Braz J Cardiovasc Surg | Rev Bras Cir Cardiovasc he Brazilian Journal of Cardiovascular Surgery (BJCVS) has one more reason to celebrate: finally we have been indexed in PubMed Central – PMC (www.ncbi.nlm.nih.gov/pmc/), on-line repository, free access of publications on health area, basis of 3.3 million of full content articles provided by 4.916 journals[1] which BJCVS is part of them now. It is one more platform we are present and I am confident that with the adoption of English language as the official language and the changing from quarterly to bimonthly, it will allow the Journal to be more recognized, accessed, attracting new readers and consequently more people will be interested in publishing their articles making our Impact Factor (IF) could grow again. The presence on PMC is one more award of the work performed since the beginning of my supervision as a Chief-Editor of BJCVS in 2002, in order to provide the journal a wider recognition in the international scenario. Since 2005, the submission and review of the manuscripts have been performed by our website (www.bjcvs.org), we have achieved the indexation in important databases such as PubMed/Medline, ISI-Thomson-Reuters, Scopus, and now PMC. It has been a tough task but pleasant and I feel glad for reaching this current level. It was only possible thanks to the support of the Editorial Staff and also the Brazilian Society of Cardiovascular Surgery (SBCCV), through the several Board of Directors ahead our Society during this time where they have never denied any support or motivation. I also cannot forget to praise my predecessors such as the late Prof. Dr. Adib Jatene, founder of BJCVS and Prof. Dr. Fabio Jatene, who, with a lot of effort have overcame several obstacles to keep a national journal dedicated to heart surgery. I cannot forget to mention GN1, our partner for 10 years, whose support and expertise in Information Technology were essential for our approval at PMC. GN1 is also responsible for creating the files of BJCVS in XML extension, a type of language that allows the sharing through the Internet of information Editorial
1Coordinator of the Pediatric Cardiac Surgery at PUC-Campinas and the Cardio Surgical Clinic ECMO group of Campinas linked to ELSO, Campinas, SP, Brazil. E-mail: ferantoniali@uol.com.br “ – Unfortunately, it is not possible to get out of cardiopulmonary bypass. We have already tried several times and it is not working. We will have to let the patient die! I will talk to the family...” This is an extremely distressing situation for all the team involved in a cardiac surgery. Everyone who has been present in a moment like this and have the humility to recognize certainly will not deny how difficult it is to make the decision: turn off the pump and allow the patient to die. Especially, if the surgery is going on for several hours and there were many attempts to wean from cardiopulmonary bypass (CPB). Especially, if the patient is a child and the parents are outside waiting anxiously for a successful surgical repair. However, for the most part of these patients, we can say that there is one more thing to be done. We cannot use this claim for all the patients with cardiac and respiratory failure after a heart surgery but for the most part of them, we can! For sure! Despite some of these patients can get out of the operating room with high doses of vasoactive drugs or high parameters of mechanical ventilation, the circulatory failure and severe hypoxia will culminate with important acidosis, multiple organ failure and the patient will die a few days later. The post-cardiotomy ECMO (Extracorporeal Membrane Oxygenation) is the best option to support these patients. Nevertheless, it is necessary to use a real post-cardiotomy ECMO because keeping the patient on CPB in the ICU will not work. If we are talking about ECMO, the numbers from the ELSO registry (Extracorporeal Life Support Organization) must be highlighted. The last ELSO international report was on July 2015 and there were 69.114 ECMO patients in the registry with an overall survival of 59%[1]. Inside of this big group of patients, 10.183 cases were neonates and infants under 16 years old with congenital heart problems and they were supported with a cardiac ECMO. The majority of them received the support because of cardiac failure after CPB or during the first postoperative day. In this post-cardiotomy ECMO group, the mean survival was 42.7%. Using these information from ELSO, at least we should say that it is mandatory remember about ECMO as a possibility of treatment for a patient with cardiac failure after CPB. However, it is not a widespread knowledge in our country and some people don’t understand it. There is no doubt that the treatment with ECMO is increasing in Brazil but we still have to expand the information about it and improve the quality of this therapeutic technique in our country. Another important action would be the incorporation of this technology on the treatment of our patients from the public health system (SUS). In order to spread information about ECMO, the First Latin American ELSO Conference was performed in Brazil on December 2014. There were over 500 health professionals present with the majority of Brazilians and this event was the first scientific meeting of the Latin American chapter of ELSO that was created in 2012 following examples as the Euro ELSO and Asian-Pacific ELSO. The registrants discussed different issues about cardiopulmonary support with more than 20 international speakers, including Dr. Robert Bartlett, called “The Father of ECMO” who, on the opening ceremony, talked about the experimental studies of his group in the 1960’s and also about the first ECMO survival patients in the 1970’s. Fortunately, ECMO is not an experimental therapy anymore and the fact of more than 69 thousands of patients had been treated until now can prove it.
