área abaixo da curva ROC apresentou-se questionável para o ACEF Score (0,625) e apropriada para o InsCor (0,744) e o EuroSCORE (0,763).Conclusão:Embora simples e prático, o ACEF Score, ao contrário do InsCor e do EuroSCORE, não se mostrou acurado para predizer mortalidade nos pacientes submetidos à cirurgia de revascularização miocárdica e/ou valvar eletiva em centro terciário brasileiro. (Arq Bras Cardiol. 2015; [online].ahead print, PP.0-0)

AbstractBackground:Risk scores for cardiac surgery cannot continue to be neglected.Objective:To assess the performance of “Age, Creatinine and Ejection Fraction Score” (ACEF Score) to predict mortality in patients submitted to elective coronary artery bypass graft and/or heart valve surgery, and to compare it to other scores.Methods:A prospective cohort study was carried out with the database of a Brazilian tertiary care center. A total of 2,565 patients submitted to elective surgeries between May 2007 and July 2009 were assessed. For a more detailed analysis, the ACEF Score performance was compared to the InsCor’s and EuroSCORE’s performance through correlation, calibration and discrimination tests.Results:Patients were stratified into mild, moderate and severe for all models. Calibration was inadequate for ACEF Score (p = 0.046) and adequate for InsCor (p = 0.460) and EuroSCORE (p = 0.750). As for discrimination, the area under the ROC curve was questionable for the ACEF Score (0.625) and adequate for InsCor (0.744) and EuroSCORE (0.763).Conclusion:Although simple to use and practical, the ACEF Score, unlike InsCor and EuroSCORE, was not accurate for predicting mortality in patients submitted to elective coronary artery bypass graft and/or heart valve surgery in a Brazilian tertiary care center. (Arq Bras Cardiol. 2015; [online].ahead print, PP.0-0)

Introdução: O modelo mais utilizado para predição de mortalidade em cirurgia cardíaca foi recentemente remodelado, mas dúvidas referentes à sua metodologia e desenvolvimento têm sido relatadas. Objetivo: O objetivo deste estudo foi avaliar o desempenho do EuroSCORE II na predição de mortalidade em pacientes submetidos a cirurgia de coronária e/ou valva na instituição. Métodos: Mil pacientes, operados consecutivamente de coronária e/ou valva, entre outubro de 2008 e julho de 2009, foram analisados. O desfecho de interesse foi mortalidade intra-hospitalar. A calibração foi realizada pela correlação entre mortalidade esperada e observada por meio do teste de Hosmer Lemeshow. A discriminação foi calculada pela área abaixo da curva ROC. O desempenho do EuroSCORE II foi comparado com os modelos EuroSCORE e InsCor (modelo local). Resultados: Na calibração, o teste de Hosmer Lemeshow foi inadequado para o EuroSCORE II (P=0,0003) e bom para os modelos EuroSCORE (P=0,593) e InsCor (P=0,184). No entanto, na discriminação, a área abaixo da curva ROC para o EuroSCORE II foi de 0,81 [IC 95% (0,76-0,85), P<0,001]; para o EuroSCORE foi de 0,81 [IC 95% (0,77-0,86), P<0,001] e para o InsCor foi de 0,79 [IC 95% (0,74-0,83), P<0,001], revelando-se adequada para todos. Conclusão: O EuroSCORE II se tornou mais complexo e, à semelhança com a literatura internacional, mal calibrado para predizer mortalidade nos pacientes operados de coronária e/ou valva em nosso meio. Esses dados reforçam a importância do modelo local.

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.

A associação de interrupção do arco aórtico e doença coronária é rara. Entretanto, recentemente nos deparamos com um paciente nessa condição, que culminou com choque cardiogênico e edema agudo de pulmão. A finalidade desta comunicação breve é transmitirmos e discutirmos se a conduta adotada foi a mais indicada. Sua coronária direita estava 100% ocluída e havia obstrução de 95% em tronco de coronária esquerda, associada à interrupção de aorta descendente. Realizamos apenas enxerto de veia safena para ramo da coronária esquerda, sem circulação extracorpórea. O paciente apresentou boa evolução imediata. Destacamos a conduta inicial adotada, diante da gravidade do caso.

Acute pulmonary edema is a serious event. Its occurrence in association with interrupted aortic arch and coronary heart disease is rare. Recently, an old patient developed cardiogenic shock and acute pulmonary edema due to acute coronary insufficiency, associated with interrupted aortic arch. The coronary angiography revealed occlusion of the right coronary artery and 95% obstruction in the left main coronary artery, associated with interruption of the descending aorta. Coronary artery bypass graft was performed, without extracorporeal circulation, to the anterior descending coronary artery. We discuss the initial management, given the seriousness of the case.

