Predictors of mortality in patients over 70 years-old undergoing CABG or valve surgery with cardiopulmonary bypass

OBJETIVO: Identificar fatores de risco em septuagenários e octogenários submetidos à cirurgia cardiovascular com circulação extracorpórea (CEC). MÉTODOS: Avaliadas variáveis peri-operatórias de 265 pacientes com mais de 70 anos; desses, 248 (93,6%) eram septuagenários e 17 (6,4%) eram octogenários. RESULTADOS: Não houve diferença de mortalidade entre eles, com mortalidade global de 22 (8,3%) pacientes. Não houve diferença em relação ao tipo de procedimento (revascularização ou tratamento valvar) (P=0,545). As variáveis pré-operatórias não aumentaram o risco de morte. Enxerto arterial ou venoso (P=0,261) e número de enxertos utilizados por paciente (P=0,131) não aumentaram a mortalidade. O grupo de sobreviventes apresentou tempo médio de CEC de 70 ± 27 minutos e o grupo óbito, 88,8 ± 25,4 minutos, com significância estatística (P<0,001). O tempo de isquemia no grupo de sobreviventes foi de 55,5 ± 20 minutos e no grupo óbito, 64,9 ± 16 minutos, com significância (P=0,014). Na regressão logística multivariada, o tempo de CEC é a variável que se associa a morte, com qui-quadrado de Pearson =0,0056. Tempo de CEC &gt; 75 minutos apresenta 3,2 vezes (IC 95%: 1,3 - 7,9), maior chance de óbito do que os pacientes com tempo de CEC < 75 minutos. Variáveis pós-operatórias: tempo de ventilação mecânica &gt; 12 horas (P< 0,001), tempo de internação na UTI (P=0,033), reoperação (P=0,001), suporte inotrópico &gt; 48 horas (P<0,001) e necessidade de hemoderivados (P<0,001) aumentam a mortalidade. CONCLUSÃO: A mortalidade global justifica a intervenção. CEC &gt; 75 minutos, tempo de ventilação mecânica superior a 12 horas, de internação em UTI, reoperação, suporte inotrópico por período superior a 48 horas e uso de hemoderivados estão associados a maior mortalidade.OBJECTIVE: To identify risk factors in septuagenarians and octogenarians submitted to cardiovascular surgery with cardiopulmonary bypass (CPB). METHODS: Per-operative variables of 265 patients over 70 years of age were analyzed. 248 (93.6%) were septuagenarians and 17 (6.4%) octogenarians. RESULTS: Overall mortality did not differ between the groups, nor did the type of procedure (CABG or valvular) (P=0.545). Pre-operative variables did not increase the death risk, nor did the use of arterial or venous grafts (P=0.261), or the number of grafts per patient (P=0.131). CPB and cross-clamp time are associated with higher mortality. The survivors' group had an average CPB time of 70 ± 27 minutes while the non-survivors group 88.8 ± 25.4 minutes (P<0.001). Cross-clamp time in the survivors was 55.5 ± 20 minutes, while 64.9 ± 16 minutes in the non-survivors (P=0.014). Using multivariate logistic regression, CPB time is associated with death (Pearson's chi square= 0.0056). CPB time over 75 minutes presents an increased risk of death of 3.2 times (CI 95%: 1.3-7.9) over those with CPB time < 75 minutes. Post-operative variables associated with increased death rates: mechanical ventilation &gt; 12 hours (P<0.001); ICU stay (P=0.033); re-exploration (P=0.001); inotropic support &gt; 48 hours (P<0.001); use of blood components (P<0.001). CONCLUSION: Overall mortality justifies the interventions. CPB time greater than 75 minutes, mechanical ventilation over 12 hours, length of ICU stay, need for reoperation, inotropic drug support over 48 hours, and use of blood components are associated with a higher mortality rate

Cost-Effectiveness Analysis for Surgical, Angioplasty, or Medical Therapeutics for Coronary Artery Disease 5-Year Follow-Up of Medicine, Angioplasty, or Surgery Study (MASS) II Trial