1Coordinator of the Pediatric Cardiac Surgery at PUC-Campinas and the Cardio Surgical Clinic ECMO group of Campinas linked to ELSO, Campinas, SP, Brazil. E-mail: ferantoniali@uol.com.br “ – Unfortunately, it is not possible to get out of cardiopulmonary bypass. We have already tried several times and it is not working. We will have to let the patient die! I will talk to the family...” This is an extremely distressing situation for all the team involved in a cardiac surgery. Everyone who has been present in a moment like this and have the humility to recognize certainly will not deny how difficult it is to make the decision: turn off the pump and allow the patient to die. Especially, if the surgery is going on for several hours and there were many attempts to wean from cardiopulmonary bypass (CPB). Especially, if the patient is a child and the parents are outside waiting anxiously for a successful surgical repair. However, for the most part of these patients, we can say that there is one more thing to be done. We cannot use this claim for all the patients with cardiac and respiratory failure after a heart surgery but for the most part of them, we can! For sure! Despite some of these patients can get out of the operating room with high doses of vasoactive drugs or high parameters of mechanical ventilation, the circulatory failure and severe hypoxia will culminate with important acidosis, multiple organ failure and the patient will die a few days later. The post-cardiotomy ECMO (Extracorporeal Membrane Oxygenation) is the best option to support these patients. Nevertheless, it is necessary to use a real post-cardiotomy ECMO because keeping the patient on CPB in the ICU will not work. If we are talking about ECMO, the numbers from the ELSO registry (Extracorporeal Life Support Organization) must be highlighted. The last ELSO international report was on July 2015 and there were 69.114 ECMO patients in the registry with an overall survival of 59%[1]. Inside of this big group of patients, 10.183 cases were neonates and infants under 16 years old with congenital heart problems and they were supported with a cardiac ECMO. The majority of them received the support because of cardiac failure after CPB or during the first postoperative day. In this post-cardiotomy ECMO group, the mean survival was 42.7%. Using these information from ELSO, at least we should say that it is mandatory remember about ECMO as a possibility of treatment for a patient with cardiac failure after CPB. However, it is not a widespread knowledge in our country and some people don’t understand it. There is no doubt that the treatment with ECMO is increasing in Brazil but we still have to expand the information about it and improve the quality of this therapeutic technique in our country. Another important action would be the incorporation of this technology on the treatment of our patients from the public health system (SUS). In order to spread information about ECMO, the First Latin American ELSO Conference was performed in Brazil on December 2014. There were over 500 health professionals present with the majority of Brazilians and this event was the first scientific meeting of the Latin American chapter of ELSO that was created in 2012 following examples as the Euro ELSO and Asian-Pacific ELSO. The registrants discussed different issues about cardiopulmonary support with more than 20 international speakers, including Dr. Robert Bartlett, called “The Father of ECMO” who, on the opening ceremony, talked about the experimental studies of his group in the 1960’s and also about the first ECMO survival patients in the 1970’s. Fortunately, ECMO is not an experimental therapy anymore and the fact of more than 69 thousands of patients had been treated until now can prove it.
