Abstract Objective: To test the German Aortic Valve (GAV) score at our university hospital in patients undergoing isolated aortic valve replacement (AVR). Methods: A total of 224 patients who underwent isolated conventional AVR between January 2015 and December 2018 were included. Patients with concomitant procedures and transcatheter aortic valve implantation were excluded. Patients’ data were collected and analyzed retrospectively. Patients’ risk scores were calculated according to criteria described by GAV score. Sensitivity, specificity, and accuracy (area under the ROC curve [AUC]) were also calculated. The calibration of the model was tested by the Hosmer-Lemeshow method. Results: The mortality rate was 8.04% (18 patients). The patients’ mean age was 58.2±19.3 years and 25% of them were female (56 patients). Mean GAV score was 1.73±5.86 (min: 0.0; max: 3.53). The GAV score showed excellent discriminative capacity (AUC 0.925, 95% confidence interval 0.882-0.956; P<0.001). The cutoff “1.8” turned out to be the best discriminatory point with the best combination of sensitivity (88.9%) and specificity (75.7%) to predict operative death. Hosmer-Lemeshow method revealed a P-value of 0.687, confirming a good calibration of the model. Conclusion: The GAV score applies to our population with high predictive accuracy.

Abstract Objective: To evaluate whether there is any difference on the results of patients treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in the setting of ischemic heart failure (HF). Methods: Databases (MEDLINE, Embase, Cochrane Controlled Trials Register [CENTRAL/CCTR], ClinicalTrials.gov, Scientific Electronic Library Online [SciELO], Literatura Latino-americana e do Caribe em Ciências da Saúde [LILACS], and Google Scholar) were searched for studies published until February 2019. Main outcomes of interest were mortality, myocardial infarction, repeat revascularization, and stroke. Results: The search yielded 5,775 studies for inclusion. Of these, 20 articles were analyzed, and their data were extracted. The total number of patients included was 54,173, and those underwent CABG (N=29,075) or PCI (N=25098). The hazard ratios (HRs) for mortality (HR 0.763; 95% confidence interval [CI] 0.678-0.859; P<0.001), myocardial infarction (HR 0.481; 95% CI 0.365-0.633; P<0.001), and repeat revascularization (HR 0.321; 95% CI 0.241-0.428; P<0.001) were lower in the CABG group than in the PCI group. The HR for stroke showed no statistically significant difference between the groups (random effect model: HR 0.879; 95% CI 0.625-1.237; P=0.459). Conclusion: This meta-analysis found that CABG surgery remains the best option for patients with ischemic HF, without increase in the risk of stroke.

Abstract Objectives: This study sought to evaluate the impact of prosthesis-patient mismatch (PPM) on the risk of early-term mortality after transcatheter aortic valve implantation (TAVI). Methods: Databases (Medical Literature Analysis and Retrieval System Online [MEDLINE], Excerpta Medica dataBASE [EMBASE], Cochrane Controlled Trials Register [CENTRAL/CCTR], ClinicalTrials.gov, Scientific Electronic Library Online [SciELO], Latin American and Caribbean Literature on Health Sciences [LILACS], and Google Scholar) were searched for studies published until February 2019. PPM after TAVI was defined as moderate if the indexed effective orifice area (iEOA) was between 0.85 cm2/m2 and 0.65 cm2/m2 and as severe if iEOA ≤ 0.65 cm2/m2. Results: The search yielded 1,092 studies for inclusion. Of these, 18 articles were analyzed, and their data extracted. The total number of patients included who underwent TAVI was 71,106. The incidence of PPM after TAVI was 36.3% (25,846 with PPM and 45,260 without PPM). One-year mortality was not increased in patients with any PPM (odds ratio [OR] 1.021, 95% confidence interval [CI] 0.979-1.065, P=0.338) neither in those with moderate PPM (OR 0.980, 95% CI 0.933-1.029, P=0.423). Severe PPM was separately associated with high risk (OR 1.109, 95% CI 1.041-1.181, P=0.001). Conclusion: The presence of severe PPM after TAVI increased early-term mortality. Although moderate PPM seemed harmless, the findings of this study cannot not rule out the possibility of it being detrimental, since there are other registries that did not address this issue yet.

Abstract Prosthesis-patient mismatch (PPM) after surgical aortic valve replacement (SAVR) is an issue that has been overlooked (not to say neglected). Cardiac surgeons must bear in mind that this is a real problem that we must tackle. The purpose of this paper is to be a wake-up call to the surgical community by giving a brief overview of what PPM is, its incidence and impact on the outcomes. We also discuss the increasing role played by imaging for predicting and assessing PPM after SAVR (with which surgeons must become more acquainted) and, finally, we present some options to avoid PPM after the surgical procedure.