Background-The Second Medicine, Angioplasty, or Surgery Study (MASS II) included patients with multivessel coronary artery disease and normal systolic ventricular function. Patients underwent coronary artery bypass graft surgery (CABG, n = 203), percutaneous coronary intervention (PCI, n = 205), or medical treatment alone (MT, n = 203). This investigation compares the economic outcome at 5-year follow-up of the 3 therapeutic strategies. Methods and Results-We analyzed cumulative costs during a 5-year follow-up period. To analyze the cost-effectiveness, adjustment was made on the cumulative costs for average event-free time and angina-free proportion. Respectively, for event-free survival and event plus angina-free survival, MT presented 3.79 quality-adjusted life-years and 2.07 quality-adjusted life-years; PCI presented 3.59 and 2.77 quality-adjusted life-years; and CABG demonstrated 4.4 and 2.81 quality-adjusted life-years. The event-free costs were $9071.00 for MT;$19 967.00 for PCI; and 18 263.00 for CABG. The paired comparison of the event-free costs showed that there was a significant difference favoring MT versus PCI (P<0.01) and versus CABG (P<0.01) and CABG versus PCI (P<0.01). The event-free plus angina-free costs were 16 553.00, $25 831.00, and$24 614.00, respectively. The paired comparison of the event-free plus angina-free costs showed that there was a significant difference favoring MT versus PCI (P=0.04), and versus CABG (P&lt;0.001); there was no difference between CABG and PCI (P&gt;0.05). Conclusions-In the long-term economic analysis, for the prevention of a composite primary end point, MT was more cost effective than CABG, and CABG was more cost-effective than PCI

Fixation of the short-term central venous catheter. A comparison of two techniques

Purpose: To compare the fixation of the central venous catheter (CVC) using two suture techniques. Methods: A clinical, analytical, interventional, longitudinal, prospective, controlled, single-blind and randomized study in adult, intensive care unit (ICU) patients. After admission and indication of CVC use, the patients were allocated to the Wing group (n = 35, catheter fixation with clamping wings and retainers) or Shoelace group (n = 35, catheter fixation using shoelace cross- tied sutures around the device). Displacement, kinking, fixation failure, hyperemia at the insertion site, purulent secretion, loss of the device, psychomotor agitation, mental confusion, and bacterial growth at the insertion site were evaluated. Results: Compared with the Wing group, the Shoelace group had a lower occurrence of catheter displacement (n = 0 versus n = 4p = 0.04), kinking (n = 0 versus n = 8p = 0.001), and fixation failure (n = 2 versus n = 8p = 0.018). No significant difference was found in bacterial growth (n = 20 versus n = 14p = 0.267) between groups. Conclusion: The Shoelace fixation technique presented fewer adverse events than the Wing fixation technique.Univ Vale Sapucai UNIVAS, Profess Masters Program Appl Hlth Sci, Pouso Alegre, MG, BrazilUniv Vale Sapucai, Profess Masters Program Appl Hlth Sci, Pouso Alegre, MG, BrazilUniv Vale Sapucai, Hosp Clin Samuel Libanio, Dept Cardiac Surg, Pouso Alegre, MG, BrazilUniv Vale Sapucai, Dept Biostat, Pouso Alegre, MG, BrazilUniv Vale Sapucai, Res Lab, Pouso Alegre, MG, BrazilUniv Vale Sapucai, Hosp Clin Samuel Libanio, Pouso Alegre, MG, BrazilUniv Vale Sapucai, Hosp Clin Samuel Libanio, Intens Care Dept, Pouso Alegre, MG, BrazilUniv Vale Sapucai, Pouso Alegre, MG, BrazilUniv Fed São Paulo UNIFESP, Div Plast Surg, São Paulo, BrazilUniv Fed São Paulo UNIFESP, Div Plast Surg, Dept Surg, São Paulo, BrazilUniv Fed São Paulo UNIFESP, Div Plast Surg, São Paulo, BrazilUniv Fed São Paulo UNIFESP, Div Plast Surg, Dept Surg, São Paulo, BrazilWeb of Scienc

