Dissertations / Theses on the topic 'Cardiac surgery mortality'

Introduction: Neurological complications and stroke in association with cardiac surgery is a serious problem. The stroke event can occur during surgery (early stroke) or in the postoperative period with a symptom free interval (delayed stroke). Particle embolization due to aortic manipulation during surgery has been suspected as a mechanism for early stroke. The present thesis address mechanisms and survival effects of stroke both clinically (I-III) and experimentally (IV-V). Methods: Study I) Within a cohort of 2641 consecutive cases, a group of cardiac surgery patients with stroke and evaluated by computed tomography (CT) were studied (n=77). CT-findings were analyzed in relation to stroke symptoms. Study II) Data from 9122 patients undergoing coronary surgery were analyzed. Records of patients with any signs of neurological complications were reviewed to extract 149 subjects with stroke at extubation (early, 1.6%) versus 99 patients having a free interval (delayed, 1.1%). Early and delayed stroke were evaluated separately. Independent risk factors for stroke were analyzed by logistic regression and survival by Cox regression (9.3 years median follow-up). Study III) Patients with early (n=223) and delayed stroke (n=116) were identified among 10809 patients undergoing cardiac and aortic surgery, both groups exposed to cardiopulmonary bypass. Stroke patients were subdivided by the hemispheric location of lesions. Subgroups were compared and their associated pre- and peroperative variables and survival were analyzed. Study IV) Aortic cross-clamp manipulation was studied in a human cadaveric perfusion model. The pressurized aorta was repeatedly cross-clamped and washout samples were collected before and after clamp maneuvers. Particles in the washout samples were evaluated by microscopy and by digital image analysis. Study V) Pig aortas were pressurized and cannulated. Washout samples were collected before and after cannulation (n = 40). Particles were deposited onto a 10-μm filter to be evaluated by microscopy and digital image analysis. Results: Study I) In the group of patients exposed to routine cardiac surgery (i.e., clamping and cannulation) and with early stroke, right-hemispheric lesions were more frequent than of the contra-lateral side (P=0.005). Patients with aortic dissections had a strong dominance of bilateral findings, which was different from the unilateral pattern in the routine-surgery group (P<0.001). Study II) Early and delayed stroke did not share any risk factors. Both early and delayed stroke explained mortality in the early postoperative period (P<0.001, P<0.001 respectively) but also at long term follow-up (P=0.008, P<0.001 respectively). For patients surviving their first postoperative year, delayed but not early stroke influenced long-term mortality (P=0.001 and P=0.695, respectively). Study III) Stroke lesions in association to cardiac surgery were near exclusively ischemic. Early stroke had a preponderance for right-hemispheric lesions (P=0.009). In contrast, patients with early stroke that had undergone surgery of the aorta with circulatory arrest showed a pattern with more bilateral lesions compared to ‘cardiac-type’ operations (P<0.001). Patients with bilateral lesions had a dramatically impaired survival compared to those with unilateral lesions (P<0.001). Study IV) In the cadaveric perfusion model, cross-clamping produced a significant output of particles, which was seen for size intervals of 1 mm and smaller (P=0.002 to P=0.022). In all size intervals the particle output correlated with the degree of overall aortic calcification (P =0.002 to P=0.025). Study V) At cannulation of the pig aorta, more particles were noted after cannulation compared to before the maneuver (P<0.001). This increase included small (<0.1 mm, P<0.001) and intermediate-size particles (0.1-0.5 mm, P< 0.001). Particles above 0.5 mm were few and were not associated with cannulation. Conclusions: The influence of stroke on mortality was devastating, for both early and delayed stroke. These two stroke groups had obvious differences in both their risk factors and their hemispheric distribution. It is here emphasized that early and delayed stroke should be considered as two separate entities with suggested mechanistic differences. Ischemic lesions accounted for near all stroke events seen in association to cardiac surgery. For early stroke, these were mostly located within the right hemisphere. Results from the experimental studies underscore microembolic risks associated with aortic manipulation.

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Congenital heart disease are a group of rare defects highly associated with mortality in infancy. In the past 25 years great improvements on the care of this patients had lead us to an augmentation in the number of surgeries but still persists differences among all centers that perform surgery for congenital heart defects. The aim of this study was identify risk factors associated with poor outcomes after cardiac surgery in a population under 18 year old at the Cardiac Surgery Unit of The University Hospital of The Federal University of Maranhao. The period of the study was from June 2001 through June 2004. There were 145 patients,of which 62% were female, with median age of 5,1 years old, 56% came from the capital of the state and 11% had another associated congenital abnormality. The RACHS-1 classification(Risk adjustment for Congenital Heart Surgery) was applied to classify the adjusted risk for each surgical procedures. The risk factors identified were age, type of cardiopathy, pulmonary blood flow, cardiopulmonary bypass-time and aortic clamp time. The RACHS-1 score was applied to all 145 patients, and demonstrated increased risk of mortality for those patients in the higher score groups, although the rate found in this study was higher than that estimated by the RACHS-1 .
As cardiopatias congênitas são defeitos raros, cuja combinação é uma causa importante de óbito na infância. Os avanços ocorridos nos últimos 25 anos permitiram a ampliação do atendimento à população pediátrica portadora destes defeitos, no entanto ainda persistem diferenças entre os mais variados serviços. Com o objetivo de conhecer, descrever e avaliar a evolução pós-operatória dos pacientes pediátricos submetidos a tratamento cirúrgico realizou-se analítico, transversal, retrospectivo, no Hospital Universitário da Universidade Federal do Maranhão (HU-UFMA), no período 18 de junho de 2001 a 30 de junho de 2004. Cento e quarenta e cinco pacientes foram identificados, 62% eram do sexo feminino, 45,5% tinham entre um e cinco anos de idade à época da cirurgia (média de 5,1 anos) e 56,5% eram procedentes da capital do Estado, outras malformações associadas estiveram associadas em 11% dos pacientes, sendo a Síndrome de Down a anormalidade cromossômica mais comum. Utilizou-se o escore de risco de ajustado para cirurgia cardíaca de cardiopatias congênitas(RACHS:-1), o qual classifica os procedimentos cirúrgicos em categorias de risco de 1 a 6, e estima a mortalidade por categorias. Os fatores de risco inicialmente identificados foram a idade, o tipo de cardiopatia, o fluxo pulmonar, o tipo de cirurgia, o tempo de CEC e o tempo de anóxia. Concluiu-se que a idade entre cinco e dez anos, o hipofluxo pulmonar, o tempo de CEC acima de 65 minutos e o tempo de anóxia maior que 35,5 minutos foram fatores de risco significantes para mortalidade nesta população;a cardiopatia acianogênica mostrou significância apenas no tratamento estatístico inicial (teste do qui-quadrado), não se confirmando na análise de regressão logística; e a compatibilização as categorias de risco mais elevado e o progressivo aumento de taxa de mortalidade, porém em percentuais mais elevados para o grupo em estudo.

