The modern era of direct myocardial revascularization started with the saphenous vein bypass grafts, with massive information coming mainly from Cleveland Clinic regarding diagnosis, selection of patients and technical challenges [3]. Nevertheless, Garret utilized years before a bypass graft instead of endarterectomy in 1962 and published a successful follow-up in 1973. It is important to remind that at that time he didn ́t have information of cinecoronarygraphy and did this option during a valve operation [4].

Knowledge is the paradox in which dividing is multiplying."During the Heart Transplantation Symposium in Maceió, in October 2019, the idea of creating the Brazilian Academy of Cardiovascular Surgery was born and aimed at documenting, for future generations of cardiac surgeons, the rich history of cardiac surgery in Brazil.First-generation Brazilian cardiac surgeons were not just spectators [1] , but participants in the development of surgical procedures in the treatment of coronary artery disease [2,3] , heart failure [4,5] , valvular heart surgery [6,7] , congenital heart surgery [8][9][10] and many others [11,12] .In addition, they developed expertise in the manufacture of medical equipment in Brazil, such as heart lung machine [13,14] , oxygenators [15,16] , pacemakers [17] , valves [18][19][20] , stents [21] and many others [1] .This allowed to overcome the difficult trade barrier for materials and equipment necessary for the development of the specialty at that time, easing costs of procedures and enabling the application of techniques and concepts from developed countries.Surgical equipment and supplies manufactured in Brazil were soon recognized for their excellent quality.They were subsequently exported and used in many countries in Latin America and other continents, contributing to the development of cardiac surgery in these countries and helping to save lives [22] .When one reads articles such as "Cardiovascular Surgery in Brazil: Achievements and possibilities", written by Euryclides de J. Zerbini, about a symposium held in 1963, with the participation os

Introduction: Coronary artery bypass grafting (CABG) is the most frequently performed heart surgery in Brazil. Recent international guidelines recommend that national societies establish a database on the practice and results of CABG. In anticipation of the recommendation, the BYPASS Registry was introduced in 2015. Objective: To analyze the profile, risk factors and outcomes of patients undergoing CABG in Brazil, as well as to examine the predominant surgical strategy, based on the data included in the BYPASS Registry. Methods: A cross-sectional study of 2292 patients undergoing CABG surgery and cataloged in the BYPASS Registry up to November 2018. Demographic data, clinical presentation, operative variables, and postoperative hospital outcomes were analyzed. Results: Patients referred to CABG in Brazil are predominantly male (71%), with prior myocardial infarction in 41.1% of cases, diabetes in 42.5%, and ejection fraction lower than 40% in 9.7%. The Heart Team indicated surgery in 32.9% of the cases. Most of the patients underwent cardiopulmonary bypass (87%), and cardioplegia was the strategy of myocardial protection chosen in 95.2% of the cases. The left internal thoracic artery was used as a graft in 91% of the cases; the right internal thoracic artery, in 5.6%; and the radial artery in 1.1%. The saphenous vein graft was used in 84.1% of the patients, being the only graft employed in 7.7% of the patients. The median number of coronary vessels treated was 3. Operative mortality was 2.8%, and the incidence of cerebrovascular accident was 1.2%. Conclusion: CABG data in Brazil provided by the BYPASS Registry analysis are representative of our national reality and practice. This database constitutes an important reference for indications and comparisons of therapeutic procedures, as well as to propose subsequent models to improve patient safety and the quality of surgical practice in the country.

