Volume 40 - Número 4

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Introduction: Diaphragm elevation is commonly seen after cardiac surgery, mostly due to phrenic nerve injury. However, only historical data is available on the incidence of diaphragm elevation and its consequences during recovery.
Objective: We aim to provide contemporary insights into the incidence of diaphragm dysfunction in patients undergoing cardiac surgery and its effect on postoperative outcomes.
Methods: Records of all patients undergoing cardiac surgery through sternotomy between 2015 and 2016 at the Radboud University MedicalCentre were retrospectively reviewed. Diaphragm position and elevation were evaluated on available chest radiography. Right-sided diaphragm elevation was defined as the right diaphragm being > 3.0 cm above the left diaphragm; left-sided diaphragm elevation was defined as < 0.5 cm below or above the level of the right diaphragm.
Results: A total of 1510 patients have undergone cardiac surgery through sternotomy during the study period, of which 1316 patients were included in the final analysis. Of these 1316 patients, 13% (n = 179) had pre-existing diaphragm elevation, 27% (n = 351) had a new diaphragm elevation postoperative-y, and 60% (n = 786) had no diaphragm elevation. No statistically significant differences were found between the groups in the occurrence of postoperative (pulmonary) complications or mortality. Of patients who developed new diaphragm elevation postoperatively, 65% recovered in the follow-up period.
Conclusion: New postoperative diaphragm elevation occurs in 27% of patients undergoing cardiac surgery. However, new postoperative diaphragm elevation is not associated with a higher incidence of postoperative complications and spontaneous recovery is seen in most patients.
Keywords: Cardiac surgery. Diaphragm Elevation. Phrenic Nerve Injury

Objective: A variety of cardioplegia techniques with different components are implemented to ensure myocardial protection, in addition to keeping the operationa field immobile and free of blood during cardiac surgery. The implemented cardioplegia has unwanted negative effects on other end organs. In this study, our aim was to compare the effects of Del Nido cardioplegia and blood cardioplegia solutions on postoperative intensive care duration, drainage, and renal functions for patients undergoing cardiopulmonary bypass and bypass graft operations.
Methods: Selections were made from patients undergoing elective bypass graft operations in our clinic from January 1, 2022 to December 31, 2023. Patients were randomly selected, retrospectively assessed, and divided into two groups — De Nido group (Group 1) and blood cardioplegia group (Group 2). Comparisons were made between these groups in terms of intensive care duration, drainage, and renal functions.
Results: The study included 120 patients. The Del Nido cardioplegia group included 60 patients, with 60 patients in the blood cardioplegia group. Comparisons between the groups found that the aortic cross-clamping duration was significantly high in Group 1 (P = 0.014). The noradrenaline dose given to Group 1 was high (P = 0.004). In terms of renal injury, significant degree of elevation was present in Group 1 (P = 0.027). The longer aortic cross-clamping duration in Group 1 may be assessed as a determinant factor for noradrenaline dose and acute kidney injury.
Conclusion: This study concluded that it willbe appropriate to choose the cardioplegia method by performing broader meta-analysis studies and minimizing limiting factors.
Keywords: Surgery. Cardiopulmonary bypass. Acute kidney injury. Induced Heart Arrest. Constriction. Drainage

Objective: To investigate the effect of preoperative and postoperative systemic immune-inflammation index (SII) values on early prognosis in patients with nonfunctional mitral regurgitation etiology undergoing isolated mitral valve replacement (MVR).
Methods: A total of 176 patients with isolated MVR performed from 2015 to 2021 were retrospectively investigated. The platelet, lymphocyte, and neutrophil counts were measured, and SII, neutrophil/lymphocyte ratio (NLR), and platelet/lymphocyte ratio (PLR) values were calculated preoperatively and on the first and fourth days postoperatively. The correlations with postoperative 30-day early-term prognosis and mortality were investigated.
Results: Mean age of the patients was 55.4 years, 69.9% were female, and 30.1% were male. At 30-day follow-up, 9% (n = 16) of patients died. There were significant positive correlations observed between age (P < 0.001), preoperative NLR (P = 0.003), preoperative SII (P = 0.02), and postoperative fourth day NLR (P < 0.001) values with 30-day mortality. Receiver operating characteristic analysis identified that age + preoperative SII (P < 0.001), age + preoperative NLR (P < 0.001), and age + postoperative fourth day NLR (P = 0.001) combinations were significant predictive factors for 30-day mortality. There was a significant positive correlation between postoperative fourth day SII value with intensive care unit (ICU) admission duration (P < 0.001, Ρ = 0.308).
Conclusion: For non-functional, isolated MVR patients, preoperative and postoperative fourth day SII and NLR values were found to provide an idea about 30-day prognosis. Additionally, patients with high postoperative fourth day SII values were observed to have longer ICU stays.
Keywords: Lymphocytes. Blood platelets. Neutrophils. Mitral valve insufficiency. Mortality. Prognosis.