Introdução: O objetivo deste estudo foi avaliar o efeito de uma estratégia restritiva de transfusão de hemácias comparada a uma estratégia liberal na evolução clínica de pacientes submetidos à cirurgia cardíaca com circulação extracorpórea. Métodos: Estudo prospectivo, randomizado, e controlado. Foram randomizados 512 pacientes para uma estratégia liberal de transfusão (hematócrito 30%) ou restritiva (hematócrito 24%). Resultados: Os pacientes apresentaram idade média de 60,7 ± 12,5 anos no grupo liberal e 58,6 ± 12,5 anos no grupo restritivo. Em ambos, houve predomínio de pacientes com fração de ejeção normal, mas 13% dos pacientes do grupo liberal e 15% do grupo restritivo apresentavam fração de ejeção abaixo de 40%. A mortalidade ou a morbidade grave em 30 dias foi semelhante nos dois grupos (10% na estratégia liberal e 11% na estratégia restritiva, P=0,518). Não houve diferença entre os grupos em relação às taxas de complicações secundárias. A média da concentração de hemoglobina foi 10,5 0,9 g/dL no grupo liberal e 9,1 1,2 gdL no grupo restritivo (P<0,001). No grupo liberal, 198 pacientes (78%) receberam transfusão de hemácias, e no grupo restritivo 118 pacientes (47%). Independente da estratégia utilizada, o número de transfusão de hemácias foi fator preditor independente para a ocorrência de complicações clínicas graves ou morte em 30 dias (OR=1,21; IC 95%=1,1-1,4, P= 0,002). Conclusão: A estratégia restritiva de transfusão foi tão segura quanto à estratégia liberal em pacientes submetidos à cirurgia cardíaca com circulação extracorpórea. Cada unidade de concentrado de hemácias administrada foi associada a aumento de 1,2 vezes no risco de mortalidade em 30 dias
Introduction: The aim of this study was to evaluate whether a restrictive strategy of red blood cells transfusion is as safe as a liberal one with respect to clinical outcomes. Methods: In this prospective, randomized, controlled clinical trial we randomly assigned 512 patients after cardiac surgery to a liberal strategy of transfusion (to maintain a hematocrit at least at 30%) or to a restrictive one (to maintain a hematocrit at least at 24%). Results: The mean age of patients was 60.7 ± 12.5 year-old in liberal group vs. 58.6 ± 12.5 year-old in restrictive group. In both groups, most patients had normal left ventricular function, but 13% of patients in the liberal group and 15% in the restrictive one presented ejection fraction of less than 40%. The primary end-point - a composite endpoint of 30 day all cause mortality or severe morbidity was similar between groups (10% in the liberal-strategy group vs. 11% in the restrictive-strategy group) (P=0.518). Also, there were no differences between groups with respect to the rates of other complications. Hemoglobin concentrations were maintained at a level of 10.5 ± 0.9 g/dL in the liberal group and 9.1 ± 1.2 g/dL in the restrictive group (P<0.001). A total of 198 patients (78%) in the liberal group and 118 patients (47%) in the restrictive group received a blood transfusion (P<0.001). Independently of the strategy group, the number of transfused RBC units was an independent risk factor for the occurrence of several clinical complications or death at 30 days (HR = 1.21; CI 95%=1.1-1.4, P=0.002). Conclusions: A restrictive transfusion strategy was as safe as a liberal strategy in patients undergoing cardiac surgery. For each RBC unit transfused, transfusion was independently associated with a 1.2-fold higher risk of death at 30 days

Introdução: Aneurismas e dissecções da aorta constituem as principais doenças da aorta, as quais podem ser submetidas a princípios e técnicas de tratamento cirúrgico em comum. A conduta clínica e cirúrgica continua sendo um desafio nos procedimentos eletivos, bem como em casos de emergência. Informações sobre variáveis prognósticas associadas independentemente com óbito hospitalar e no longo prazo, são escassas, havendo necessidade da identificação destes fatores para a avaliação apropriada sobre o risco cirúrgico desta população. Objetivos: Primário: identificar variáveis prognósticas associadas independentes ao óbito hospitalar em pacientes submetidos a procedimento cirúrgico para correção de doenças da aorta. Secundários: identificar variáveis prognósticas associadas independentes ao óbito tardio e ao desfecho clínico composto (óbito, sangramento, disfunção ventricular e complicações neurológicas). Casuística e Métodos: Delineamento transversal com componente longitudinal, com coleta de dados retrospectiva e prospectiva. Pacientes consecutivos, portadores de aneurisma de aorta ascendente ou dissecção crônica de aorta tipo A de Stanford, foram incluídos por meio de revisão de prontuários. Foram incluídos 257 pacientes, cujos critérios de inclusão envolviam aqueles que foram operados por dissecção crônica de aorta tipo A de Stanford e aneurisma de aorta ascendente. Foram excluídos pacientes com dissecção aguda de aorta, de qualquer tipo, e pacientes que tiveram aneurisma de aorta em outro segmento da aorta que não fosse a aorta ascendente. Os desfechos clínicos avaliados foram óbito, sangramento clinicamente relevante, complicações neurológicas e disfunção ventricular, fase hospitalar e óbito no longo prazo. As variáveis prognósticas avaliadas incluíram: demografia, fatores pré-operatórios, fatores intra-operatórios e complicações pós-operatórias. O seguimento médio foi de 970 dias. O tamanho de amostra foi definido por conveniência aliado a publicações prévias sobre o tópico. Análise univariada foi realizada para selecionar variáveis para serem inseridas no modelo multivariado para identificação das variáveis prognósticas independentemente associados aos desfechos clinicamente relevantes. Resultados: As seguintes variáveis prognósticas apresentaram associação independente como o risco aumentado de óbito na fase hospitalar (RC; IC95%; P valor): etnia negra (6.8; 1.54-30.2; 0,04), doença cerebrovascular (10.5; 1.12-98.7; 0,04), hemopericárdio (35.1; 3.73-330.2; 0,002), cirurgia de Cabrol (9.9; 1.47-66.36; 0,019), cirurgia de revascularização miocárdica (4.4; 1.31-15.06; 0,017), revisão de hemostasia (5.72 ;1.29-25.29; 0,021) e circulação extra-corpórea [min] (1.016; 1.007-1.026; 0,001). A presença de dor torácia associou-se independentemente com o risco reduzido de óbito hospitalar (0.27; 0.08-0.94; 0,04). As seguintes variáveis apresentaram associação independente com o risco aumentado do desfecho clínico composto na fase hospitalar: uso de antifibrinolítico (3.2; 1.65-6.27; 0,0006), complicação renal (7.4; 1.52-36.0; 0,013), complicação pulmonar (3.7; 1.5-8.8; 0,004), EuroScore (1.23; 1.08-1,41; 0,003) e tempo de CEC [min] (1.01; 1.00-1.02; 0,027). As seguintes variáveis apresentaram associação independente com o risco aumentado de óbito no longo prazo: doença arterial obstrutiva periférica (7.5; 1.47-37.85; 0,015), acidente vascular cerebral prévio (7.0; 1.46-33.90; 0,015), uso de estatina na alta hospitalar (4.9; 1.17-21.24; 0,029) e sangramento aumentado nas primeiras 24 horas (1.0017; 1.0003-1.0032; 0,021). Conclusão: Etnia negra, doença cerebrovascular, hemopericárcio, cirurgia de Cabrol, revascularização miocárdica cirúrgica associada, revisão de hemostasia e tempo de CEC associaram-se independentemente com risco aumentado de óbito hospitalar. A presença de dor torácica associou-se independentemente com o risco reduzido de óbito hospitalar. Doença arterial obstrutiva periférica prévia, acidente vascular cerebral prévio, uso de estatina na alta hospitalar e sangramento aumentado nas primeiras 24 horas associaram-se independentemente com risco aumentado de óbito no prazo longo. Uso de antifibrinolítico, complicação renal, complicação pulmonar, EuroScore e tempo de CEC associaram-se independentemente com o risco aumentado de desfecho clínico composto hospitalar (óbito, sangramento, disfunção ventricular e complicações neurológicas).