Objective: Intraoperative blood salvage (cell saver technique) in cardiac surgery is universally used in surgical procedures with a marked risk of blood loss. The primary objectives of this study were to determine the concentration of residual heparin in the final product that is reinfused into the patient in the operating room and to evaluate the efficacy and safety of the cell saver technique. Method: Twelve patients undergoing elective cardiac surgery were enrolled in this study. Using the XTRA Autotransfusion System, blood samples were collected from the cardiotomy reservoir, both prior to blood processing (pre-sample) and after it, directly from the bag with processed product (post-sample). Hematocrit and hemoglobin levels, the protein, albumin and residual heparin concentrations, hemolysis index, and the platelet, erythrocyte and leukocyte counts were measured. Results: Hematocrit and hemoglobin levels and red blood cell counts were higher in post-processing samples, with a mean variation of 54.78%, 19.81 g/dl and 6.84 x 10(6)/mm(3), respectively (p < 0.001). The mean hematocrit of the processed bag was 63.49 g/dl (range: 57.2-67.5). The residual heparin levels were <= 0.1 IU/ml in all post-treatment analyses (p = 0.003). No related adverse events were observed. Conclusion: The reduced residual heparin values (<= 0.1 IU/ml) in processed blood found in this study are extremely important, as they are consistent with the American Association of Blood Banks guidelines, which establish target values below 0.5 IU/ml. The procedure was effective, safe and compliant with legal requirements and the available international literature. (C) 2019 Associacao Brasileira de Hematologia, Hemoterapia e Terapia Celular. Published by Elsevier Editora Ltda.

Objective:To report the early results of the BYPASS project - the Brazilian registrY of adult Patient undergoing cArdiovaScular Surgery - a national, observational, prospective, and longitudinal follow-up registry, aiming to chart a profile of patients undergoing cardiovascular surgery in Brazil, assessing the data harvested from the initial 1,722 patients.Methods:Data collection involved institutions throughout the whole country, comprising 17 centers in 4 regions: Southeast (8), Northeast (5), South (3), and Center-West (1). The study population consists of patients over 18 years of age, and the types of operations recorded were: coronary artery bypass graft (CABG), mitral valve, aortic valve (either conventional or transcatheter), surgical correction of atrial fibrillation, cardiac transplantation, mechanical circulatory support and congenital heart diseases in adults.Results:83.1% of patients came from the public health system (SUS), 9.6% from the supplemental (private insurance) healthcare systems; and 7.3% from private (out-of -pocket) clinic. Male patients comprised 66%, 30% were diabetics, 46% had dyslipidemia, 28% previously sustained a myocardial infarction, and 9.4% underwent prior cardiovascular surgery. Patients underwent coronary artery bypass surgery were 54.1% and 31.5% to valve surgery, either isolated or combined. The overall postoperative mortality up to the 7th postoperative day was 4%; for CABG was 2.6%, and for valve operations, 4.4%.Conclusion:This first report outlines the consecution of the Brazilian surgical cardiac database, intended to serve primarily as a tool for providing information for clinical improvement and patient safety and constitute a basis for production of research protocols.

Objectives:Reoperative procedure for the treatment of a failed mitral bioprosthesis is associated with considerable risk. In some cases, mortality is high and might contraindicate the benefit of the procedure. The minimally invasive valve-in-valve (ViV) transcatheter mitral valve implant offers an alternative less-invasive approach, reducing morbidity and mortality. The objective of this paper was to evaluate the mitral ViV approach using the Braile Inovare prosthesis.Methods:The transcatheter balloon-expandable Braile Inovare prosthesis was used in 12 cases. Procedures were performed in a hybrid operating room, under fluoroscopic and echocardiographic control. Through left minithoracotomy, the prostheses were implanted through the cardiac apex. Serial echocardiographic and clinical examinations were performed. Follow-up varied from 1 to 30 months.Results:A total of 12 transapical mitral ViV procedures were performed. Patients had a mean age of 61.6 ± 9.9 years and 92% were women. Mean logistic EuroSCORE was 20.1%. Successful valve implantation was possible in all cases. In one case, a right lateral thoracotomy was performed for the removal of an embolized prosthesis. There was no operative mortality. Thirty-day mortality was 8.3%. Ejection fraction was preserved after the implant (66.7%; 64.8%; P  = 0.3). The mitral gradient showed a significant reduction (11 mmHg; 6 mmHg; P  < 0.001). Residual mitral regurgitation was not present. There was no left ventricular outflow tract obstruction.Conclusions:The mitral ViV implant in a failed bioprosthesis is an effective procedure. This possibility might alter prosthesis selection in the future initial surgical prosthesis selection, favouring bioprostheses. Further large trials should explore its safety.