1Specialist Member of the Brazilian Society of Cardiovascular Surgery. Title of specialist in cardiovascular surgery by the Brazilian Medical Association. Specialist Member of the Brazilian Society of Cardiology. Title of specialist in cardiology by the Brazilian Medical Association. Qualified member of the Department of Cardiac Pacing (DECA).Cardiovascular Surgeon of Real e Benemérita Associação Portuguesa de Beneficência, Pulmo Cor Pneumologia e Cardiologia Clínica e Cirúrgica, and Associação Beneficente e Filantrópica da Cruz Azul de São Paulo. São Paulo, SP, Brazil. E-mail: piccardivl@hotmail.com MEMORIAL
1International Board Heart Rhythm Examiners Certified Cardiac Device Specialist. Director of Pacemaker Service of Instituto Dante Pazzanese de Cardiologia (IDPC), Sao Paulo, SP, Brazil. E-mail: pachon@usp.br Chagas disease or American trypanosomiasis is a chronic parasitosis affecting most Latin American countries where an estimated 8 million people are infected. Current assessments have shown that even in the United States there is a total of 300,000 infected individuals, essentially all of whom are immigrants from the endemic countries. It is a tropical parasitic disease caused by the protozoan Trypanosoma cruzi that is transmitted to humans by blood-sucking triatomine bugs, known as “Kissing Bug”, and via blood transfusion, mother-to-baby or organ transplant. This protozoan causes an acute systemic inflammatory illness that usually progresses to chronic myocarditis and autonomic disease leading to electrical and/or severe dilated cardiomyopathy. Myocardial damage is disseminated throughout the heart. The outcome may present cardiac arrhythmias, life-threatening heart failure, thromboembolism, stroke and sudden death. The latter is sometimes the first manifestation of the disease, even in the structurally normal heart (latent phase). In many patients, a chronic immunologic process may feed the inflammatory phenomenon even without the parasite. As a rule, extensive involvement of the autonomic nervous system and the cardiac conduction system results in a huge variety of supraventricular and ventricular cardiac arrhythmias. As a corollary, in approximately 60% of cases, the sinus node is injured, developing a more or less extensive sick sinus syndrome. Additionally, many patients have to be treated for heart failure and cardiac arrhythmias. Thanks to a coordinated multi-country program in the Southern Cone countries, the transmission of Chagas disease by vectors and via blood transfusion was interrupted in Uruguay in 1997, in Chile in 1999 and Brazil in 2006. For this reason, the incidence of new infections by T. cruzi across the South American continent has decreased by 70%. The natural course of the disease and the very common pharmacological requirement for treating numerous arrhythmias cause a high sick sinus node syndrome prevalence. One frequent expression of this condition is the “Chronotropic Incompetence” (CI).
1Centro Universitario Lusiada (UNILUS), Santos, SP, Brazil. E-mail: edag@uol.com.br Detection and characterization of mortality predictors is becoming an interesting approach in the field of cardiovascular surgery, particularly in valve and CABG procedures. Yet there is a paucity of trials in order to obtain precise data on this topic using statistic criteria. In the last decades, many cardiologists have turned attention to underlying role of inflammation in heart diseases and different types of heart operation. The key point raised by these experts is that main expression from inflammatory cardiovascular process can be translated into serologic appearance of some markers[1-3]. From the publication “Predictors of mortality in cardiac surgery: B-type natriuretic peptide’’ by Murad Junior et al.[4], the first observation can be drawn is epidemiologic quality of retrospective study of valve and CABG patients. Undoubtedly main step for identifying a mortality predictor using statistical analysis is to know how patients were selected and included in the study.
