Brazilian journal of cardiovascular surgery最新文献

Introduction: Globally, cardiovascular diseases remain a predominant cause of mortality. Effective fluid management is particularly critical in older adults undergoing cardiac surgery, due to their heightened risk of postoperative complications. Tolvaptan, an oral vasopressin V2 receptor antagonist, has emerged as a promising agent for fluid regulation in cardiac patients. However, its efficacy in the elderly undergoing cardiac surgery is not thoroughly evaluated.

Methods: This single-center retrospective analysis included 146 older adults (≥ 65 years) who underwent cardiac surgery between January 2018 and December 2022. Patients were categorized into two groups: those receiving tolvaptan and a control group receiving traditional diuretics post-surgery. We assessed several outcomes, including hospital length of stay, 30-day mortality, postoperative renal function, and complications.

Results: The study found a significantly reduced hospitalization duration in the tolvaptan group (P=0.044), with no escalation in adverse events. The tolvaptan cohort exhibited a considerable increase in urine output on the postoperative day (POD) three (P=0.003), indicating enhanced renal function and fluid management. Serum creatinine levels notably declined by POD3 (P=0.012), and blood urea nitrogen levels were appreciably lower by POD5 (P<0.001) in the tolvaptan group. Furthermore, serum sodium levels significantly escalated on POD3 and POD5 (P<0.01) in this group, while serum potassium levels remained unchanged.

Conclusion: Tolvaptan significantly optimizes postoperative fluid management in older adults undergoing cardiac surgery. Its administration is linked to improved renal function and a shortened hospital stay, without amplifying adverse effects. These insights could enhance clinical practices and facilitate the management of fluid overload in this vulnerable demographic.

Introduction: The efficacy and outcomes of on-pump and off-pump coronary artery bypass grafting (CABG) remain uncertain, especially in Latin America. Our study aims to explore survival and shortand mid-term outcomes in the first reported Peruvian registry of patients treated with both techniques.

Methods: This is an observational, analytical, and longitudinal study using a propensity score-matched (PSM) analysis in a single-center retrospective registry of 2280 patients during 2000-2019; 846 patients were analyzed after PSM (on-pump = 423 vs. off-pump = 423). Baseline variables, comorbidities, and major outcomes were studied in the short term (≤ 30 days) and in midterm (30 days-36 months) with major adverse cardiac and cerebrovascular events. The matched groups were compared by descriptive, multivariate, and Kaplan-Meier survival analyses.

Results: Before PSM, previous myocardial infarction < 7 days (27.03%) and ejection fraction ≥ 50% (45.72%) were higher in off-pump CABG (P<0.05). After PSM, pre-surgery percutaneous coronary intervention (27.18% vs. 26.71%, P=0.049) and Society of Thoracic Surgeons risk score (1.98% vs. 1.90%, P=0.047) were higher in off-pump CABG. In the short term, there was higher mortality (2.12% vs. 0.47%, P=0.048), blood transfusion > 500 ml (57.91% vs. 7.56%, P=0.049), reintervention (7.32% vs. 2.12%, P=0.045), hospital stay (nine vs. four days, P=0.048), arrhythmia (9.92% vs. 4.96%, P=0.049), and renal failure (20.09% vs. 5.91%, P=0.009) in on-pump CABG. Long-term mortality (4.25% vs. 1.65%, P=0.044), myocardial infarction (17.02% vs. 7.32%, P=0.046), and repeat revascularization (17.49% vs. 8.26%, P=0.045) predominated in on-pump CABG. There was a higher 36-month adjusted survival for off-pump over on-pump CABG (97.88% vs. 93.63%, P=0.046).

Conclusion: This first reported Peruvian registry of patients treated with CABG has demonstrated that off-pump CABG is associated with lower shortand mid-term morbidity and mortality rates and better-adjusted survival rates compared to on-pump CABG; however, further multicenter studies in Latin America are needed to elucidate its benefits over classic on-pump CABG.