Introduction: Both aortic aneurisms and dissections constitute the main aortic diseases, sharing common principles and surgical procedure approaches. Medical and surgical management are seen as a medical challenge concerning elective procedures as well as in emergency cases. Data on prognostic variables independently associated with both hospital and long term death are scarce, leading to a need for appropriate identification of those factors for proper surgical risk evaluation of this population. Objectives: Primary: to identify prognostic variables independently associated with hospital death in patients who underwent surgical procedures for aortic disease correction. Secondary: to identify prognostic variables independently associated with long term death and with composite clinical endpoint (death, bleeding, ventricular dysfunction and neurological complications). Methods: Cross-sectional design plus a longitudinal component, with a retrospective and prospective data collection. Consecutive patients, diagnosed with ascendant aortic aneurism or type A of Stanford aortic chronic dissection were included by means of hospital chart revision and data extraction. A total of 257 patients were recruited and eligibility criteria included those who underwent surgical procedures due to ascendant aortic aneurism or type A of Stanford aortic chronic dissection. Patients with acute aortic dissection and with aortic aneurism in a different segment location other than ascendant aorta were excluded. Clinical endpoints evaluated were death, clinically relevant bleeding, ventricular dysfunction and neurological complications, during the hospital phase and long-term death. Prognostic variables evaluated included: demography, pre-operative factors, intra-operative factors and post-operative complications. Mean follow up was of 970 days. Sample size estimation was defined by a convenience sample along with previous publications. Univariate analysis was conducted to select key variables to be inserted in the multivariate model and to identify the prognostic variables independently associated with clinically relevant endpoints. Results: The following prognostic variables have been identified as independently associated with increased risk of hospital death (OR; 95%IC; P value): black ethnicity (6.8; 1.54-30.2; 0,04), cerebrovascular disease (10.5; 1.12-98.7; 0,04), hemopericardium (35.1; 3.73-330.2; 0,002), Cabrol operation (9.9; 1.47-66.36; 0,019), associated coronary artery bypass graft (4.4; 1.31-15.06; 0,017), reoperation for bleeding (5.72; 1.29-25.29; 0,021) and cardiopulmonary bypass time (CPB) [min] (1.016; 1.007-1.026; 0,001). Presence of chest pain was independently associated with reduced risk of hospital death (0.27; 0.08-0.94; 0,04). The following variables were independently associated with increased risk of composite clinical endpoint during hospital phase: antifibrinolitic use (3.2; 1.65-6.27; 0,0006), renal failure (7.4; 1.52-36.0; 0,013), respiratory failure (3.7; 1.5-8.8; 0,004), EuroScore (1.23; 1.08-1,41; 0,003) and cardiopulmonary bypass time (CPB) [min] (1.01; 1.00-1.02; 0,027). The following variables were independently associated with increased risk of long term death: peripheral obstructive arterial disease (7.5;1.47-37.85;0,015), previous stroke (7.0;1.46-33.90;0,015), at discharge statin use (4.9;1.17-21.24;0,029) and first 24-hour increased bleeding (1.0017;1.0003-1.0032;0,021). Conclusion: Black ethnicity, cerebrovascular disease, hemopericadium, Cabrol operation, associated coronary artery bypass graft, reoperation for bleeding, and cardiopulmonary bypass time were associated with increased risk of hospital death. Presence of chest pain was associated with reduced risk of hospital death. Peripheral obstructive arterial disease, previous stroke, at discharge statin use and first 24-hour increased bleeding were associated with increase risk of long-term death. Use of antifibrinolitic, renal failure, respiratory failure, EuroScore and cardiopulmonary bypass time were associated with increased risk of hospital composite clinical endpoint (death, bleeding, ventricular dysfunction and neurological complications).

Some CBC parameters have been implicated in individual susceptibility to death, both in heart disease and cardiac surgery populations. The cellular elements of blood are widely affected during cardiopulmonary bypass (CPB), technique used in cardiac surgery. A Complete Blood Count called Risk Score (CBC-RS) was calculated from the average of the deviations of the various elements of the CBC and has been previously validated and published. The CBC-RS showed as excellent predictor of death from all causes in large healthy and cardiovascular risk populations. Despite the effect of CPB on the blood cells, there is no acknowledgement from the prior assessment of this score in the surgical setting. The aim of this study was to evaluate the role of CBC-RS in the surgical risk prediction (mortality and morbidity) in patients undergoing cardiac surgery with CPB. For this, it was evaluated a historical cohort of 428 patients undergoing cardiac surgery with CPB. The individual CBC-RS was calculated using the collected blood count of patients preoperatively. Logistic regression and statistical C analyzed the predictive accuracy of this score. The primary endpoint was in-hospital mortality (all-cause) and secondary outcomes included the majors and bleeding complications. In our study, CBC-RS was a predictor of hospital mortality (OR = 1.28 for each score increments, 95% CI = 1123-1458, p <0.001) and secondary outcomes (OR = 1.208, 95% CI = 1.103 to 1.323, p <0.001). The areas under the curve (AUC) was 0.697 (p <0.001) and 0.636 (p <0.001) for both the primary and secondary endpoints, respectively. In multivariate analysis, after adjustment for other risk predictors (EuroSCORE II and CPB time), the CBC-RS remained significant and was the strongest predictor of mortality. Therefore, the CBC-RS proved to be an independent predictor of mortality and surgical complications during hospitalization. It may be a useful tool in risk assessment of patients undergoing cardiac surgery.
Dentre os diversos parâmetros fornecidos pelo hemograma, alguns já foram implicados em aumento da suscetibilidade individual à morte, tanto em pacientes com patologias cardíacas quanto os submetidos à cirurgia cardíaca. Os elementos celulares do sangue são amplamente afetados durante a circulação extracorpórea (CEC), técnica usada nas cirurgias cardíacas. Um escore calculado a partir dos desvios da média dos diversos componentes do hemograma foi previamente validado, publicado e chamado de Complete Blood Count Risk Score (CBC-RS). O CBC-RS se mostrou excelente preditor de morte por todas as causas em grandes populações saudáveis ou com fatores de risco cardiovascular. Apesar do efeito da CEC sobre as células sanguíneas, não se tem conhecimento da avaliação prévia deste escore no contexto cirúrgico. O objetivo do presente trabalho foi avaliar o papel do CBC-RS na predição de risco cirúrgico (mortalidade e morbidade hospitalar) em pacientes submetidos à cirurgia cardíaca com CEC. Para isso, uma coorte histórica de 428 pacientes submetidos à cirurgia cardíaca com CEC foi avaliada. O CBC-RS individual foi calculado utilizando o hemograma coletado dos pacientes no pré-operatório. A acurácia preditora deste escore foi analisada através regressão logística e estatística C. O desfecho primário avaliado foi a mortalidade hospitalar (por todas as causas) e os desfechos secundários incluíram as complicações maiores e sangramento. Em nosso estudo, o CBC-RS foi um preditor de mortalidade hospitalar (OR = 1,28 por cada aumento de pontuação do CBC-RS, IC 95% = 1.123 - 1.458, p <0,001) e dos desfechos secundários (OR = 1,208, IC 95% = 1,103 - 1,323, p <0,001). As áreas sob a curva (AUC) foram 0,697 (p <0,001) e 0,636 (p <0,001) para os desfechos primário e secundário, respectivamente. Na análise multivariada, após ajuste para preditores de risco pré-operatório (EuroSCORE II) e transoperatório (tempo de CEC) conhecidos, o CBC-RS permaneceu significativo e foi o preditor de mortalidade mais forte. Sendo assim, o CBC-RS se mostrou um preditor independente da mortalidade e complicações cirúrgicas no período hospitalar, podendo representar uma ferramenta útil na avaliação de risco de pacientes submetidos à cirurgia cardíaca.

