Banco de dados de cirurgia cardiovascular do Hospital de Clínicas de Porto Alegre – Projeto Ancora – HCPA : da elaboração à prática

A necessidade crescente de melhoria na qualidade do atendimento aos pacientes e a busca do aprimoramento constante dos resultados cirúrgicos depende, sobretudo, da análise de dados precisos e confiáveis. Elaborar registros clínicos de alta qualidade implica no desenvolvimento de bancos de dados bem elaborados, de fácil aplicabilidade e reprodutíveis. Com este objetivo idealizou-se a criação do Projeto ANCORA-HCPA, bANCo de dadOs da ciruRgia cardiovasculAr do Hospital de Clínicas de Porto Alegre, uma plataforma totalmente informatizada para coleta, armazenamento e análise de dados em cirurgia cardiovascular. Neste trabalho são descritas as etapas de construção e execução desta iniciativa, bem como os resultados preliminares obtidos após sua implementação no Hospital de Clínicas de Porto Alegre, um hospital universitário terciário do Sul do Brasil. A nova plataforma foi criada baseada nas ferramentas do Google®. Dados de 271 pacientes consecutivos arrolados de maio de 2015 a fevereiro de 2017 foram prospectivamente recordados e analisados. Como resultado, obteve-se uma taxa de inclusão de 100% dos pacientes, sem perda de dados em um banco de dados composto por mais de 500 variáveis (235 pré-operatórias, 170 trans-operatórias, 37 durante internação em unidade de terapia intensiva e 73 pós-operatórias). Os principais desfechos adversos pós-operatórios precoces observados foram: fibrilação atrial nova (22,5%), broncopneumonia (10,7%), delirium (10,3%), insuficiência renal aguda (10%) e acidente vascular cerebral (5%). Comparando-se as taxas de mortalidade no primeiro e segundo ano da iniciativa, uma redução de 10,8% para 4% (p =0,042), respectivamente, foi evidenciada. Esta nova proposta de registro e análise de dados mostrou-se plenamente factível, efetiva e de ampla aplicabilidade, permitindo a avaliação das taxas de sucesso e complicações e o consequente desenvolvimento de programas de melhoria de qualidade cirúrgica.Improvement in healthcare quality and surgical outcomes depends, first of all, on analysis of precise and reliable data. Building high-quality clinical records implies designing an accessible, easy-to-apply and reproducible database. We aimed to describe in a practical, step-by-step manner, the construction of a fully electronic cardiovascular database and the initial experience of working with it in a tertiary university hospital by 6 presenting the preliminary outcomes data. We described the creation and implementation of a novel biomedical database with the intent to be an easy and accessible tool with the potential to improve healthcare quality. The platform was created based on the Google ToolsTM. Data of 271 consecutive patients were prospectively recorded and analyzed. The initiative was implemented with plenty success. A 100% patient inclusion rate was obtained, with no data loss in a database composed by more than 500 variables (235 preoperative, 170 transoperative, 37 while in intensive care unit, and 73 postoperative). The more frequently observed early postoperative outcomes were: new atrial fibrillation (22.5%), bronchopneumonia (10.7%), delirium (10.3%), acute renal failure (10%) and stroke (5%). Comparing mortality rate between the first and second years, a significant reduction, from 10.8% to 4%, respectively, was made evident (p =0.042). This new proposal of data recording proved itself to be easy, feasible and with broad utility since it uses a free platform, universally available, in a process to uncover success and complication rates, thus leading to debate and healthcare quality improvement as demonstrated by our preliminary data analysis

Punção de veia axilar guiada por ultrassonografia versus dissecção de veia cefálica para implante de eletrodos de marcapasso e cardiodesfibrilador : um ensaio clínico randomizado

