Volume 39 - Número 6
EDITORIAL
Editorial Profile of the BJCVS’ Present, Past, and Future
Braz J Cardiovasc Surg 39;
e20240997
Publish in: 8/2/2025
ORIGINAL ARTICLE
Is It Safe to Use Arterial Grafts in Patients with Acute Myocardial Infarction? Short-Mid-Term Propensity Analysis
Braz J Cardiovasc Surg 39;
Publish in: 8/2/2025
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.
ORIGINAL ARTICLE
Methylene Blue and Blood Transfusion in Hemorrhagic Shock Resuscitation: An Experimental Porcine Study
Braz J Cardiovasc Surg 39;
e20230480
Publish in: 8/2/2025
Introduction: Hemorrhagic shock requires immediate treatment to prevent mortality and organ
dysfunction. This study evaluates the efficacy of methylene blue (MB) with
blood transfusion (BT) as a potential rescue therapy in acute severe
bleeding in pigs.
Methods: Thirty animals were randomly assigned to one of six groups following the induction of fixed-pressure hemorrhagic shock, after reaching a mean arterial pressure (MAP) of 55 mmHg - Group 1 (60 BT: BT after 60 minutes), Group 2 (60 MB: MB infusion after 60 minutes), Group 3 (60 MB + BT: MB and BT after 60 minutes), Group 4 (15 MB + BT: MB and BT after 15 minutes), Group 5 (15 BT + 60 MB: BT after 15 minutes and MB infusion after 60 minutes), and Group 6 (15 MB + 60 BT: MB infusion after 15 minutes and BT after 60 minutes). Hemodynamic and blood gas parameters were meticulously recorded, reversal of the shock was considered when MAP reached 90% of the baseline MAP.
Results: Except for Group 2, all groups reverted from the shock. However, groups that received MB in combination with BT, specifically Groups 3 and 4, exhibited statistically significant higher ratios of maximum MAP to baseline MAP.
Conclusion: Using MB concomitant with BT allowed the reversal of hemorrhagic shock with higher median arterial pressure levels compared to BT alone or applying MB separately from BT. This suggests that simultaneous application of MB and BT could be a more effective strategy for reversing the effects of severe acute bleeding.
Keywords: Animal Model; Methylene blue; Hemorrhagic Shock; Circulatory shock; Bleeding Control; Blood Transfusion;
Methods: Thirty animals were randomly assigned to one of six groups following the induction of fixed-pressure hemorrhagic shock, after reaching a mean arterial pressure (MAP) of 55 mmHg - Group 1 (60 BT: BT after 60 minutes), Group 2 (60 MB: MB infusion after 60 minutes), Group 3 (60 MB + BT: MB and BT after 60 minutes), Group 4 (15 MB + BT: MB and BT after 15 minutes), Group 5 (15 BT + 60 MB: BT after 15 minutes and MB infusion after 60 minutes), and Group 6 (15 MB + 60 BT: MB infusion after 15 minutes and BT after 60 minutes). Hemodynamic and blood gas parameters were meticulously recorded, reversal of the shock was considered when MAP reached 90% of the baseline MAP.
Results: Except for Group 2, all groups reverted from the shock. However, groups that received MB in combination with BT, specifically Groups 3 and 4, exhibited statistically significant higher ratios of maximum MAP to baseline MAP.
Conclusion: Using MB concomitant with BT allowed the reversal of hemorrhagic shock with higher median arterial pressure levels compared to BT alone or applying MB separately from BT. This suggests that simultaneous application of MB and BT could be a more effective strategy for reversing the effects of severe acute bleeding.
Keywords: Animal Model; Methylene blue; Hemorrhagic Shock; Circulatory shock; Bleeding Control; Blood Transfusion;
Thromboelastography with Platelet Mapping to Optimize Surgical Timing in Coronary Artery Bypass Grafting Patients on P2Y12 Receptor Blockers Therapy
Braz J Cardiovasc Surg 39;
e20230292
Publish in: 8/2/2025
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.
Keywords: Coronary artery bypass; Thrombolastography; Clopidogrel; Prasugrel Hydrochloride; Ticagrelor; Waiting Lists
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.