La morbimortalidad de la cirugía cardiaca y el análisis de los factores pronósticos muestran resultados discrepantes. Se analizaron las complicaciones postoperatorias y la mortalidad hospitalaria y a medio plazo, en relación con la edad y otros factores de riesgo asociados. Se realizó en el hospital universitario Son Dureta (Palma de Mallorca), con una unidad de cuidados intensivos específica para dicho paciente. La mortalidad hospitalaria y a medio plazo fue menor, comparada con otras series. El Euroscore sobrevaloró la mortalidad global observada. La edad ≥70 años, la fracción de eyección preoperatoria <30%, la hipertensión pulmonar severa, la diabetes mellitus y la anemia preoperatoria fueron predictores independientes de mortalidad. La disfunción renal moderada preoperatoria fue un predictor independiente de morbilidad en la cirugía valvular. La neumonía nosocomial se asoció con una mayor mortalidad y un aumento del tiempo de ventilación mecánica y de la estancia en cuidados intensivos y hospitalaria.

Background: Despite the recent improvements in surgical techniques and postoperative patient care, atrial fibrillation (AF) remains the most frequent complication after cardiac surgery. Although postoperative AF is often regarded as a benign clinical condition, this arrhythmia has significant adverse effects on patient recovery and postoperative survival. Its exact pathophysiology has not yet been elucidated. The present thesis aims to analyze AF risk factors and their interaction, pre-existing histological explanatory alterations of the atrium, the AF impact on postoperative survival and the compliance of a prophylactic drug regimen. Methods: During a 10-year period, consecutive cardiac surgery cases with complete data on AF occurrence and postoperative survival were extracted. All patients were operated on for coronary or valvular surgery, with cardiopulmonary bypass (CPB). Hospital and long-term survival data were obtained from Swedish population registry. Study I) Isolated coronary artery bypass grafting (CABG, n=7056), aortic valve replacement (n=690) and their combination (n=688) were considered. Independent AF risk factors and AF effects on early and 1 year mortality were investigated. Study II) Patients affected by postoperative AF among isolated CABG patients (n=7621), valvular surgeries (n=995) and their combination (n=879) were studied. Long-term survival was obtained and prognostic factors identified. Study III) Seventy patients were randomized to on-pump (n=35) or off-pump (n=35) CABG. Samples from the right atrial appendage were collected and histology was evaluated by means of light and electronic microscopy with reference to preexistent alterations related to postoperative AF. Study IV) Cardiac surgery patients with complete data on smoking status (n=3245) were reviewed. Effects of smoking on AF development and interaction among variables were explored. Study V) CABG patients without clinical contraindications to receive oral sotalol (80 mg twice daily) and magnesium were prospectively enrolled (n = 49) and compared with a matched contemporary control CABG group (n = 844). The clinical compliance to the AF prophylactic drug regimen was tested. Results: The overall AF incidence was around 26%, subdivided into 23%, 40% and 45% for isolated CABG, valve procedures and their combined surgeries, respectively. Age was the strongest predictor of postoperative AF. Coronary disease superimposed risk factors with reference to myocardial conditions at CPB weaning. Considering the preoperative smoking condition, smokers demonstrated a reduced AF incidence compared to non-smokers (20% versus 27%, p<0.001). An interaction between smoking status and inotropic support was observed: without this interaction smoking conferred a 46% risk reduction of AF (p=0.011). At the histological level, myocyte vacuolization and nuclear derangement represented anatomical independent AF predictors (p=0.002 and p=0.016, respectively). CPB exposure was not associated to postoperative AF nor histological changes. Although, postoperative AF increases the length of hospitalization in all patient groups, it did not affect the hospital survival. However, AF independently impaired the late survival, a phenomenon seen in the CABG group only. With reference to the tested sotalolmagnesium drug regimen, only 55% of CABG patients were compliant to the treatment, with marginal effects on AF occurrence. Conclusions: In addition to age, details at the CPB weaning period, pre-existing histopathological changes, the hyperadrenergic state and catecholamines are key mechanisms in the pathophysiology of postoperative AF. In particular, the CPB period hides valuable information for timely AF prophylactic stratifications. Further, compliance effects due to patient selection should also be considered in a prophylactic therapy model. Postoperative AF increases late mortality after isolated CABG surgery, but not after valvular procedures. Although the mechanisms are unclear, our results draw the attention to possible AF recurrence after hospital discharge, indicating a strict postoperative surveillance.

Antecedents: No existeixen eines predictores de la mortalitat allunyada després d’una cirurgia cardíaca valvular basades només en la informació disponible en el preoperatori. Objectius: Determinar les variables preoperatòries amb significació pronòstica en la supervivència a 4 anys després de cirurgia valvular i construir una escala de predicció de mortalitat enfocada en la classificació en grups de risc. Material i mètodes: Intervencions de cirurgia valvular en l’Hospital Sant Pau en 5 anys, excloent la síndrome aòrtica aguda, seguiment a 4 anys. Determinació per partició recursiva i regressió de Cox dels predictors de mortalitat en els supervivents i desenvolupament d’una escala de risc per partició recursiva per l’algorisme CHAID exhaustiu. Conjunció d’aquesta escala amb les escales EuroSCORE (ES) i ES-II, i una específica valvular (Ambler) per a construir escales globals de mortalitat. Resultats: Es van incloure 1380 pacients entre 2009 i 2013 (edat mitjana de 69,2 anys, 55% homes). La mortalitat operatòria va ser del 7,76% (n=107); la mortalitat observada/pronosticada va ser de 0,84 (ES logístic), de 1,35 (ES-II) i de 1,12 (Ambler). El seguiment va ser complet en el 98,3% dels pacients, i la mortalitat a 4 anys del 15,4% (n=212) dels supervivents. Es van identificar 15 predictors de mortalitat allunyada, a partir dels quals es va desenvolupar un model amb 6 variables (edat, índex de massa corporal, hemoglobina, cirurgia coronària, fracció d’ejecció i prioritat) que va classificar els supervivents en 9 grups entre el 4,6 i el 45,3% de mortalitat. L’edat va obtenir la capacitat pronòstica més gran: Chi2(2) = 71,1; p<0,005. Les escales globals van tenir un rendiment adequat: en la conjunció amb l’ES-II, àrea sota la corba de 0,76 (IC 95% 0,73-0,78; p<0,005), calibratge correcte (Chi2 (8) = 7,7; p = 0,46), i adequada distribució del risc. Conclusions: És possible predir la mortalitat allunyada en els supervivents després d’una cirurgia valvular sobre la base de variables preoperatòries. La conjunció amb les escales de risc quirúrgic aporta models que poden millorar el coneixement pronòstic i la informació dels pacients, identificant potencials àrees de millora.