Abstract Objective: This study sought to evaluate the impact of prosthesis-patient mismatch on the risk of perioperative and long-term mortality after mitral valve replacement. Methods: Databases were researched for studies published until December 2018. Main outcomes of interest were perioperative and 10-year mortality and echocardiographic parameters. Results: The research yielded 2,985 studies for inclusion. Of these, 16 articles were analyzed, and their data extracted. The total number of patients included was 10,239, who underwent mitral valve replacement. The incidence of prosthesis-patient mismatch after mitral valve replacement was 53.7% (5,499 with prosthesis-patient mismatch and 4,740 without prosthesis-patient mismatch). Perioperative (OR 1.519; 95%CI 1.194-1.931, P<0.001) and 10-year (OR 1.515; 95%CI 1.280-1.795, P<0.001) mortality was increased in patients with prosthesis-patient mismatch. Patients with prosthesis-patient mismatch after mitral valve replacement had higher systolic pulmonary artery pressure and transprosthethic gradient and lower indexed effective orifice area and left ventricle ejection fraction. Conclusion: Prosthesis-patient mismatch increases perioperative and long-term mortality. Prosthesis-patient mismatch is also associated with pulmonary hypertension and depressed left ventricle systolic function. The findings of this study support the implementation of surgical strategies to prevent prosthesis-patient mismatch in order to decrease mortality rates.

Abstract The best treatment for patients with ischemic heart failure (HF) is still on debate. There is growing evidence that coronary artery bypass graft (CABG) benefits these patients. The current recommendations for revascularization in this context are that CABG is reasonable when it comes to decreasing morbidity and mortality rates for patients with severe left ventricular dysfunction (ejection fraction <35%), and significant coronary artery disease (CAD) and should be considered in patients with operable coronary anatomy, regardless whether or not there is a viable myocardium (class IIb). Percutaneous coronary intervention (PCI) does not have enough data to allow the panels to reach a conclusion. The Korean Acute Heart Failure registry (KorAHF) had its data released recently, showing that patients with acute HF who underwent CABG had lower death rates, more complete revascularization and less adverse outcomes compared with patients treated with PCI. Recent ESC/EACTS guidelines on myocardial revascularization clearly recommended CABG as the first choice of revascularization strategy in patients with multivessel disease and acceptable surgical risk to improve prognosis in this scenario of left ventricular dysfunction. However, a high peri-procedural risk must be compared with the benefit of late mortality, and pros and cons of each strategy (either PCI or CABG) must be weighed in the decision-making process. Spurred on by the publication of the above-mentioned article and the release of new guidelines, we went on to write an overview of the current practice of state-of-the-art coronary revascularization options in patients with HF.

Abstract Objective: We aimed to analyze whether patent foramen ovale (PFO) closure reduces the risk of stroke, assessing also some safety outcomes after the publication of a new trial. Introduction: The clinical benefit of closing a PFO has been an open question, so it is necessary to review the current state of published medical data in regards to this subject. Methods: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were used to search for randomized controlled trials (RCTs) that reported any of the following outcomes: stroke, death, major bleeding or atrial fibrillation. Six studies fulfilled our eligibility criteria and included 3560 patients (1889 for PFO closure and 1671 for medical therapy. Results: The risk ration (RR) for stroke in the “closure” group compared with the “medical therapy” showed a statistically significant difference between the groups, favouring the “closure” group (RR 0.366; 95%CI 0.171–0.782, P=0.010). There was no statistically significant difference between the groups regarding the safety outcomes, death and major bleeding, but we observed an increase in the risk of atrial fibrillation in the “closure” group (RR 4.131; 95%CI 2.293–7.443, P<0.001). We also observed that the larger the proportion of effective closure, the lower the risk of stroke. Conclusion: This meta-analysis found that stroke rates are lower with percutaneously implanted device closure than with medical therapy alone, being these rates modulated by the rates of hypertension, atrial septal aneurysm and effective closure. The publication of a new trial did not change the scenario in the medical literature.