Introduction: Pulmonary artery angiosarcoma is a rare and extremely severe tumor. Our study summarizes the clinical data of patients treated for pulmonary artery angiosarcoma over the period of 2010-2020.
Methods: We retrospectively analyzed cases of surgical treatment of patients with diagnosis of pulmonary artery angiosarcoma at our center. Data of operative findings, short-term follow-up, and the long-term results were reviewed where available.
Results: The 30-day mortality rate was six (67%) out of nine patients. Three (33%) patients were discharged. Data on pulmonary vascular resistance in the earlyand long-term postoperative periods were assessed if possible. Certain computed tomography signs have been identified that can be used to suspect pulmonary artery angiosarcoma and make a differential diagnosis with chronic thromboembolic pulmonary hypertension.
Conclusion: The surgical treatment of choice is pneumonectomy with contralateral pulmonary endarterectomy. Oncological vigilance regarding angiosarcoma in occlusive-stenotic lesions of the pulmonary artery is extremely important. Patients’ assessment must be carried out in an expert cardiothoracic surgery center with the involvement of an oncological crew.
Keywords: Pulmonary artery. Pulmonary hypertension. Endarterectomy. Pneumonectomy. Vascular Resistence.

Introduction: The present study evaluated systemic microcirculatory alterations occurring in the early postoperative period of cardiopulmonary bypass-assisted heart valve surgery compared to preoperative parameters through noninvasive point-of-care microcirculatory imaging of the sublingual area using incident dark field imaging.
Methods: This was a single-center cross-sectional observational study that included 23 patients aged 49 ± 13 years. Sublingual microcirculatory density and perfusion were evaluated using a handheld camera based on incident dark field imaging before surgery and in the early postoperative period.
Results: The total number of capillary vessels (1029 ± 13, P=0.0006), total length of capillary vessels (29.4 ± 3.2 mm, P=0.0005), and capillary vessel density (16.8 ± 1.8 mm/mm2, P=0.0005) were all higher after surgery. On the other hand, the total number of noncapillary vessels (85 ± 34, P=0.05), total length of noncapillary vessels (1.9 ± 0.8 mm, P=0.07), and noncapillary vessel density (1.1 ± 0.5 mm/mm2, P=0.07) were similar before and after surgery. The total number of capillary vessels was higher after surgery (1109 ± 92) in patients who received milrinone infusion (P=0.002) but not in patients who did not receive milrinone (986 ± 129, P=0.05).
Conclusion: After cardiac valve surgery, there was an improvement in microvascular parameters concerning capillary vessels and in the total number of microvessels. Moreover, significant positive correlations were found between the use of milrinone and these parameters. The study demonstrated the usefulness of handheld cameras for bedside evaluation of the microcirculation.
Keywords: Capillares. Milronone. Reference Standards. Microcirculation. Cardiopulmonary bypass. Microvessels. Point-of-Care-Systems.