Antecedentes: No existen herramientas predictoras de la mortalidad alejada tras cirugía cardiaca valvular basadas solo en la información disponible en el preoperatorio. Objetivos: Determinar las variables preoperatorias con significación pronóstica en la supervivencia a 4 años tras cirugía valvular y construir una escala de predicción de mortalidad enfocada en la clasificación en grupos de riesgo. Material y métodos: Intervenciones de cirugía valvular en el Hospital Sant Pau en 5 años, excluyendo el síndrome aórtico agudo, seguimiento a 4 años. Determinación por partición recursiva y regresión de Cox de los predictores de mortalidad en los supervivientes y desarrollo de una escala de riesgo por partición recursiva por el algoritmo CHAID exhaustivo. Conjunción de dicha escala con las escalas EuroSCORE (ES) y ES-II, y una específica valvular (Ambler) para construir escalas globales de mortalidad. Resultados: Se incluyeron 1380 pacientes entre 2009 y 2013 (edad media de 69,2 años, 55% varones). La mortalidad operatoria fue del 7,76% (n=107); la mortalidad observada/pronosticada fue de 0,84 (ES logístico), de 1,35 (ES-II) y de 1,12 (Ambler). El seguimiento fue completo en el 98,3% de los pacientes, y la mortalidad a 4 años del 15,4% (n=212) de los supervivientes. Se identificaron 15 predictores de mortalidad alejada, a partir de ellos se desarrolló un modelo con 6 variables (edad, índice de masa corporal, hemoglobina, cirugía coronaria, fracción de eyección y prioridad) que clasificó los supervivientes en 9 grupos entre el 4,6 y el 45,3% de mortalidad. La edad tuvo la mayor capacidad pronóstica: Chi2(2) = 71,1; p<0,005. Las escalas globales tuvieron un rendimiento adecuado: en la conjunción con el ES-II, área bajo la curva de 0,76 (IC 95% 0,73-0,78; p<0,005), calibración correcta (Chi2(8) = 7,7; p=0,46), y adecuada distribución del riesgo. Conclusiones: Es posible predecir la mortalidad alejada en los supervivientes tras cirugía valvular en base a variables preoperatorias. La conjunción con las escalas de riesgo quirúrgico aporta modelos globales que pueden mejorar el conocimiento pronóstico, la información a los pacientes e identificar potenciales áreas de mejora.
Background: There are no tools to predict late mortality after valvular heart surgery based only on the information available in the preoperative period. Objectives: To determine the preoperative variables with prognostic significance in 4-year survival after valve surgery and to develop a mortality prediction scale focused on risk group classification. Material and methods: Valve surgery interventions at the Hospital Sant Pau in 5 years, excluding acute aortic syndrome; 4-year follow-up. Determination by recursive partitioning and Cox regression of mortality predictors in survivors and development of a risk scale by recursive partitioning based on the exhaustive CHAID algorithm. This scale is combined with the EuroSCORE (ES), ES-II scales, and a specific valve scale (Ambler) to construct global mortality scales. Results: We included 1380 patients between 2009 and 2013 (mean age 69.2 years, 55 % male). Surgical mortality was 7.76% (n=107); observed/predicted mortality was 0.84 (logistic ES), 1.35 (ES-II) and 1.12 (Ambler). Follow-up was complete in 98.3% of patients, and 4-year mortality was 15.4% (n=212) of survivors. Fifteen predictors of late mortality were identified, from which a model was developed with 6 variables (age, body mass index, haemoglobin, coronary surgery, ejection fraction and priority) that classified the survivors in 9 groups between 4.6 and 45.3% mortality. Age obtained the highest prognostic capacity: Chi2(2) = 71.1; p<0.005. Global scales had an adequate performance: in conjunction with the ES-II, area under ROC curve of 0.76 (95% CI 0.73-0.78; p<0.005), correct calibration (Chi2(8) = 7.7; p = 0.46), and adequate risk distribution. Conclusions: It is possible to predict late mortality in survivors after valve surgery based on preoperative variables. The conjunction with surgical risk scales provides global models that can improve prognostic knowledge and patient information, identifying potential areas for improvement.

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Introduction: Acute kidney injury is a complex syndrome characterized by rapid (hours or days) reduction in renal excretion that occurs in a wide variety of situations. It has wide variability of epidemiology and is a common complication in critically ill and intensive care patients. Acute kidney injury generate increased hospital costs and is associated with high mortality rates being independent predictor of death. Currently, three diagnostic criteria for acute kidney injury has been highlighted: RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease), AKIN (Acute Kidney Injury Network) and KDIGO (Kidney Disease: Improving Global Outcomes). Objectives: To evaluate the incidence, morbidity and mortality associated with acute kidney injury (and its value as a predictor of 30-day mortality) in patients undergoing on-pump coronary artery bypass grafting (article 1), patients undergoing cardiac valve surgery (article 2), patients with elevated preoperative baseline creatinine (article 3) and, in general, in patients undergoing cardiac surgery (coronary artery bypass grafting or cardiac valve surgery) (article 4). Methods: (Article 1) Patients undergoing on-pump CABG from January 2003 to January 2008 (817 patients) were divided according to the AKIN classification in AKI (+) and AKI (-) patients. Multivariable logistic regression was used to determine independent predictors of 30-day mortality. (Article 2) Patients undergoing cardiac valve surgery from January 2003 to May 2010 (837 patients) were divided according to the presence of infective endocarditis. Cox regression analysis was used to determine independent predictors of 30-day mortality. (Article 3) Patients with elevated baseline serum creatinine underwent cardiac surgery (CABG or CVS) from January 2003 to June 2013 (918 patients) were evaluated to determine whether the development of post-operative acute kidney injury based on KDIGO criteria was an independent predictor of 30-day mortality. (Article 4) Patients undergoing cardiac surgery (CABG or CVS) between January 2003 and June 2013 (2804 patients) were evaluated to determine if acute kidney injury based on KDIGO criteria was an independent predictor of 30-day mortality. Results: (all articles) Patients who developed AKI postoperatively had more clinical complications. The 30-day mortality increased progressively in all stages of acute kidney injury. Based on AKIN and KDIGO criteria, AKI was an independent predictor of 30-day mortality. Conclusions: (all articles) In this population, acute kidney injury after cardiac surgery was an independent predictor of 30-day mortality.
Introdução: Disfunção renal aguda é uma síndrome complexa caracterizada pela rápida (horas ou dias) redução da excreção renal que ocorre em uma grande variedade de situações. Ela tem ampla variabilidade epidemiológica e é complicação comum em pacientes gravemente enfermos e de terapia intensiva gerando aumento dos custos hospitalares e associando-se a altas taxas mortalidade sendo preditor independente do risco de morte. Atualmente, três critérios diagnósticos para lesão renal aguda tem se destacado: RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease), AKIN (Acute Kidney Injury Network) e KDIGO (Kidney Disease: Improving Global Outcomes). Objetivos: Avaliar a incidência, morbidade e mortalidade associada a lesão renal aguda (e seu valor como preditor de óbito em 30 dias) em pacientes submetidos a cirurgia de revascularização do miocárdio com CEC, pacientes submetidos a cirurgia valvar, pacientes com creatinina basal elevada no pré-operatório e, de maneira global, em pacientes submetidos a cirurgia cardíaca (revascularização do miocárdio ou cirurgia valvar). Métodos: (artigo 1) Pacientes submetidos a RM com CEC no período de janeiro de 2003 a janeiro de 2008 (817 pacientes) foram divididos de acordo com a classificação AKIN em LRA (+) e LRA (-). Regressão logística multivariada foi utilizada para determinação de preditores independentes para óbito em 30 dias; (artigo 2) Pacientes submetidos a cirurgia valvar no período de janeiro de 2003 a maio de 2010 (837 pacientes) foram divididos de acordo com a presença de endocardite infecciosa. Regressão de Cox foi usada para determinar preditores independentes para óbito em 30 dias; (artigo 3) Pacientes portadores de creatinina basal elevada (pré-operatório) submetidos a cirurgia cardíaca (RM ou CV) entre janeiro de 2003 a junho de 2013 (918 pacientes) foram avaliados para determinar se o desenvolvimento de lesão renal aguda pós-operatória baseada nos critérios KDIGO foi preditor independente de óbito em 30 dias; (artigo 4) Pacientes submetidos a cirurgia cardíaca (RM ou CV) entre janeiro de 2003 a junho de 2013 (2804 pacientes) foram avaliados para determinar se o desenvolvimento de lesão renal aguda pós-operatória baseada nos critérios KDIGO foi preditor independente de óbito em 30 dias. Resultados: (todos artigos) Pacientes que evoluíram com LRA tiveram mais complicações no pós-operatório. A mortalidade em 30 dias aumentou progressivamente em todos os estágios de lesão renal aguda. Baseado nos critérios AKIN e KDIGO, LRA foi preditor independente de óbito em 30 dias. Conclusões: (todos artigos) Na população estudada, alteração aguda da função renal no pós-operatório foi preditor independente de óbito em 30 dias.