Objective: In 1996, the Brazilian cardiovascular surgeon, Dr. Randas Batista, introduced a surgical technique called partial left ventriculectomy, where he admitted the possibility of reducing the diameter of the left ventricle through the sectioning of one section of its wall.After the publication of this study, thousands of case reports and procedure analysis have been published, and due to several disappointing results, many doctors and institutions failed to execute it.As the main objective of this study, stands out the search for success cases of ventriculectomy in the last 12 years and if during this period it was achieved some significant development in this procedure that allows obtaining lower mortality rate postoperatively. Methods: Systematic review of indexed scientific literature over the past 12 years and the term "Partial Left Ventriculectomy".Results: There has been a considerable number of reported successful cases and highly significant findings in regard to determining the most suitable region for the section, proper selection of the patients indicated to the procedure, including the influence of the coronary artery anatomy in the nomination procedure and the need for preservation of ventricular geometry to ensure better quality of ventricular contractions after the sectioning.Conclusion: This surgical procedure has been successfully performed, mainly in Japan, improvements in its efficiency were found and the need for a mathematical modeling of the slice to be severed is a prominent factor in many studies.
Objective Coronary artery bypass grafting is currently the best treatment for dialysis patients with multivessel coronary artery involvement. Vasoplegic syndrome of inflammatory etiology constitutes an important postoperative complication, with highly negative impact on prognosis. Considering that these patients have an intrinsic inflammatory response exacerbation, our goal was to evaluate the incidence and mortality of vasoplegic syndrome after myocardial revascularization in this group. Methods A retrospective, single-center study of 50 consecutive and non-selected dialysis patients who underwent myocardial revascularization in a tertiary university hospital, from 2007 to 2012. The patients were divided into 2 groups, according to the use of cardiopulmonary bypass or not (off-pump coronary artery bypass). The incidence and mortality of vasoplegic syndrome were analyzed. The subgroup of vasoplegic patients was studied separately. Results There were no preoperative demographic differences between the cardiopulmonary bypass (n=20) and off-pump coronary artery bypass (n=30) group. Intraoperative data showed a greater number of distal coronary arteries anastomosis (2.8 vs. 1.8, P<0.0001) and higher transfusion rates (65% vs. 23%, P=0.008) in the cardiopulmonary bypass group. Vasoplegia incidence was statistically higher (P=0.0124) in the cardiopulmonary bypass group (30%) compared to the off-pump coronary artery bypass group (3%). Vasoplegia mortality was 50% in the cardiopulmonary bypass group and 0% in the off-pump coronary artery bypass group. The vasoplegic subgroup analysis showed no statistically significant clinical differences. Conclusion Cardiopulmonary bypass increased the risk for developing postoperative vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure.
The article “Analysis of steps adapted protocol for cardiac rehabilitation during hospitalization”[1] aims to demonstrate the effectiveness of a cardiac rehabilitation program carried out by the physiotherapist during hospitalization in respect to post-operative complications, mortality and length of hospital stay. It stresses that there is a lack of cardiac rehabilitation protocols and is supported by the current literature on the effectiveness of physiotherapy techniques after heart surgery, as well as new strategies centered on multidisciplinary care. All this demonstrates that the article is in tune with proposals of this specialized scientific universe. It is noteworthy that the treatment of complex cardiovascular diseases has changed significantly with the development of new care strategies, with an ever increasing amount of data based on scientific evidence and criteria on appropriate use at presentation and recommendations to the patient and family[2]. This article adopted a protocol that ensured that the heart surgery team could standardize the care of professionals and document activities in a comprehensive and systematic way, with immediate benefits from the applicability of early mobilization, followed by sitting and assisted or unassisted standing. The progression of the amount of effort exerted followed the Steps program depending on the situation of each patient. This program corresponds to a group of exercises at an intensity and repetition, wherein the energy spent is related to the consumption of oxygen required by the body. However, this protocol is not used in the daily clinical practice, and therefore the morbidity and mortality rates are higher with increased costs to the National Health Service, as was recently reported by the British Cardiovascular Society[3]. I should also stress the importance of this article to heart surgery which is a complex procedure that has important organic implications and causes changes to the physiological mechanism of the patient, resulting in a higher incidence of complications that tend to significantly affect recovery. Hence, rehabilitation, by improving physical functioning, reducing immediate disability, and preventing or minimizing future dysfunction or disability, proposes a multiprofessional approach to recover the biopsychosocial well-being of the patient by a technically autonomous team. With this in mind, early mobilization interventions are necessary to prevent physical and psychological problems, and to avoid the risks involved with prolonged hospitalization and immobility.