Background Myocardial revascularization surgery is the best treatment for dyalitic patients with multivessel coronary disease. However, the procedure still has high morbidity and mortality. The use of extracorporeal circulation (ECC) can have a negative impact on the in-hospital outcomes of these patients. Objectives To evaluate the differences between the techniques with ECC and without ECC during the in-hospital course of dialytic patients who underwent surgical myocardial revascularization. Methods Unicentric study on 102 consecutive, unselected dialytic patients, who underwent myocardial revascularization surgery in a tertiary university hospital from 2007 to 2014. Results Sixty-three patients underwent surgery with ECC and 39 without ECC. A high prevalence of cardiovascular risk factors was found in both groups, without statistically significant difference between them. The group "without ECC" had greater number of revascularizations (2.4 vs. 1.7; p <0.0001) and increased need for blood components (77.7% vs. 25.6%; p <0.0001) and inotropic support (82.5% vs 35.8%; p <0.0001). In the postoperative course, the group "without ECC" required less vasoactive drugs, (61.5% vs. 82.5%; p = 0.0340) and shorter time of mechanical ventilation (13.0 hours vs. 36,3 hours, p = 0.0217), had higher extubation rates in the operating room (58.9% vs. 23.8%, p = 0.0006), lower infection rates (7.6% vs. 28.5%; p = 0.0120), and shorter ICU stay (5.2 days vs. 8.1 days; p = 0.0054) as compared with the group with ECC surgery. No difference in mortality was found between the groups. Conclusion Myocardial revascularization with ECC in patients on dialysis resulted in higher morbidity in the perioperative period in comparison with the procedure without ECC, with no difference in mortality though.

Introduction Aortic Stenosis (AoS) is the valvular pathology most frequently acquired in developed countries, present in 4% of individuals over 85 years of age. Patients with severe AoS may have comorbidities, presenting greater risk of thrombotic and bleeding events. Heyde’s Syndrome was described in 1958 by E. C. Heyde1 as he observed the relation between aortic valve stenosis and gastrointestinal bleeding. In 1992, Warkentin et al.2 observed the loss of the largest Willebrand factor multimers, characterizing the Acquired type 2A3,4 von Willebrand syndrome. Von Willebrand Factor (vWF) is a multimeric protein, secreted by endothelial cells and platelets.5 It promotes adherence of platelets to vascular lesion sites through glycoprotein Ib-vWF interactions. A change in the shape of vWF occurs in AoS, making such protein more susceptible to proteolytic cleavage. As a consequence, vWF is degraded specifically by protease ADAMTS13, hindering vWF-mediated platelet adhesion, thus generating a lack of these multimers and causing bleeding, especially in pre-existing lesions such as gastrointestinal angiodysplasia.6-8 Treatment for this syndrome may be obtained with surgical aortic valve replacement, and percutaneous implantation of aortic valve (TAVI), whose effect is still under investigation.9

Aims: Transcatheter aortic valve implantation has emerged as an alternative to conventional aortic valve replacement in high-risk patients. Diverse prostheses are currently under investigation. The aim of this study was the clinical, safety and efficacy assessment of Braile Inovare Transcatheter Aortic Prosthesis usage.Methods and results: Ninety high-risk or inoperable patients underwent transcatheter aortic valve implantation. The mean logistic EuroSCORE was 39.3%. All patients presented calcified aortic stenosis. The procedures were performed under fluoroscopic and echocardiographic guidance. Prostheses were implanted through the transapical approach under rapid ventricular pacing. Echocardiographic and angiographic controls were included. Implantation was feasible in 87 cases. There was only one case of operative mortality, and 30-day mortality was 13.3%. The median transvalvular aortic gradient was reduced from 44.8+15.3 to 14.1 +/- 8.0 mmHg. Left ventricular function improved in the first seven postoperative days. Paravalvular aortic regurgitation was present in 29.7% of cases, mostly trace. One case presented a major vascular complication, and there were two cases of permanent pacemaker implantation. Two cases of major stroke occurred.Conclusions: Transcatheter aortic valve replacement using the Braile Inovare prosthesis is able to provide encouraging results with significant functional and structural cardiac improvement. It is mandatory to continue follow-up to measure the benefits of this device as well as to improve selection criteria of patients.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effectiveness and safety of TAVI compared with aortic valve replacement in patients with severe aortic stenosis with high‐risk of death.