Keywords: Coronary artery bypass; Thrombolastography; Clopidogrel; Prasugrel Hydrochloride; Ticagrelor; Waiting Lists
Effects of Concomitant Intra-Aortic Balloon Pump Usage and Different Cannulation Techniques on Venoarterial Extracorporeal Membrane Oxygenation Support in Terms of Organ Perfusion
Braz J Cardiovasc Surg 39;
e20230241
Publish in: 8/2/2025
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.
Keywords: Extracorporeal membrane oxygenation; Cost-Benefit Analysis; Perfusion; Cardiovascular System; Catherization;
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.
Keywords: Extracorporeal membrane oxygenation; Cost-Benefit Analysis; Perfusion; Cardiovascular System; Catherization;
Survival and Mid-Term Outcomes of On‑Pump vs. Off‑Pump Coronary Artery Bypass Grafting: A Propensity Score-Matched Analysis in A First Peruvian Registry
Braz J Cardiovasc Surg 39;
e20230242
Publish in: 8/2/2025
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.
Keywords: Coronary artery bypass; Extracorporeal membrane oxygenation; Coronary disease; Survival; Propensity Score;
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.
Keywords: Coronary artery bypass; Extracorporeal membrane oxygenation; Coronary disease; Survival; Propensity Score;
Coronary Artery Bypass Grafting Plus Mitral Valve Plasty May Not Provide More Advantage in Patients with Coronary Heart Disease and Moderate Ischemic Mitral Regurgitation: An Inverse Probability of Treatment Weighting Retrospective Cohor
Braz J Cardiovasc Surg 39;
e20230254
Publish in: 8/2/2025
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.
Keywords: Coronary Heart Bypass; Coronary disease; Mammary arteries; Mitral valve insufficiency; Treatment Outcome;
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.
Keywords: Coronary Heart Bypass; Coronary disease; Mammary arteries; Mitral valve insufficiency; Treatment Outcome;
The Effect of Silymarin on the Prevention of Atrial Fibrillation After Coronary Artery Bypass Grafting
Braz J Cardiovasc Surg 39;
e20230422
Publish in: 8/2/2025
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.
Keywords: Atrial Fibrilation; C-reactive protein; Aspartate Aminotransferases; Erythrocyte transfusion; Coronary artery bypass; Control Groups;
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.
Keywords: Atrial Fibrilation; C-reactive protein; Aspartate Aminotransferases; Erythrocyte transfusion; Coronary artery bypass; Control Groups;
Efficacy of Tolvaptan in Older Adults Undergoing Cardiac Surgery: A Single-Center Retrospective Analysis
Braz J Cardiovasc Surg 39;
e20230507
Publish in: 8/2/2025
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.
Keywords: Tolvaptan; Diuretics; Length of stay; Cardiac surgical procedures; Aged; Kidney; Potassium; Sodium;
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.
Keywords: Tolvaptan; Diuretics; Length of stay; Cardiac surgical procedures; Aged; Kidney; Potassium; Sodium;
REVIEW ARTICLE
Cardiac Tumors: Review
Braz J Cardiovasc Surg 39;
e20230405
Publish in: 8/2/2025
Cardiac tumors are rare and encompass a variety of presentations. Clinical
symptoms are usually nonspecific, but they can present as obstructive, embolic, or
constitutional symptoms. Treatment options and prognosis vary highly depending
on the subtype, tumor size, and location. Surgical resection is usually the first-line
therapy, except for cardiac lymphomas, and provides favorable long-term prognosis in most benign tumors. Cardiac sarcomas, however, are usually diagnosed in
advanced stages, and the treatment relies on a multimodal approach with
chemotherapy and radiotherapy. Metastatic cardiac tumors are usually related to
advanced disease and carry an overall poor prognosis.
Keywords: Heart Neo plasms; Prognosis; Lymphoma
Right Ventricular Perforation by Fractured Sternal Wires: A Narrative Review
Braz J Cardiovasc Surg 39;
e20230461
Publish in: 8/2/2025
Introduction: Migration of a fragmented sternal wire is an unusual and rare phenomenon
following cardiovascular surgery. It can present with variable clinical
presentations, ranging from incidental findings to hemodynamic instability.
Here, we described two cases of fragmented sternal wire migration to the
right ventricle.