OBJETIVOS: O objetivo do estudo foi avaliar se a transfusão de hemácias no intraoperatório de cirurgia cardíaca com circulação extracorpórea está associada a complicações clínicas incluindo choque cardiogênico, arritmia, insuficiência renal aguda, isquemia miocárdica, choque séptico, necessidade de reintubação orotraqueal, acidente vascular cerebral ou mortalidade durante a internação hospitalar. DESENHO: Estudo clínico de coorte retrospectivo e unicêntrico com escore de propensão, realizado no Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. PACIENTES: Pacientes adultos submetidos à cirurgia cardíaca eletiva com circulação extracorpórea no período de janeiro de 2004 a dezembro de 2008. DESFECHO PRIMÁRIO: Complicações clínicas durante a internação hospitalar (choque cardiogênico, arritmia, insuficiência renal aguda, isquemia miocárdica, choque séptico, necessidade de reintubação orotraqueal, acidente vascular cerebral ou mortalidade hospitalar). DESFECHO SECUNDÁRIO: 1- Avaliar o efeito da transfusão de hemácias no intraoperatório no tempo livre de inotrópicos e vasopressores, tempo de ventilação mecânica e tempo de permanência na UTI e internação hospitalar. 2- Avaliar o efeito do número das unidades de hemácias transfundidas no intraoperatório na ocorrência de mortalidade hospitalar, choque cardiogênico, arritmia, isquemia miocárdica, choque séptico, acidente vascular cerebral e reintubação orotraqueal. 3- Avaliar o efeito da anemia à admissão e durante internação hospitalar na ocorrência de complicações pós-operatórias. INTERVENÇÃO: Não houve intervenção. RESULTADOS: Foram incluídos 2851 pacientes na análise final, dos quais 1471(51,6%) foram expostos a transfusão de hemácias e 1380 (48,4%) não receberam transfusão no intraoperatório. Os pacientes transfundidos apresentaram maior incidência das seguintes complicações: mortalidade (2,1% vs 0,4%, P < 0,001), insuficiência renal aguda (9,1% vs 3,9%, P<0,001), reintubação orotraqueal (3,8% vs 1,4%, P < 0,001) e choque séptico (2,2% vs 0,4%, P < 0,001). Os pacientes transfundidos também apresentaram maior tempo de internação hospitalar [16 dias (12-23) vs 13 dias (9-18), P < 0,001] e em unidade de terapia intensiva [3 dias (2-6) vs 2 dias (2-4), P < 0,001]. A concentração da hemoglobina menor que 9 g/dL ocorreu em 1847 pacientes (64,7%) durante a internação hospitalar e foi associada a maior risco de insuficiência renal aguda e de acidente vascular cerebral. O escore de propensão identificou 588 pacientes pareados em relação à exposição à transfusão, e essa análise demonstrou que a transfusão intraoperatória de hemácias não aumentou a ocorrência de complicações no período de internação hospitalar. Contudo a transfusão de 4 ou mais unidades de hemácias está associada a maior ocorrência de mortalidade hospitalar, choque cardiogênico e IRA, maior incidência de reintubação orotraqueal, choque séptico e AVC. Além de uma relação direta entre as unidades de hemácias transfundidas e a ocorrência de morte. CONCLUSÃO: Esse estudo observacional demonstrou que a anemia é frequentemente detectada no pós-operatório de cirurgia cardíaca, e está associada a maior incidência de complicações. Além disso, a transfusão de hemácias no intraoperatório não modifica a ocorrência das complicações pós-operatórias em pacientes submetidos a cirurgia cardíaca. No entanto a transfusão de 4 ou mais hemácias está associada a maior incidência de complicações clínicas, além de uma relação dose-dependente. Estratégias como detecção precoce de anemia e emprego de técnicas alternativas à transfusão no manejo devem ser estimuladas no ambiente perioperatório
OBJECTIVE: The objective of this study was to evaluate whether the transfusion of red blood cells in the intraoperative cardiac surgery with extracorporeal circulation is associated with complications after cardiac surgery. DESIGN: A retrospective cohort study with a propensity score analysis, performed at Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. PATIENTS: Adult patients undergoing elective cardiac surgery with cardiopulmonary bypass in the period of January to 2008 December. PRIMARY OUTCOME: Clinical complications during hospital stay (cardiogenic shock, arrhythmia, cardiogenic shock, acute kidney injury, myocardial ischemia, septic shock, tracheal reintubation, stroke or hospital mortality). SECONDARY OUTCOME: 1- Evaluate the effect of intraoperative red blood cell transfusion in inotropic and vasopressor free time, mechanical ventilation time, length of ICU stay and hospital stay. 2- Evaluate the effect of the number of units of transfused red blood cells intraoperatively on the occurrence of hospital mortality, cardiogenic shock, arrhythmia, myocardial ischemia, septic shock, stroke and orotracheal reintubation. 3- Evaluate the effect of anemia on admission and during hospitalization in the occurrence of postoperative complications. RESULTS: In the final analysis, 2851 patients were included. Of these patients, 1471(51.6%) were exposed to red blood cell transfusion (RBC) and 1380 (48.4%) were not exposed to RBC during intraoperative. Transfused patients had higher incidence of the following complications: mortality (2.1% vs. 0.4%, P < 0.001), acute kidney injury (9.1% vs. 3.9%, P < 0,001), tracheal reintubation (3.8% vs. 1.4%, P < 0.001) and septic shock (2.2% vs. 0.4%, P < 0.001). Transfused patients also had a longer length of hospital stay [16 days (12-23) vs. 13 days (9-18), P<0.001] and prolonged intensive care unit stay [3 days (2-6) vs. 2 days (2-4), P < 0.001]. Hemoglobin lower than 9 g/dL was found in 1847 patients (64.7%) during hospital stay and was associated to a higher risk of acute kidney injury and stroke. The propensity score identified 588 paired patients in relation to transfusion exposure, and this analysis demonstrated that intraoperative transfusion of red blood cells did not increase the occurrence of complications during hospitalization. However, transfusion of 4 or more units of red blood cells is associated with a higher occurrence of hospital mortality, cardiogenic shock and acute renal failure, a higher incidence of orotracheal reintubation, septic shock and stroke. In addition to a direct relationship between the units of transfused red blood cells and the occurrence of death. CONCLUSIONS: This observational study demonstrated that anemia is frequently detected in the postoperative period of cardiac surgery, and is associated with a higher incidence of complications. In addition, red blood cell transfusion in the intraoperative does not modify the occurrence of postoperative complications in patients undergoing cardiac surgery. However, transfusion of 4 or more erythrocytes is associated with a higher incidence of clinical complications, in addition to a dose-dependent relationship. Strategies such as early detection of anemia and use of alternative techniques to transfusion in management should be stimulated in the perioperative environment