Mononuclear stem cells have been studied for their potential in myocardial ischemia. In our previous published article, ReACT ® phase I/II clinical trial, our results suggest that a certain cell population, promonocytes, directly correlated with the perceived angiogenesis in refractory angina patients. This study is ReACT's clinical update, assessing long-term sustained efficacy. The ReACT phase IIA/B noncontrolled, open-label, clinical trial enrolled 14 patients with refractory angina and viable ischemic myocardium, without ventricular dysfunction, who were not suitable for myocardial revascularization. The procedure consisted of direct myocardial injection of a specific mononuclear cell formulation, with a certain percentage of promonocytes, in a single series of multiple injections (24—90; 0.2 ml each) into specific areas of the left ventricle. Primary endpoints were Canadian Cardiovascular Society Angina Classification (CCSAC) improvement at the 12-month follow-up and ischemic area reduction (scintigraphic analysis) at the 12-month follow-up, in correlation with ReACT's formulation. A recovery index (for patients with more than 1 year follow-up) was created to evaluate CCSAC over time, until April 2011. Almost all patients presented progressive improvement in CCSAC beginning 3 months ( p = 0.002) postprocedure, which was sustained at the 12-month follow-up ( p = 0.002), as well as objective myocardium ischemic area reduction at 6 months (decrease of 15%, p < 0.024) and 12 months (decrease of 100%, p < 0.004) The recovery index ( n = 10) showed that the patients were graded less than CCSAC 4 for 73.9 ± 24.2% over a median follow-up time of 46.8 months. After characterization, ReACT's promonocyte concentration suggested a positive correlation with CCSAC improvement ( r = −0.575, p = 0.082). Quality of life (SF-36 questionnaire) improved significantly in almost all domains. Cost-effectiveness analysis showed decrease in angina-related direct costs. Refractory angina patients presented a sustained long-term improvement in CCSAC and myocardium ischemic areas after the procedure. The long-term follow-up and strong improvement in quality of life reinforce effectiveness. Promonocytes may play a key role in myocardial neoangiogenesis. ReACT dramatically decreased direct costs.

Mononuclear stem cells have been studied for their potential in myocardial ischemia. In our previous published article, ReACT® phase I/II clinical trial, our results suggest that a certain cell population, promonocytes, directly correlated with the perceived angiogenesis in refractory angina patients. This study is ReACT's clinical update, assessing long-term sustained efficacy. The ReACT phase IIA/B noncontrolled, open-label, clinical trial enrolled 14 patients with refractory angina and viable ischemic myocardium, without ventricular dysfunction, who were not suitable for myocardial revascularization. The procedure consisted of direct myocardial injection of a specific mononuclear cell formulation, with a certain percentage of promonocytes, in a single series of multiple injections (24—90; 0.2 ml each) into specific areas of the left ventricle. Primary endpoints were Canadian Cardiovascular Society Angina Classification …

The sequential implantation of a transcatheter heart valve (THV) within a similar device, also known as valve-in-valve-in-valve, will be an important concept in the future, considering patients with elevated surgical risk and failed THVs within surgical aortic valves (SAV). However, this procedure

Background Coronary artery bypass grafting currently is the best treatment for dialytic patients with multivessel coronary disease, but hospital morbidity and mortality related to procedure is still high. Objective Evaluate results and in-hospital outcomes of coronary artery bypass grafting in dialytic patients. Methods Retrospective unicentric study including 50 consecutive and not selected dialytic patients, who underwent coronary artery bypass grafting in a tertiary university hospital from 2007 to 2012. Results High prevalence of cardiovascular risk factors was observed (100% hypertensive, 68% diabetic and 40% dyslipidemic). There was no intra-operative death and 60% of the procedures were performed off-pump. There were seven (14%) in-hospital deaths. Postoperative infection, previous heart failure, cardiopulmonary bypass, abnormal ventricular function and surgical re-exploration were associated with increased mortality. Conclusion Coronary artery bypass grafting is feasible to dialytic patients although high in-hospital morbidity and mortality. It is necessary better understanding about metabolic aspects to plan adequate interventions.