Methods: Retrospective review of the clinical course of two patients presenting with a fragmented sternal wire embedded in the right ventricle after sternotomy for cardiovascular surgery. We also conducted a literature review to identify similar cases, compared them based on reported clinical variables, and discussed the role of diagnostic imaging and management.
Results: We identified 13 patients (11 from the literature), of which 85% were men, and the median age was 64 years; 46% presented with hemorrhagic shock, another 46% had other cardiovascular symptoms, and 8% were asymptomatic. The presentation was bimodal, 54% presented within three weeks of the original sternotomy, while 46% had sternotomy more than a year before. Sternal dehiscence/instability was observed in 61% of cases. Computed tomography scan was the most common diagnostic modality (54%). Two patients did not undergo surgery, and two others died after surgery, while others had a successful surgical repair.
Conclusion: Migration of a fragmented sternal wire is a phenomenon presented on a dehisced and unstable sternum that can occur days or years after sternotomy. These findings and the associated cardiac injury can be easily missed on computed tomography scan reporting if one is not looking for it. After diagnosis, treatment should be individualized according to the patient’s needs.
Keywords: Bone wires; Sternum; Heart injuries; Penetrating Trauma; Postoperative complications; Incidental Findings;
Methods: Retrospective review of the clinical course of two patients presenting with a fragmented sternal wire embedded in the right ventricle after sternotomy for cardiovascular surgery. We also conducted a literature review to identify similar cases, compared them based on reported clinical variables, and discussed the role of diagnostic imaging and management.
Results: We identified 13 patients (11 from the literature), of which 85% were men, and the median age was 64 years; 46% presented with hemorrhagic shock, another 46% had other cardiovascular symptoms, and 8% were asymptomatic. The presentation was bimodal, 54% presented within three weeks of the original sternotomy, while 46% had sternotomy more than a year before. Sternal dehiscence/instability was observed in 61% of cases. Computed tomography scan was the most common diagnostic modality (54%). Two patients did not undergo surgery, and two others died after surgery, while others had a successful surgical repair.
Conclusion: Migration of a fragmented sternal wire is a phenomenon presented on a dehisced and unstable sternum that can occur days or years after sternotomy. These findings and the associated cardiac injury can be easily missed on computed tomography scan reporting if one is not looking for it. After diagnosis, treatment should be individualized according to the patient’s needs.
Keywords: Bone wires; Sternum; Heart injuries; Penetrating Trauma; Postoperative complications; Incidental Findings;
SPECIAL ARTICLE
Life & Advice from the Giants in Cardiac Surgery: Giving & Receiving; Leading & Following
Braz J Cardiovasc Surg 39;
e20240995
Publish in: 8/2/2025
CLINICAL-SURGICAL CORRELATION
Modified Senning Procedure for Treatment of Transposition of the Great Arteries with Crisscross Heart
Braz J Cardiovasc Surg 39;
e20230244
Publish in: 8/2/2025
Clinical data: A nine-month-old female infant diagnosed with transposition of the great
arteries with symptoms of heart failure associated with cyanosis and
difficulty in gaining weight was referred to our center with late diagnosis
(at nine months of age).
Chest radiography: Electrocardiography: Sinus rhythm with biventricular overload and aberrantly conducted supraventricular extra systoles.
Echocardiography: Wide atrial septal defect, ventricular axis torsion with concordant atrioventricular connection and discordant ventriculoarterial connection.
Computed tomography angiography: Concordant atrioventricular connection, right ventricle positioned superiorly and left ventricle positioned inferiorly; discordant ventriculoarterial connection with right ventricle connected to the aorta and left ventricle connected to pulmonary artery.
Diagnosis: Crisscross heart is a rare congenital heart defect, accounting for 0.1% of congenital heart diseases. It consists of the 90º rotation of ventricles’ axis in relation to their normal position; therefore, ventricles are positioned in the superior-inferior direction rather than anterior-posterior. Most cases have associated cardiac anomalies, and in this case, it is associated with transposition of the great arteries. The complexity and rarity of its occurrence make diagnosis and surgical treatment challenging.
Operation: Modified Senning procedure using the pericardial sac in the construction of a tunnel from pulmonary veins to the right atrium. Cardiopulmonary bypass time of 147 minutes with nine minutes of total circulatory arrest.