OBJETIVO: Utilização de nova tecnologia na desmineralização química da valva aórtica, em cirurgia cardíaca com circulação extracorpórea, avaliação de suas alterações hemodinâmicas e reportar eventos relacionados à técnica. MÉTODO: Cinco pacientes, submetidos à revascularização miocárdica e portadores de estenose aórtica leve a moderada, receberam tratamento químico na valva aórtica. A idade dos pacientes variou de 65 a 81 anos, com média de 73 anos; sendo todos do sexo masculino. Um paciente tinha doença uniarterial e quatro, multiarterial (quatro vasos). O gradiente médio variou de 13 a 49 mmHg, com média de 25 mmHg. A área média do orifício aórtico variou de 0,8 a 1,3 cm², com média de 1,1cm². Os antecedentes observados foram: hipertensão arterial, hipercolesterolemia, diabete melito e fumo. RESULTADOS: O período de pinçamento aórtico variou de 94 a 126 minutos, com média de 107 minutos. O tempo de "bypass" variou de 134 a 171 minutos, com média de 152 minutos. O tempo de tratamento variou de 13 a 33 minutos, com média de 28 minutos. Não foi observado nenhum óbito. Complicações pós-operatórias observadas foram: bloqueio atrioventricular total em três pacientes. Não foram observados eventos que comprometessem a integridade da valva aórtica ou provocassem insuficiência aórtica pós-tratamento. Também não se observaram eventos neurológicos, sistêmicos, metabólicos ou hematológicos. O gradiente transvalvar pós-operatório, determinado pelo ecocardiograma, demonstrou melhora no gradiente sistólico e médio. CONCLUSÕES: O tratamento demonstrou ser efetivo e seguro, não causando lesão à valva ou algum evento sistêmico. As alterações do sistema de condução parecem relacionadas com o equipamento e seu sistema de liberação da substância de lavagem. A utilização desta tecnologia poderá ser, no futuro, um importante coadjuvante na substituição da valva aórtica por via transcutânea.

OBJECTIVE: To discuss the use of new technology in the chemical demineralization of the aortic valve in coronary artery bypass surgery, together with its hemodynamic changes and to report events related to the technique. METHOD: Five patients with mild to moderate aortic stenosis submitted to myocardial revascularization underwent chemical treatment of the aortic valve. The patients' ages ranged from 65 to 81 years, with a mean of 73 years. All were men. One patient had the involvement of a single artery and four multiple arteries (four vessels). The gradient ranged from 13 to 49 mmHg, with a mean of 25 mmHg. The size of the aortic orifice ranged from 0.8 to 1.3 cm², with a mean of 1.1 cm². The following antecedents were observed: arterial hypertension, hypercholesterolemia, diabetes mellitus and smoking. RESULTS: The aorta clamping time ranged from 94 to 126 minutes, with a mean of 107 minutes and the bypass time was from 134 to 171 minutes, with a mean of 152 minutes. The time of surgery was from 13 to 33 minutes with a mean of 28 minutes. No deaths were recorded. The only postoperative complication noted was a total AV block in three patients. No events were observed that might impair the integrity of the aortic valve or cause aortic insufficiency following treatment. Likewise, no neurologic, systemic, metabolic or hematologic events were seen. The postoperative transvalvular gradient identified by echocardiography showed an improvement in the systolic gradient and in the mean gradient. CONCLUSIONS: The treatment proved to be effective and safe, causing no lesions of the valve or any systemic event. The changes in the conduction system appear to be related to the equipment and its system of releasing the lavage solution. The use of this technology may, in the future, be an important adjuvant in aorta valve replacement using percutaneous techniques.

OBJETIVO: O objetivo do presente trabalho é comparar e analisar os benefícios da cirurgia com e sem CEC, em pacientes octogenários. MÉTODO: Foram analisados dados retrospectivos dos pacientes com 80 anos de idade ou mais, no período de dezembro 1995 a dezembro de 2003. Neste período, 73 pacientes foram submetidos à revascularização do miocárdio (RM), sendo 26 (35,6%) com CEC e 47 (64,4%), sem CEC. Os dados demográficos, fatores de risco pré-operatório, comorbidades, classe da angina (CCVS), complicações pós-operatórias e resultados cirúrgicos foram comparados entre os dois grupos (com CEC e sem CEC). Utilizou-se o teste de "t de Student" na comparação entre os grupos e foi considerado um nível de significância de p < 0,05. RESULTADOS: Ambos os grupos apresentaram maior risco pré-operatório, embora o grupo sem CEC tenha exibido menor mortalidade cirúrgica (11,5% x 2,1%, p<0,05). Não foi observado acidente vascular cerebral (AVC) nos pacientes operados sem CEC (11,5% x 0,0% p<0,005). Foi menor a presença de nova fibrilação atrial (FA), no pós-operatório imediato, no grupo operado sem CEC (30,8% x 12,8% p<0,005). O tempo de ventilação mecânica, no pós-operatório, e a presença de insuficiência respiratória foram menores no grupo sem CEC (p<0,001). Presença de insuficiência renal aguda (IRA) foi de 19,2% nos pacientes operados com CEC e nula nos operados sem CEC (p<0,05). Necessidade de transfusão de sangue ou hemoderivados foi menor no grupo sem CEC (69,2% x 31,9%, p<0,005). O tempo médio de permanência na UTI e hospitalar foi menor no grupo sem CEC (p<0,05). Nos pacientes livres de complicações no pós-operatório, o grupo sem CEC foi maior 89,4% x 61,5% nos pacientes operados com CEC (p<0,001). CONCLUSÕES: O presente estudo sugere que pacientes com 80 anos ou mais de idade se beneficiam quando submetidos à cirurgia de RM sem CEC, e este procedimento está associado a baixas taxas de complicações pós-operatórias: AVC, FA, IRA e insuficiência respiratória, bem como menor tempo de UTI e de permanência hospitalar, menor uso de hemoderivados e menor mortalidade. Em pacientes octogenários, a cirurgia de RM sem CEC é uma técnica segura e eficaz, podendo ser a operação de escolha, quando aplicada com a devida indicação.