OBJETIVO: Avaliação clínica e ecocardiográfica tardia da miectomia septal cirúrgica de pacientes com cardiomiopatia hipertrófica obstrutiva (CMHO). MÉTODOS: Foram analisados, retrospectivamente, 34 pacientes adultos (média de 55,7±15,2 anos) portadores de CMHO operados consecutivamente na instituição entre 1988 e 2008. Apenas quatro (11,8%) pacientes tinham conhecimento de história familiar para CMHO. Nove (26,5%) pacientes apresentavam insuficiência cardíaca (NYHA) classe funcional IV. Trinta (88,2%) pacientes apresentavam CMHO isolada e, em quatro (11,8%), a CMHO estava associada à insuficiência coronária. A técnica cirúrgica utilizada em todos os casos foi a miectomia septal transaórtica. RESULTADOS: Em 26 (76,5%) pacientes, a insuficiência mitral decorrente do movimento anterior sistólico regrediu após a miectomia. Em oito (23,5%) pacientes, houve necessidade de abordagem da valva mitral. Houve um (2,9%) óbito hospitalar. Dois (5,9%) pacientes necessitaram de marcapasso definitivo no pós-operatório. Em média, o gradiente de pico pré-operatório na via de saída do ventrículo esquerdo, que era de 84,9±29,0 mmHg, diminuiu para 27,8±12,9 mmHg no pós-operatório inicial e caiu para 19,2±11,2 mmHg no pós-operatório tardio (49,0±33,0 meses). A classe funcional (NYHA) que, em média, era de 3,1±0,8 passou para 1,4±0,5 no pós-operatório. Com seguimento médio de 9,6±8,4 anos, a sobrevida foi de 87,9% e a sobrevida livre de eventos cardiovasculares foi de 77,7%. CONCLUSÃO: A miectomia septal cirúrgica pode ser realizada de modo seguro, com excelente sobrevida, melhora dos sintomas e alívio da obstrução na via de saída do ventrículo esquerdo em pacientes com CMHO. Os benefícios iniciais se mantiveram a longo prazo.

OBJECTIVE: This study analyzed the clinical and echocardiographic late outcomes of surgical septal myectomy in patients with obstructive hypertrophic cardiomyopathy (OHCM). METHODS: We examined, retrospectively, 34 consecutive adult patients (age 55.7±15.2 years) with OHCM operated on in our institution from 1988 to 2008. Only four (11.8%) patients had family history of OHCM. Nine (26.5%) patients were in New York Heart Association (NYHA) funcional class IV. Thirty (88.2%) patients had solely OHCM, and four (11.8%) had OHCM associated with coronary insufficiency. The surgical technique used in all patients was septal myectomy performed through an aortotomy. RESULTS: In 26 (76.5%) patients the mitral insufficiency due to systolic anterior motion, decreased after the myectomy. Eight (23.5%) patients had mitral valve procedures. There was one hospitalar death (2.9%). Two (5.9%) patients required permanent pacemaker for complete heart block after the myectomy. The mean peak preoperative left ventricular outflow tract (LVOT) obstruction gradient was 84.9±29.0 mmHg, and decreased to 27.8±12.9 mmHg in the early postoperative and it was 19.2±11.2 mmHg in the late postoperative period (49.0±33.0 months). The NYHA functional class improved from 3.1±0.8 to 1.4±0.5 in the postoperative period. Survival free from death was 87.9% and survival free from cardiovascular events was 77.7% with mean follow-up 9.6±8.4 years. CONCLUSION: Surgical septal myectomy can be performed safely, with excellent survival, improvement from symptoms and relief for LVOT obstruction in patients with OHCM. The early benefits were remained at long term.

OBJETIVO: A fim de melhorar a metodologia de mensuração das aderências pericárdicas, avaliamos, durante um estudo de prevenção de aderências pericárdicas, a possibilidade da utilização de três de novas variáveis contínuas e numéricas. MÉTODOS: Para validar estas novas variáveis numéricas - tempo de dissecção (Δt), quantidade de dissecção cruenta (ShpD) e a área de colágeno na aderência (ACA) como instrumentos precisos na quantificação das aderências pericárdicas, foram analisados os dados de um estudo para prevenção de aderências que envolveu 24 porcos. Foram aplicados modelos de regressão e o teste de Spearman para avaliar a força e os tipos correlações entre os resultados do escore padrão de classificação de aderências (SS) e o Δt, entre o SS e o ShpD, e, também, entre o SS e a ACA. RESULTADOS: Foram evidenciadas correlações, estatisticamente significativas, entre o SS e o Δt, entre o SS e o ShpD, também como entre o SS e a ACA avaliadas através do teste de Spearman (r=0,897, r=0,932 , r=0,66; p<0,001, respectivamente). Identificou-se, através de regreção não-linear, uma relação exponencial do SS com o ShpD (R²=0,915) e com o Δt (R²= 0,917). CONCLUSÃO: Este estudo mostrou que o Δt e o ShpD são variáveis poderosas para avaliar os resultados dos métodos utilizados para prevenção das aderências pericárdicas.

PURPOSE: To improve the measurement system, during a research for the prevention of adhesions, we explored the feasibility of introducing three continuous numeric variables to quantify the intensity of pericardial adhesions. METHODS: To validate these three new numeric variables - time spent to dissect the adhesions (Δt), the amount of sharp dissection (ShpD) and the adhesion's collagen area (ACA) - as useful tools in measuring the severity of pericardial adhesions, data from a randomized study on adhesion prevention enrolling twenty-four swine, were analysed. A statistical Spearman's test and regressions models were applied to verify the correlation and the relationship between the results of a standard severity score (SS) and Δt, between SS and ShpD used in adhesiolysis and, also, between SS and ACA. RESULTS: There was a statistically significant correlation between SS and Δt, between SS and ShpD, as well as between SS and ACA, all measured by the Spearman's test (r=0.897, r=0.932, r=0.66; p<0.01, respectively). Through a non-linear regression, an exponential relation of SS with ShpD (R²=0.915) and SS with Δt (R²= 0.917) was found. CONCLUSION: The time spent to dissect the adhesions (Δt) and the amount of sharp dissection (ShpD) are new powerful measurement tools in evaluating outcomes of the methods used to prevent pericardial adhesions.