Keywords: Arterial Switch Operation; Cardiopulmonary bypass; Delayed Diagnosis; Pulmonary artery; Crisscross heart; Transposition of great vessels; Heart ventricles
Chest radiography: Electrocardiography: Sinus rhythm with biventricular overload and aberrantly conducted supraventricular extra systoles.
Echocardiography: Wide atrial septal defect, ventricular axis torsion with concordant atrioventricular connection and discordant ventriculoarterial connection.
Computed tomography angiography: Concordant atrioventricular connection, right ventricle positioned superiorly and left ventricle positioned inferiorly; discordant ventriculoarterial connection with right ventricle connected to the aorta and left ventricle connected to pulmonary artery.
Diagnosis: Crisscross heart is a rare congenital heart defect, accounting for 0.1% of congenital heart diseases. It consists of the 90º rotation of ventricles’ axis in relation to their normal position; therefore, ventricles are positioned in the superior-inferior direction rather than anterior-posterior. Most cases have associated cardiac anomalies, and in this case, it is associated with transposition of the great arteries. The complexity and rarity of its occurrence make diagnosis and surgical treatment challenging.
Operation: Modified Senning procedure using the pericardial sac in the construction of a tunnel from pulmonary veins to the right atrium. Cardiopulmonary bypass time of 147 minutes with nine minutes of total circulatory arrest.
Keywords: Arterial Switch Operation; Cardiopulmonary bypass; Delayed Diagnosis; Pulmonary artery; Crisscross heart; Transposition of great vessels; Heart ventricles
CASE REPORT
The Usefulness of Microcirculatory Assessment After Cardiac Surgery: Illustrative Case Report
Braz J Cardiovasc Surg 39;
e20230383
Publish in: 8/2/2025
Cardiac tumors are rare and encompass a variety of presentations. Clinical
symptoms are usually nonspecific, but they can present as obstructive, embolic, or
constitutional symptoms. Treatment options and prognosis vary highly depending
on the subtype, tumor size, and location. Surgical resection is usually the first-line
therapy, except for cardiac lymphomas, and provides favorable long-term prognosis in most benign tumors. Cardiac sarcomas, however, are usually diagnosed in
advanced stages, and the treatment relies on a multimodal approach with
chemotherapy and radiotherapy. Metastatic cardiac tumors are usually related to
advanced disease and carry an overall poor prognosis.
Keywords: Microcirculation; MitralValve; Cardiac surgical procedures; Hemodynamics; Perfusion; Oxygen
Resolution of Acute Respiratory Distress Syndrome-Induced Takotsubo Cardiomyopathy with Venovenous Extracorporeal Membrane Oxygenation
Braz J Cardiovasc Surg 39;
e20230117
Publish in: 8/2/2025
Introduction: Takotsubo cardiomyopathy (TTCM) can occur in acute respiratory distress syndrome (ARDS) and a few cases in literature were reported to be associated with hemodynamic instability. All these patients were managed with venoarterial extracorporeal membrane oxygenation (VA-ECMO).
Case presentation: We present two patients with ARDS-induced TTCM who were managed successfully with venovenous ECMO (VV-ECMO).
Conclusion: Ventricular function in both patients fully recovered three days after ECMO initiation, and they were subsequently weaned from ECMO once pulmonary function improved.
Bypass and Ligation of Right Subclavian Artery Aneurysm in a Patient with Marfan’s Syndrome via Reoperative Partial Upper Median Sternotomy
Braz J Cardiovasc Surg 39;
e20230300
Publish in: 8/2/2025
Subclavian artery aneurysms are rare and can result in thromboembolism or rupture. We present the case of a 41-year-old man with a history of Marfan’s syndrome and multiple previous operations, who presented with an enlarging asymptomatic 5.2 cm right subclavian artery aneurysm and was successfully treated with a hybrid surgical operation.
Keywords: Marfan syndrome; Subclavian artery; Aneurysm; Thromboembolism;
LETTER TO THE EDITOR
DO₂/VCO₂ Ratio Improvement on Cardiopulmonary Bypass During Minimally Invasive Mitral Valve Repair
Braz J Cardiovasc Surg 39;
e20230464
Publish in: 8/2/2025