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.

OBJETIVO: Nos últimos anos, tem-se observado um grande avanço na cirurgia de revascularização miocárdica sem circulação extracorpórea (RMSCEC). Esse desenvolvimento deveu-se à combinação dos avanços da técnica cirúrgica e ao desenvolvimento de instrumentos que possibilitam a realização deste procedimento nas mais variadas situações. Este é um estudo retrospectivo, que visa avaliar nossa experiência com este procedimento nos últimos 11,5 anos. Os autores enfatizam o rápido progresso do método nos últimos anos, suas indicações, contra-indicações e resultados. MÉTODO: No período de agosto de 1991 e dezembro de 2002, 3.410 pacientes consecutivos, portadores de angina do peito, foram submetidos a cirurgia de revascularização miocárdica sem circulação extracorpórea. 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-operatória foi baixa (0,4%). A mortalidade hospitalar (trinta dias de pós-operatório) foi de 2,58%. A mortalidade e morbidade, no grupo dos pacientes octogenários, foram extremamente baixas em relação aos pacientes operados com circulação extracorpórea (2,2% x 12,6%) (p<0,001). As complicações pós-operatórias que não resultaram em óbito foram de 7,6%. No último ano, não observamos diferença entre o número de condutos nos pacientes operados com e sem CEC [com CEC 2,81,2 e sem CEC 2,80,8 (NS)]. Infarto agudo do miocárdio foi a complicação não fatal mais freqüente, observada em 2,8% dos pacientes. O tempo médio de permanência na UTI foi de 22,3 horas. CONCLUSÕES: A RMSCEC, usada como técnica de revascularização em pacientes multiarteriais, é um procedimento reproduzível e apresenta resultados semelhantes aos obtidos com a operação convencional com CEC. Nesta série foi possível revascularizar o miocárdio sem circulação extracorpórea em mais de 95% dos pacientes, tornando assim, a princípio, todos os pacientes, com indicação de revascularização miocárdica, potenciais candidatos à operação de RMSCEC.

OBJECTIVES: Over the past few years, great strides have been made in off-pump coronary surgery. This progress is due to a combination of the advances in surgical techniques and the development of instruments that make it possible to perform this procedure in the most varied situations. This is a retrospective study, the purpose of which is to assess our experience with this procedure over the last eleven and a half years. The authors underscore the rapid progress of the method in recent years and report on its indications, contraindications and results. METHODS: In the period from August 1991 to December 2003, 3,410 consecutively patients suffering from angina pectoris were submitted to off-pump coronary surgery. Ages ranged from 13 to 93 years, with a mean of 63 ± 12.0 years. Males accounted for 58% of the cases. The angina was rated according to the criteria of the Canadian Cardiovascular Society, 6.1% of the patients being in Class I, 6.8% in Class II, 46.3% in Class III and 40.8% in Class IV. RESULTS: Intraoperative mortality was low (0.4%). Hospital mortality (30 postoperative days) was 2.5%. Mortality and morbidity among the octogenarian patients were extremely low compared with patients operated on with cardiopulmonary bypass (CPB) (2.2% versus 12.6%) (p<0.001). Postoperative complications regarded as nonfatal occurred in 7.6%. In the final year no difference was observed between the number of conduits in the patients operated on with and without CPB [with CPB 2.8 ± 1.2 and without 2.8 ± 0.8 (NS)]. Acute myocardial infarction was the most frequent complication, occurring in 2.7% of the patients. The mean time in the intensive care unit was 22.3 hours. CONCLUSIONS: Off-pump coronary surgery, employed as a revascularization technique in patients requiring multiple grafts, is a reproducible procedure, the results of which are similar to those obtained from conventional surgery with CPB. In the present series it was possible to perform coronary artery bypass grafting without CPB in 95% of the patients, thus making all patients with indication for grafting potential candidates for the procedure without CPB.