OBJECTIVE To test several weaning predictors as determinants of successful extubation after elective cardiac surgery. METHODS The study was conducted at a tertiary hospital with 100 adult patients undergoing elective cardiac surgery from September to December 2014. We recorded demographic, clinical and surgical data, plus the following predictive indexes: static compliance (Cstat), tidal volume (Vt), respiratory rate (f), f/ Vt ratio, arterial partial oxygen pressure to fraction of inspired oxygen ratio (PaO2/FiO2), and the integrative weaning index (IWI). Extubation was considered successful when there was no need for reintubation within 48 hours. Sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were used to evaluate each index. RESULTS The majority of the patients were male (60%), with mean age of 55.4±14.9 years and low risk of death (62%), according to InsCor. All of the patients were successfully extubated. Tobin Index presented the highest SE (0.99) and LR+ (0.99), followed by IWI (SE=0.98; LR+ =0.98). Other scores, such as SP, NPV and LR-were nullified due to lack of extubation failure. CONCLUSION All of the weaning predictors tested in this sample of patients submitted to elective cardiac surgery showed high sensitivity, highlighting f/Vt and IWI.
Objective: To compare the efficacy of a cycle ergometer-based exercise program to a standard protocol on the increment of the maximum distance walked during the six-minute walk test in the postoperative rehabilitation of patients submitted to coronary artery bypass grafting.Methods: A controlled clinical trial pilot, blinded to the outcome, enrolled subjects who underwent coronary artery bypass grafting in a hospital from Southern Brazil. Subjects were designated for the standard physical rehabilitation protocol or to an alternative cycle ergometer-based protocol through simple random sampling. The primary outcome was the difference in the maximum distance walked in the six-minute walk test before and after the allocated intervention.Results: Twenty-four patients were included in the analysis, 10 in the standard protocol and 14 in the alternative protocol group. There was an increment in the maximum distance walked in both groups, and borderline superiority in the intervention group comparing to the control group (312.2 vs. 249.7; P=0.06).Conclusion: There was an increase in the maximum distance walked in the alternative protocol compared to the standard protocol. Thus, it is postulated that the use of a cycle ergometer can be included in physical rehabilitation in the hospital phase of postoperative coronary artery bypass grafting. However, randomized studies with larger sample size should be conducted to assess the significance of these findings.
Objective To determine the incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting. Methods A retrospective study with analysis of 230 medical records between January 2011 and October 2013 was conducted. Results Fifty-six (24.3%) out of the 230 patients were female. The average age of patients undergoing on-pump coronary artery bypass grafting was 59.91±8.62 years old, and off-pump was 57.16±9.01 years old (P=0.0213). The average EuroSCORE for the on-pump group was 3.37%±3.08% and for the off-pump group was 3.13%±3% (P=0.5468). Eighteen (13.43%) patients who underwent off-pump coronary artery bypass grafting developed postoperative atrial fibrillation, whereas for the onpump group, 19 (19.79%) developed this arrhythmia, with no significant difference between the groups (P=0.1955). Conclusion Off-pump coronary artery bypass grafting did not reduce the incidence of atrial fibrillation in the postoperative period. Important predictors of risk for the development of this arrhythmia were identified as: patients older than 70 years old and presence of atrial fibrillation in perioperative period in both groups, and non-use of beta-blockers drugs postoperatively in the on-pump group.