A punção venosa axilar guiada por ultrassonografia surgiu como uma alternativa válida para implante de eletrodos de marcapasso e cardiodesfibrilador. Objetivo: Comparar a punção axilar guiada por ultrassonografia com a dissecção de veia cefálica para implante de eletrodos de marcapasso e cardiodesfibrilador. Métodos: Ensaio clínico randomizado com arrolamento de 88 participantes adultos, na razão de 1:1. O desfecho primário foi a taxa de sucesso na obtenção do acesso venoso. Os desfechos secundários foram a necessidade de mudança do sítio de acesso venoso, o tempo para obtenção do acesso, o tempo total de procedimento e a taxa de complicação precoce. Os desfechos foram analisados por intenção de tratar. Os procedimentos foram realizados por operadores sem experiência prévia com o acesso axilar. Resultados: A taxa de sucesso (97,7% vs. 54,5%; p=0,001), a necessidade de mudança do sítio venoso (2,3% vs. 40,9%; p=0,001), o tempo para obtenção do acesso (5 vs. 15 minutos; p=0,001) e o tempo total de procedimento (40 vs. 51 minutos; p=0,010) foram significativamente melhores no grupo axilar, sem diferença significativa na taxa de complicação precoce (2,3% vs. 11,4%; p=0,20). Conclusão: Este é o primeiro estudo randomizado comparando a punção axilar guiada por ultrassonografia com a dissecção de veia cefálica no implante de eletrodos de marcapasso e cardiodesfibrilador. Os resultados demonstraram superioridade da estratégia de punção axilar guiada por ultrassonografia.Axillary vein puncture guided by ultrasound has emerged as a valid alternative access route to pacemaker and defibrillator lead insertion. Objective: To evaluate whether axillary vein puncture guided by ultrasound compared to cephalic vein dissection improves success and early complications in pacemaker or defibrillator implant. Methods: Randomized clinical trial enrolling 88 adult patients, randomized 1:1 to axillary puncture guided by ultrasound (n=44) or cephalic vein dissection (n=44). The procedures were performed by operators with no previous experience in axillary approach. Primary endpoint was success rate. Secondary endpoints were venous access site change, time to obtain venous access, total procedural time, and early complication rate. Analyses were performed using the intention-to-treat principle. Results: Success rate (97.7% vs. 54.5%; p=0.001), venous access site change (2.3% vs. 40.9%; p=0.001), time to obtain venous access (5 vs. 15 minutes; p=0.001) and total procedural time (40 vs. 51 minutes; p=0.010) were improved in axillary group, with no difference in early complication rate (2.3% vs. 11.4%; p=0.20). Conclusion: This is the first randomized trial comparing self-learned ultrasound-guided axillar vein 9 puncture to cephalic vein dissection in cardiac lead implantation. The results indicate that the axillary approach was superior in terms of success rate, time to obtain venous access and procedural time, with similar complication rate

The use of BASILICA Technique to prevent coronary obstruction in a TAVI-TAVI procedure

Transcatheter aortic valve implantation (TAVI) to manage structural bioprosthetic valve deterioration has been successful in mitigating the risk of a redo cardiac surgery. However, TAVI-in-TAVI is a complex intervention, potentially associated with feared complications such as coronary artery obstruction. Coronary obstruction risk is especially high when the previously implanted prosthesis had supra-annular leaflets and/or the distance between the prosthesis and the coronary ostia is short. The BASILICA technique (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) was developed to prevent coronary obstruction during native or valve-in-valve interventions but has now also been considered for TAVI-in-TAVI interventions. Despite its utility, the technique requires a not so widely available toolbox. Herein, we discuss the TAVI-in-TAVI BASILICA technique and how to perform it using more widely available tools, which could spread its use

Balloon fracturing valve-in-valve : how to do it and a case report of TAVR in a rapid deployment prosthesis

Transcatheter aortic valve replacement (TAVR) to treat degeneration of bioprosthetic heart valves (BHVs), called as valve-in-valve (ViV), is becoming a key feature since the number of BHVs requiring intervention is increasing and many patients are at high risk for a redo cardiac surgery. However, a TAVR inside a small previous cardiac valve may lead to prosthesis-patient mismatch (PPM) and not be as effective as we hoped for. An effective option to decrease the chance of PPM is to fracture the previous heart valve implanted using a high-pressure balloon. By performing a valve fracture, the inner valve ring of small BHVs can be opened up by a single fracture line, allowing subsequent implantation of a properly sized transcatheter heart valve, without increasing substantially the procedure risk. In this article, we provide a step-by-step procedure on how to safely and properly fracture a BHV and report a case of a TAVR in a degenerated rapid deployment valve

Update in heart rhythm abnormalities and indications for pacemaker after transcatheter aortic valve implantation

Objective: Rhythm abnormalities following transcatheter aortic valve implantation (TAVI) and indications for permanent pacemaker implantation (PPI) were reviewed, which aren’t well established in the current guidelines. New left bundle branch block and atrioventricular block are the most common electrocardiographic changes after TAVI. PPI incidence ranges from 9-42% for selfexpandable and 2.5-11.5% for balloon expandable devices. Not only anatomical variations in conduction system have an important role in conduction disorders, but different valve characteristics and their relationship with cardiac structures as well. Previous right bundle branch block has been confirmed as one of the most significant predictors for PPI