OBJETIVO: Analisar o comportamento hemodinâmico do coração na revascularização do miocárdio sem a utilização da circulação extracorpórea, através da cateterização da artéria pulmonar com cateter de San-Ganz. MATERIAL E MÉTODOS: No período de agosto de 1991 a junho de 1999, foram operados 616 pacientes portadores de angina do peito, que foram submetidos a revascularização do miocárdio sem a utilização da circulação extracorpórea. Em 18 pacientes foram estudados os parâmetros hemodinâmicos intra-operatórios. RESULTADOS: A freqüência cardíaca manteve-se elevada durante todos os momentos de posicionamento do coração (p=0,0007). O débito cardíaco ao longo do procedimento apresentou variação mínima nos diversos momentos de posicionamento do coração e exposição das artérias coronárias. Entretanto, com o coração na posição normal final, observou-se um aumento importante do débito cardíaco (p=0,010). A pressão arterial média apresentou-se diminuída em todos os momentos do procedimento de exposição das artérias coronárias (p=0,022). A pressão arterial pulmonar apresentou-se diminuída durante todos os momentos de mobilização (NS). A pressão capilar pulmonar oscilou bastante durante a exposição das coronárias (NS). A pressão venosa central comportou-se de maneira mais variada durante a exposição das artérias (NS). A resistência vascular sistêmica apresentou-se diminuída durante todo o procedimento (p=0,0001). A resistência vascular pulmonar apresentou-se diminuída em todos os momentos do procedimento (p=0,002). O "stroke volume" apresentou-se inalterado durante a anastomose da interventricular anterior e só se observaram diferenças estatísticas na coronária direita (p=0,002) e artéria circunflexa (p=0,0006) e seus ramos. O índice cardíaco apresentou-se diminuído durante o procedimento (p=0,0011). CONCLUSÕES: A) A técnica presente permite a mobilização máxima do coração sem indução de instabilidade hemodinâmica. B) A melhora de alguns parâmetros de hemodinâmica ao final do procedimento pode ser justificada: 1) devido à resposta à revascularização miocárdica; 2) decorrente da liberação de catecolaminas após a manipulação do coração nas diversas posições; 3) decorrente da liberação de mediadores vasoativos depois da tração prolongada do pericárdio.

BACKGROUND: To analyze the hemodynamic behavior of the heart in revascularization of the myocardium without use of extracorporeal circulation. MATERIAL AND METHODS: From August 1991 to June 1999, 616 patients suffering from angina of the chest underwent revascularization of the myocardium without use of extracorporeal circulation. In 18 patients the intraoperative hemodynamic parameters were studied. RESULTS: Heart rate remained high at all times during positioning of the heart (p=0.0007). Cardiac output throughout the procedure presented a very slight variation at different moments of positioning of the heart and exposure of the coronary arteries. However, once the heart was in its final normal position a major increase in output was noted (p=0.010). Mean blood pressure was found to be decreased throughout the procedure for exposing the coronary arteries (p=0.022). Arterial pulmonary pressure proved to be reduced at all times during mobilization, but without statistical significance. Pulmonary capillary pressure showed considerable, but statistically insignificant variation during exposure of the arteries. Central venous pressure behaved in a more varied fashion during exposure of the arteries, but again without statistical significance. Systemic vascular resistance proved to be diminished throughout the procedure (p=0.0001). Pulmonary vascular resistance remained reduced at all times during the procedure (p=0.002). Stroke volume was unchanged during anastomosis of the anterior interventricular artery and statistically significant differences were observed only in the right coronary (p=0.002) and right circumflex (p=0.0006) artery and its branches. The cardiac index was shown to be diminished throughout the procedure (p=0.0011). CONCLUSIONS: A) The present technique allows for maximum mobilization of the heart without inducing hemodynamic instability. B) The improvement of a number of hemodynamic parameters at the end of the procedure may be accounted for by: (1) the response to the myocardial revascularization; (2) the release of catecholamines following manipulation of the heart in the different positions and (3) the release of vasoactive mediators following prolonged traction of the pericardium.