Introdução: O balão de contrapulsação intra-aórtico (BIA) é usado em uma variedade de contextos relacionados à disfunção miocárdica. Na cirurgia cardíaca, seu papel em desfechos clínicos é motivo de debate devido a resultados conflitantes de análises retrospectivas e limitações de recentes estudos prospectivos. Objetivo: O objetivo do presente estudo foi avaliar a eficácia e segurança do BIA eletivo na ocorrência de um desfecho composto de complicações clínicas incluindo mortalidade em pacientes de alto risco submetidos a cirurgia cardíaca de revascularização miocárdica (RM). Métodos: Estudo clínico prospectivo e randomizado realizado no Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Foram incluídos 181 pacientes adultos submetidos a cirurgia cardíaca de RM no período de abril de 2014 a junho de 2016, com um ou mais dos seguintes critérios: fração de ejeção menor ou igual a 40% e/ou EuroScore maior ou igual a 6. Os pacientes foram randomizados para uso do BIA logo após a indução anestésica ou para grupo controle. Após 24 horas do procedimento, o suporte com o balão intra-aórtico era suspenso se o paciente apresentasse índice cardíaco maior ou igual a 2,2 L/min/m2 com suporte inotrópico mínimo (dobutamina menor ou igual a 5 mcg/Kg/min) ou se o paciente apresentasse efeito colateral grave relacionado ao balão. O desfecho primário foi um composto de mortalidade e complicações graves em 30 dias após a cirurgia (choque cardiogênico, necessidade de reoperação, acidente vascular cerebral, insuficiência renal aguda, infecção de ferida esternal profunda e tempo de ventilação mecânica prolongada). Resultados: Dos pacientes incluídos no estudo, 90 foram alocados para a estratégia de uso do balão intra-aórtico eletivo e 91 para a estratégia controle. O desfecho primário foi observado em 47,8% do grupo BIA e em 46,2% do grupo controle (P=0,456). Não houve diferenças significativas entre os grupos BIA e controle respectivamente, em relação à ocorrência de óbito em 30 dias (14,4% vs 12,1%, P=0,600), choque cardiogênico (18,0% vs 18,9%, P=0,982), reoperação (3,4% vs 4,4%, P=1,000), tempo de ventilação mecânica prolongado (5,6% vs 7,7%, P=0,696), insuficiência renal aguda (22,2% vs 14,3%, P=0,123), acidente vascular cerebral (2,2% vs 2,2%, P=0,123) ou infecção de ferida operatória profunda (7,8% vs 14,3%, P=0,249). O tempo de uso de inotrópico foi significativamente maior no grupo BIA em comparação ao grupo controle (51 horas [32-94] vs 39 horas [25-66], P=0,007). O tempo de internação em UTI foi mais prolongado no grupo BIA comparado ao grupo controle (5 dias [3-8] vs 4 dias [3-6], P=0,035). O tempo de internação hospitalar foi semelhante entre os grupos (13 dias [9-18] vs 11 dias [8-17], P=0,302). Não houve diferença em relação a incidência de complicações relacionadas ao uso do BIA entre os dois grupos. Conclusão: A estratégia de uso do balão intra-aórtico eletivo em pacientes de alto risco submetidos a cirurgia de revascularização miocárdica não reduziu o desfecho combinado de óbito e/ou complicações graves em 30 dias
Introduction: The intra-aortic balloon pump (IABP) is used in a variety of clinical settings in which myocardial function is reduced. In cardiac surgery, its role on clinical outcomes is debated due to conflicting results of retrospective analysis and limitations of recent prospective studies. Objective: The purpose of this study was to evaluate the efficacy and safety of elective IABP use on outcomes in high-risk patients undergoing cardiac surgery. Methods: A prospective randomized controlled trial that evaluated 181 patients undergoing coronary artery bypass at the Heart Institute/University of Sao Paolo from 2014 April to 2016 June. Inclusion criteria were left ventricular ejection fraction (LVEF) <= 40% and/or EuroSCORE>= 6. Eligible patients were randomly assigned, in a 1:1 ratio, to IABP group (n=90) or control group (n=91). Removal of IABP catheter was accomplished after 24 hours of the procedure under the following circumstances: cardiac index >= 2.2 L/min/m2 and dobutamine infusion dose <= 5 ?g/kg/min. The catheter was immediately removed if a severe adverse event related to the procedure was detected. The primary outcome was the composite endpoint of mortality and major morbidity in 30 days after cardiac surgery (cardiogenic shock, need for reoperation, stroke, acute renal failure, mediastinitis and prolonged mechanical ventilation ( > 24 hours). Results: The primary outcome was observed in 47,8% in the IABP group and 46,2% in the control group (P=0,456). There were no differences in the primary outcome: 30-day mortality (14,4% vs 12,1%, P=0,600), cardiogenic shock (18,0% vs 18,9%, P=0,982), need for reoperation (3,4% vs 4,4%, P=1,000), prolonged mechanical ventilation (5,6% vs 7,7%, P=0,696), acute renal failure (22,2% vs 14,3%, P=0,123), stroke (2,2% vs 2,2%, P=0,123) or mediastinitis (7,8% vs 14,3%, P=0,249). Patients from the IABP group had a greater duration of inotrope use (51 hours [32-94] vs 39 hours [25-66], P=0,007) and longer intensive care unit length of stay (five days [3-8] vs four days [3-6], P=0,035). The length of hospital stay was similar (13 days [9-18] vs 11 days [8-17], P=0,302). There were no differences on the incidence of complications related to the IABP use in both groups. Conclusions: The elective IABP use did not reduce 30-day major complications in high-risk patients undergoing cardiac surgery

Apesar dos crescentes avanços no controle e tratamento da insuficiência cardíaca, sejam eles na área clinica ou cirúrgica, o tratamento definitivo permanece sendo o transplante cardíaco. No entanto, o transplante cardíaco tem enfrentado o grave problema da escassez de doadores. Atualmente, estima-se que entre 20% e 40% dos pacientes selecionados falecem na fila de espera em todo o mundo sendo que a maioria, por falência circulatória progressiva. Para esses pacientes, a utilização de dispositivos de assistência circulatória mecânica é, muitas vezes, a única possibilidade de sobrevivência durante a espera do doador. No Brasil, a experiência com o emprego de métodos de assistência circulatória mecânica no tratamento do choque cardiogênico é pequena. Paralelamente, a expectativa de vida dos pacientes nesta situação, em particular os de etiologia chagásica, é muito limitada, e nenhum programa regular foi ainda introduzido com a finalidade de utilizar estes dispositivos no tratamento do choque cardiogênico refratário, especialmente como ponte para o transplante cardíaco. Objetivos: O objetivo deste estudo é determinar a viabilidade e segurança do implante do DAV-InCor como ponte para o transplante cardíaco, avaliando o seu desempenho hemodinâmico, a evolução clínica e as alterações da resposta inflamatória dos pacientes submetidos a este procedimento. Métodos: Este estudo foi realizado em pacientes que estavam na fila de espera para o transplante cardíaco, no período de outubro de 2003 a abril de 2006, e se apresentavam em quadro clínico de choque cardiogênico refratário. Durante os primeiros dias, foram analisadas as medidas de pressão capilar pulmonar (PCP), pressão de artéria pulmonar (PAP), pressão venosa central (PVC), débito cardíaco e índice cardíaco (IC). O cálculo do fluxo indexado era obtido pela divisão entre o fluxo do dispositivo pela superfície corpórea. Durante o seguimento pós-operatório imediato, a saturação venosa central de oxigênio (SVO2), os níveis de lactato sérico, uréia, creatinina, bilirrubinas e desidrogenase lática foram dosados diariamente. Os níveis séricos do peptídeo natriurético central (BNP), das interleucinas (IL6 e IL8), do fator de necrose tumoral alfa (TNF alfa) e da proteína C reativa (PCR) foram dosados nos três primeiros dias de seguimento e posteriormente a cada semana. Resultados: No período do estudo, 29 pacientes foram indicados em caráter de prioridade para o transplante cardíaco. Destes pacientes, 11 evoluíram em choque cardiogênico refratário à terapêutica farmacológica e ao implante de balão intra-aórtico. O implante do DAV-Incor foi realizado em sete destes pacientes. O diagnóstico etiológico foi cardiopatia chagásica em cinco (71%) e cardiomiopatia dilatada idiopática em dois (29%) dos sete pacientes estudados. Cinco pacientes eram do sexo masculino. A idade variou entre 34 e 54 anos (média de 39,5 anos). A assistência circulatória mecânica ao ventrículo esquerdo foi mantida nos 7 pacientes por períodos que variaram de 14 a 42 dias, com média de 26,2 dias. Neste período, o desempenho hemodinâmico foi adequado, sendo observada a normalização do índice cardíaco, das pressões em território pulmonar, da SVO2 e do lactato sérico. A avaliação da resposta inflamatória sistêmica demonstrou a elevação do TNF e das interleucinas, principalmente nos pacientes que evoluíram com alterações infecciosas. O transplante cardíaco foi realizado em 2 pacientes e os outros 5 faleceram em uso do DAV Incor por infecção sistêmica ou falência de múltiplos órgãos. Não ocorreram complicações relacionadas ao DAV em 6 pacientes nos primeiros 30 dias de seguimento. Um paciente apresentou episódio de acidente vascular cerebral extenso aos 26 dias de pós-operatório. Conclusões: Os resultados deste estudo demonstram que, apesar do alto índice de complicações apresentado pelos pacientes, a assistência circulatória mecânica ao ventrículo esquerdo pode ser realizada como ponte para transplante cardíaco em nosso meio.