Objective: To compare the efficacy of isolated off-pump coronary artery bypass grafting (OPCABG) and of coronary artery bypass grafting (CABG) plus mitral valve plasty (MVP) in treating coronary heart disease with moderate ischemic mitral regurgitation to find a better surgical method.

Methods: Clinical data of 822 patients diagnosed with coronary heart disease and moderate ischemic mitral regurgitation were analyzed retrospectively. Patients were divided into the OPCABG and CABG+MVP groups according to surgical methods. Baseline data of both groups were corrected, and clinical efficacy of the two surgical methods was analyzed and compared using the propensity score inverse probability of treatment weighting (IPTW) method.

Results: There were no significant differences in the use of mammary artery grafts, number of grafts, and blood product consumption between the two groups (P>0.05) after IPTW. However, the CABG+MVP group had a significantly longer operation time than the OPCABG group (4.13 ± 0.85 hours vs. 5.65 ± 1.02 hours, P<0.001). No statistically significant differences in postoperative major adverse cardiac and cerebrovascular events were observed between the two groups. However, the intra-aortic balloon pump rate was higher in the CABG+MVP group than in the OPCABG group (12.3% vs. 25.0%, P=0.012). Although CABG+MVP can improve ischemic mitral regurgitation significantly (95.4% vs. 81.2%, P<0.001), there were no significant differences in the cumulative survival rate and the incidence of major adverse cardiac and cerebrovascular events between the groups (P>0.05) after IPTW.

Conclusion: CABG+MVP may not provide more advantage in patients with coronary heart disease and moderate ischemic mitral regurgitation.

Introduction: Various cannulation strategies for venoarterial extracorporeal membrane oxygenation (V-A ECMO) support are currently in use according to the clinical urgency and experience of the rescuing team. Although central V-A ECMO is considered more effective than a peripheral approach, the superiority of one cannulation configuration instead of another remains a controversial subject. This study mainly aims to compare the contribution of V-A ECMO circulatory support modalities to patients' improvement according to various cannulation site strategies and additional usage of intra-aortic balloon pump (IABP).

Methods: The study design involved the categorization of all patients into two groups: isolated V-A ECMO support and V-A ECMO plus IABP support. Secondly, we divided the patients into four groups considering V-A ECMO cannulation sites, such as central (aorto-atrial), axillo-femoral, femoro-femoral, and jugulo-femoral. We analyzed the parameters regarding the outcome for each group.

Results: When comparing cannulation sites in relation to laboratory parameters for assessing organ perfusion, no statistically significant differences were observed among the groups. We found no statistically significant result within the groups affecting organ perfusion. The complication rates were higher in patients with concomitant IABP support, but the difference was not statistically significant likewise.

Conclusion: V-A ECMO provides effective perfusion, no matter which cannulation site is preferred during the decision-making process, and the utilization of IABP support has no additional contribution to the outcomes. We believe that the most suitable strategy should be a tailor-made decision according to the clinical status of patients, the pathology, urgency, and cost-effectiveness.

Introduction: Postoperative atrial fibrillation is a frequent complication after coronary artery bypass grafting and is associated with increased mortality. The effects of various drugs on the occurrence of postoperative atrial fibrillation have been studied, but no one has looked into the effect of silymarin on the occurrence of postoperative atrial fibrillation.

Methods: This prospective experimental study included 160 patients undergoing coronary artery bypass grafting. The experimental group received 400 mg of silymarin orally three days before the surgery, while the control group did not. The occurrence of postoperative atrial fibrillation was monitored. Patients' clinical data and postoperative characteristics were investigated to elucidate their impact on postoperative atrial fibrillation.