Behavior of Ultrasensitive C-Reactive Protein in Myocardial Revascularization with and without Cardiopulmonary Bypass

Abstract Objective: To analyze the inflammation resulting from myocardial revascularization techniques with and without cardiopulmonary bypass, based on ultrasensitive C-reactive protein (US-CRP) behavior. Methods: A prospective non-randomized clinical study with 136 patients was performed. Sixty-nine patients were enrolled for Group 1 (on-pump coronary artery bypass - ONCAB) and 67 patients were assigned to Group 2 (off-pump coronary artery bypass - OPCAB). All study participants had blood samples collected for analysis of glucose, triglycerides, creatinine, total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) and creatinephosphokinase (CPK) in the preoperative period. The samples of creatinephosphokinase MB (CKMB), troponin I (TnI) and US-CRP were collected in the preoperative period and at 6, 12, 24, 36, 48 and 72 hours after surgery. We also analyzed the preoperative biological variables of each patient (age, smoking, diabetes mellitus, left coronary trunk lesion, body mass index, previous myocardial infarction, myocardial fibrosis). All angiographically documented patients with >70% proximal multiarterial stenosis and ischemia, documented by stress test or classification of stable angina (class II or III), according to the Canadian Cardiovascular Society, were included. Reoperations, combined surgeries, recent acute myocardial infarction, recent inflammatory disease, deep venous thrombosis or recent pulmonary thromboembolism, acute kidney injury or chronic kidney injury were not included. Results: Correlation values between the US-CRP curve and the ONCAB group, the treatment effect and the analyzed biological variables did not present expressive results. Laboratory variables were evaluated and did not correlate with the applied treatment (P>0.05). Conclusion: The changes in the US-CRP at each moment evaluated from the postoperative period did not show any significance in relation to the surgical technique applied

Tumor lamination in mediastinal giant tumors

ABSTRACT Mediastinum tumors may grow slowly and reach giant proportions without symptoms, hindering surgical removal. Tumor big dimensions difficult surgical maneuvers, with risk of uncontrollable bleeding and prejudice to surrounding structures. It may be necessary the use of exceptional measures such as venous-venous circulatory deviation, pre-operatory embolization and total extracorporeal circulation. We describe the technique of tumor lamination that allows for complete or almost complete resection of such tumors that in many occasions are not resectable. The description is based on the results of four patients treated with mediastinum giant tumors

Reparo de rotura de ventrículo esquerdo após uso de tenecteplase no tratamento do infarto agudo do miocárdio

A utilização do trombolítico no tratamento do infarto agudo do miocárdio apresentou um impacto importante na diminuição da mortalidade geral, porém não alterou a incidência da rotura cardíaca. Esta complicação deve ser reconhecida e tratada rapidamente, necessitando um alto nível de suspeição clínica. Os autores relatam um caso de reparo cirúrgico de rotura precoce de ventrículo esquerdo, após utilização de tenecteplase associado à heparina não fracionada, no tratamento do infarto agudo do miocárdio

Effects of massive transfusion on oxygen availability

OBJECTIVE: To determine oxygen derived parameters, hemodynamic and biochemical laboratory data (2,3 Diphosphoglycerate, lactate and blood gases analysis) in patients after cardiac surgery who received massive blood replacement. DESIGN: Prospective study. SETTING: Heart Institute (Instituto do Coração), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Brazil. PARTICIPANTS: Twelve patients after cardiac surgery who received massive transfusion replacement; six of them evolved to a fatal outcome within the three-day postoperative follow-up. MEASUREMENTS AND MAIN RESULTS: The non-survivors group (n=6) presented high lactate levels and low P50 levels, when compared to the survivors group (p<0.05). Both groups presented an increase in oxygen consumption and O2 extraction, and there were no significant differences between them regarding these parameters. The 2,3 DPG levels were slightly reduced in both groups. CONCLUSIONS: This study shows that patients who are massively transfused following cardiovascular surgery present cell oxygenation disturbances probably as a result of O2 transport inadequacy