Cardiac transplantation faces a serious problem of lack of donation. Between 20 and 40% of the listed patients died while waiting for heart transplantation, most of them because of progressive heart failure. For these patients, the use of mechanical circulatory assist devices is the only choice of surviving during that time. In Brazil, the experience with mechanical circulatory support is limited and there is no regular program of the use of these devices as bridge to heart transplantation. Objectives: To evaluate the hemodynamic performance and the systemic inflammatory response during the clinical application of the ventricular assist device type InCor (DAV-InCor) as bridge to heart transplantation. Methods: Between October 2003 and April 2006, 11 patients on the waiting list for heart transplantation have hemodynamic deterioration to refractory cardiogenic shock. Hemodinamic profile (cardiac index, capilar pressure, pulmonary artery pressure and central venous pressure) was analised during early post-operative days. Serum levels of central venous saturation, lactate, urea, creatinin, bilirrubin and lacti desidrogenase were measured every day Blood drawn from patients for 3 days and once a week was assayed for levels of BNP, interleukin 6, interleukin 8, and tumor necrosis factor-alfa. Results: During the study, 11 patients listed for cardiac transplantation as urgent status have deteriorated to refractory cardiogenic shock. Seven of these patients were submitted to DAV-InCor implantation for left ventricular assistance. The etiologic diagnosis was Chagas\' disease in 5 patients (71%) and idiopathic dilated cardiomyopathy in 2 (29%). There were 5 male and 2 female. The age ranged from 34 and 54 years (mean 39,5). Duration of left ventricular assistance ranged from 14 to 42 days (mean 26.2 days). During this period, the hemodynamic performance of the DAV-InCor was adequate to support a normal hemodynamic condition. There was normalization of cardiac index, central venous oxygen saturation and serum lactate. The systemic inflammatory response showed elevated TNF-alfa, Interleukin-6 and interleukin-8 concentrations. Two patients were submitted to heart transplantation, while the other 5 patients died under assistance due to infection and multiple organ failure. There were no complications related to the device in 6 patients. One patient had a stroke by the 26st day Conclusions: Mechanical circulatory support can be performed as bridge to heart transplantation with the DAV-InCor, in spite of the high incidence of complications.

碩士
國立臺灣大學
流行病學與預防醫學研究所
103
Background High mortality after cardiac surgery was related to poor functional capacity which can be evaluated by six-minute walking test (6MWT). Scanty literature was about the relationship between 6MWT distance and the mortality after heart surgery. Material and methods We conducted a retrospective cohort from National Taiwan University Hospital who received CABG and/or valve surgery in 2011 and 2012. We put 6MWT distance as the independent variable into Cox proportional hazards model for survival analysis. Outcome is cardiovascular mortality till 2013/12/31 via linking data to the Collaboration Center of Information Application (CCHIA). Results A total of 383 patients (mean age 60.5±11.3 years old, 28.5% female) undertook 6MWT (301.3±97.1m) during post-surgical hospitalization, and 14 died of cardiovascular causes during a follow-up of median 24 months (interquartile range, IQR=12 months). When 6MWT distance was put as continuous variable, the hazard radio (HR) was 0.27 (95% Confidence interval, CI: 0.10-0.69, p=0.007) with 100m increment. While compared with <200m group, HR of ≥200m and <300m group was 0.22 (95% CI: 0.05-0.91), and HR of ≥300m group was 0.09 (95% CI: 0.01-0.59). Subgroup analysis showed that 6MWT distance was a significant factor of predicting cardiovascular mortality in the lower LVEF group (<60%), but not in the higher LVEF group. Conclusion Our findings demonstrated the prognostic value of 6MWT in post cardiac surgery patients, implying to identify the vulnerable patients who may need more intensive follow-up and active participation in cardiac rehabilitation.

碩士
高雄醫學大學
醫務管理暨醫療資訊學系碩士在職專班
103
Background Cardiac surgery is getting more and more popular in the modern years due to the development of the device and surgical techniques. However, high risk patients who received cardiac surgery are still challenges to every single cardiac surgeon. European system for cardiac operative risk evaluation (EuroSCORE) is a well-accepted, effective risk evaluation system for patient underwent cardiac surgery since the establishment in 1999. But many literatures indicated that origin EuroSCORE overestimated the surgical mortality in past few years. After the Latest evaluation model of EuroSCORE II was published in 2011, there are many studies discussing the validation of the EuroSCORE II. This study is made to figure out the performance of EuroSCORE II in a single medical center in the south Taiwan. Patients and methods From January 2012 to December 2014, there are 719 adult patients who underwent cardiac surgery in Veteran General Hospital Kaohsiung (VGHKS) were included in this study. All risk factors and EuroSCORE II score were collected from the electric medical record and the electric critical care chart. Short term mortality and medical resource with risk subgroups use were analyzed. Results There are 719 patients included in this study. The mean age is 62.98, and the percentage of female patient is 29.21%. 30 days mortality is 8.34%, which the area under curve (AUC) of receiver operating characteristic curve (ROC curve) is 0.819. The calibration of observed 30 days mortality and with the predicted mortality is 1.16. The in-hospital mortality is 11.73%, and the AUC of ROC curve of EuroSCORE II is 0.834. The observed and predicted in-hospital mortality ratio is 1.65. Of all the 644 patients included in the medical resource use analysis, mean length of hospital stay is 27.70 days, and the mean hospital cost is 844,550 NTD. EuroSCORE II risk subgroup and four major complication are significant related to the length of hospitalization. And the hospital cost is significant related to high EuroSCORE II score (EuroSCORE II >4), mediastinitis and respiratory failure. Conclusion EuroSCORE II predicted short term mortality well in VGHKS cardiac surgery population. The five subgroup according to the EuroSCORE II score (0-2,2-4,4-8,8-15,>15) represent a simple and effective risk classification model to predict the mortality and length of hospital stay and hospital cost. Major complications also affect the medical resource use quietly, while mediastinitis and stroke and respiratory failure increase the length of hospital stay, and acute renal failure decrease the hospital stay. Only mediastinis and respiratory failure wound increase the hospital cost.