Results: Postoperative atrial fibrillation occurred in significantly fewer patients in the experimental group (14 vs. 30, P=0.008). There were also lower mean values of postoperatively measured C-reactive protein (P<0.0005) and aspartate aminotransferase (P=0.001) in the experimental group. Within the multivariate regression model, a non-silymarin group (odds ratio 0.296 [0.109-0.807], P=0.005), postoperative red blood cell transfusion (odds ratio 5.218 [1.930-14.107], P=0.001), left atrial diameter (odds ratio 7.800 [2.122-28.672], P=0.002), postoperative C-reactive protein (odds ratio 1.020 [1.008-1.032], P=0.001), and CHA₂DS₂-VASc score (standing for congestive heart failure, hypertension, age ≥ 75 years [doubled], diabetes, stroke [doubled], vascular disease, age 65 to 74 years, and sex category [female]) (odds ratio 1.873 [1.279-2.743], P=0.001) proved to be independently associated with the development of postoperative atrial fibrillation.

Conclusion: This study showed that preoperative administration of silymarin significantly reduces the development of atrial fibrillation after coronary artery bypass grafting.

Introduction: The use of multiple arterial grafts (MAGs) has an impact on patient survival; however, preference for its use in the acute phase of myocardial infarction (AMI) has not yet been established. This study aimed to compare the short-mid-term clinical results of AMI patients undergoing coronary artery bypass grafting (CABG) with a single arterial graft (SAG) vs. MAGs.

Methods: This is a cross-sectional cohort study of 4,053 patients from the Registro Paulista de Cirurgia Cardiovascular II (REPLICCAR II). CABG in the AMI was considered when performed between one and seven days after diagnosis (n=238). Thirty-five patients underwent surgery with ≥ 2 arterial grafts (MAG group), population adjustment in SAG group was performed using the propensity score matching (PSM). Clinical follow-up was performed by telephone to assess need for readmission, new AMI, reoperation, and death.

Results: After PSM, 70 patients were evaluated. During hospitalization, a significant statistical difference was observed in the surgery duration: the MAG group had a median of 4.78 hours while the SAG group had 4.11 hours (P=0.040). Within the MAG group, there was a predominance use of bilateral internal thoracic artery (62.86%), followed by radial graft associated with the use of left internal thoracic artery (28.57%) and the combination of the three grafts (8.57%). There were no significant differences between the groups in terms of outcomes up to 30 days after CABG or up to five years after CABG.

Conclusion: In REPLICCAR II, usage of MAGs in the AMI was not associated with clinical worsening of patients until the mid-term follow-up.

Introduction: An increasing number of patients attending coronary artery bypass grafting (CABG) receive preoperative antiplatelet drugs (acetylsalicylic acid, clopidogrel, prasugrel, ticagrelor). The optimal assessment of preoperative platelet function is the aim of this study for a shorter surgical timing in patients undergoing elective coronary artery bypass grafting.

Methods: This study was performed on patients presenting for first-time isolated CABG on therapy with an P2Y12 receptor blockers loading dose (clopidogrel [300 mg] or prasugrel [60 mg] or ticagrelor [180 mg]) or P2Y12 receptor blockers maintenance therapy at least for five days (clopidogrel [75 mg once daily], prasugrel [10 mg once daily], ticagrelor [90 mg twice daily]). All patients received simultaneously acetylsalicylate acid (100 mg daily). Exclusion criterion was emergency CABG regardless of preoperative antiplatelet and anticoagulant therapy. All patients' data were recorded in an Excel® file and analyzed using RStudio® software.

Results: Forty-eight consecutive adult patients presenting for CABG were enrolled. Preoperative thromboelastography-platelet mapping showed platelet resistance to P2Y12 blockers receptor - 25% for clopidogrel (6/24), 33% for ticagrelor (6/18), 33% for prasugrel (2/6), and this data was useful to obtain a shorter CABG waiting time in comparison with current guidelines (2.7 vs. five days for clopidogrel, 2.5 vs. five days for ticagrelor, 3.3 vs. seven days for prasugrel).

Conclusion: Preoperative thromboelastography-platelet mapping is helpful to detect harmful P2Y12 receptor blockers resistance and to minimize CABG waiting time avoiding unnecessary and life-threatening delays.