Mortality Predictors in the Surgical Treatment of Active Infective Endocarditis

<div><p>Abstract Introduction: Active infective endocarditis is associated with high morbidity and mortality. Surgery is indicated in high-risk conditions, and the main determinants of mortality in surgical treatment should be evaluated. Objective: To identify mortality predictors in the surgical treatment of active infective endocarditis in a long-term follow-up. Methods: This prospective observational study involved 88 consecutive patients diagnosed with active infective endocarditis, who underwent surgery between January 2005 and December 2015. Fifty-eight (65.9%) patients were male, the mean age was 50.87±16.15 years. A total of 31 (35.2%) patients had a history of rheumatic fever; 48 (54.5%) had had heart surgery with prosthetic valve implantation; 45 (93.8%) had biological prosthetic valve endocarditis and 3 (6.3%) mechanical prosthetic valve; 40 (45.5%) patients had the disease in their native valve. The mean EuroSCORE II was 8.9±6.5%, and the main surgical indication was refractory heart failure in 38 (43.2%) patients. A total of 68 bioprosthesis (36 aortic, 32 mitral) and 29 mechanical prostheses (12 aortic, 17 mitral) were implanted and three mitral valve plasties performed. A total of 25 (28.4%) patients underwent double or triple valve procedures. Aortic annulus reconstruction by abscess was performed in 18 (20.5%) and six (6.81%) patients had combined procedure. The mean surgery time was 359±97.6 minutes. Results: The overall survival in up to a 10-year follow-up period was 79.5%. In the univariate analysis, the main mortality predictors were positive blood cultures (P=0.003), presence of typical microorganisms (P=0.008), most frequently Streptococcus viridans (12 cases; 25%); C-reactive protein (hazard ratio [HR] 1.034, 95% confidence interval [CI] 1.000 to 1.070, P=0.04); creatinine clearance (HR 0.977, 95% CI 0.962 to 0.993, P=0.005); length of surgery: every five minutes multiplies the chance of death 1.005-fold (HR 1.005, 95% CI 1.001 to 1.009, P=0.0307); age (HR 1.060, 95% CI 1.026 to 1.096, P=0.001); and EuroSCORE II (HR 1.089, 95% CI 1.030 to 1.151, P=0.003). Conclusion: A positive blood culture with typical microorganism, C-reactive protein, age, EuroSCORE II, total surgical time and the presence of postoperative complications were the major predictors of mortality and significantly impacted survival in up to a 10-year follow-up period.</p></div

Use of Doppler Ultrasound for Saphenous Vein Mapping to Obtain Grafts for Coronary Artery Bypass Grafting

<div><p>Abstract Introduction: The great saphenous vein is widely used as a graft in coronary artery bypass grafting surgery. Complications due to saphenous vein harvesting can be minimized when using ultrasonography mapping and marking. Objective: To analyze by clinical trial the use of vascular ultrasonography to map the saphenous vein in coronary artery bypass grafting to determine viability and dissection site. Methods: A total of 151 consecutive patients submitted to coronary artery bypass surgery with the use of the great saphenous vein as a graft were selected for this prospective study. They were divided into two groups: Group 1 - 84 patients were submitted to ultrasonographic mapping and marking of the saphenous vein; Group 2 - 67 patients had saphenous vein harvested without any previous study. Both groups were coupled with follow-up on the 1st, 5th and 30th postoperative days. Primary endpoints were need for incision of the contralateral leg and wound complications within 30 days. Results: Both legs had to be incised in 6 (8.95%) patients from Group 2 (P=0.0067). Wound complications occurred in 33 (23.4%) patients within 30 days, 21 (35%) from Group 2 e 12 (14.8%) from Group 1 (OR 3.095, 1.375-6.944, CI 95%, P=0.008). Within 30 days there were 4 (2.8%) deaths, all in Group 2 (P=0.036). Conclusion: The use of vascular ultrasonography for mapping of the great saphenous vein in coronary artery bypass surgery has properly identified and evaluated the saphenous vein, significantly reducing wound complications and unnecessary incisions. It would be advisable to use this noninvasive and easy to use method routinely in coronary artery bypass surgery.</p></div