Introduction: The Norwood operation has transformed the approach to hypoplastic left heart syndrome and its variants. Given the complexity of this procedure, postoperative residual injuries are prevalent.
Objective: To evaluate the impact of significant residual injuries on clinical outcomes and mortality in Norwood procedure patients at a high-volume tertiary center in a developing nation using the technical performance score (TPS).
Methods: This single-center, retrospective study included patients who underwent the Norwood procedure between December 2018 and February 2023. Data on demographics, echocardiograms, complications, intensive care unit stay, and mortality were collected. Logistic regression and linear analyses assessed the impact of TPS on outcomes.
Results: Of 69 patients, nine (13%) were excluded due to incomplete echocardiographic data, leaving 60 (87%) for TPS classification. Among them, 28 (47%) were male. TPS classification was as follows: 40 (66%) in class 1 (excellent), five (8.3%) in class 2 (adequate), and 15 (25%) in class 3 (inadequate), indicating significant residual lesions or need for reintervention. The 30-day mortality rate was 21.6%, increasing to 41.6% before the next stage. In TPS class 3, 30-day mortality was 33% vs. 17% in classes 1 and 2 (P = 0.27). Interstage mortality was 60% in class 3 compared to 35% in other groups (P = 0.13). Major complications were significantly higher in TPS class 3 (93% vs. 55.5%, P = 0.04).
Conclusion: TPS effectively predicts major complications post-Norwood and serves as a valuable tool for improving patient outcomes.
Keywords: Hypoplastic left heart syndrome. Norwood Procedure. Surgery For Congenital Heart Diseases. Reference Standards. Hospital Mortality.

Introduction: Transcatheter aortic valve replacement (TAVR) has revolutionized the management of patients with aortic valve disease. However, the need for pacemaker implantation remains a frequent complication. The objectives of this study were to estimate the incidence of permanent pacemaker implantation and to determine the associated risk factors.
Methods: This is a retrospective cohort study of adults who underwent TAVR, developed cardiac conduction disease, and required permanent pacemaker implantation during hospitalization. Groups were compared according to post procedure pacemaker implantation or not; and recognized preoperative and echocardiographically identified anatomic factors related to the procedure were evaluated. A predictive model was generated using multiple logistic regression.
Results: A total of 234 patients were included. The pacemaker implantation rate was 14%, and risk factors associated with this procedure were age (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.01 - 1.22), female sex (OR 0.11, 95% CI 0.01 - 0.61), body surface area > 1.51 m2 (OR 9.78, 95% CI 2.13 - 73.6), right bundle branch block (OR 22.5, 95% CI 2.62 - 242), first-degree atrioventricular block (OR 18.8, 95% CI 3.04 - 150), and implantation depth measured via echocardiography (OR 1.76, 95% CI 1.26 - 2.64). The model demonstrated good predictive capability with an area under the receiver operating characteristic curve of 0.934 (P < 0.001, 95% CI 0.878 - 0.988).
Conclusion: A well-performing predictive model was developed with six independent risk factors for the need for pacemaker implantation after TAVR, based on factors related to anatomic echocardiographic measurements associated with classic risk factors.
Keywords: Atrioventricular block. Transcatheter Aortic Valve Replacement. Artificial pacemaker. Risk factors.

Introduction: Delirium is one of the most serious and common neuropsychological complications in the immediate postoperative period of cardiac surgery, always resulting in negative consequences, prolonged hospitalization, and increased early and late morbidity and mortality.
Methods: An active search for acute cognitive dysfunction was performed in the electronic medical records written by the multidisciplinary team about the immediate postoperative period of 262 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass operated on in 2019 at the Instituto do Coração of Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo. To maintain randomness, data were collected from 25 patients per month for a total of 10 months.
Results: Seventy-three patients (27.9%) presented symptoms of delirium or perioperative neurocognitive disorder in the postoperative period, with a median time of four days. The most frequent symptoms were changes in cognition (25.6%), attention (25.2%), and agitation (24.8%). Patients with delirium had a longer intensive care unit stay (median seven days vs. three days, P < 0.001), longer mechanical ventilation (median 977 vs. 535, P < 0.001), longer hospital stay (median 20 days vs. 13 days, P < 0.001), and higher incidence of hospital death (22.2% vs. 3.2%, P < 0.001).
Conclusion: The incidence of delirium immediately after cardiac surgery was high, around 27.9%, which is consistent with values found in the literature. The occurrence of delirium was highly associated with worse outcomes, such as longer hospital stays and mortality.

Keywords: Cardiopulmonary bypass; Cardiac surgical procedures; Delirium; Postoperative period; Cognitive Dysfunction; Incidence

Introduction: Cardiovascular problems are one of the major causes of morbidity and mortality among renal transplant and hemodialysis patients. This study evaluates the preoperative risk factors and postoperative outcomes in patients undergoing heart surgery.
Methods: A total of 83 patients (47 post-renal transplant recipients and 36 on hemodialysis) who underwent cardiac surgery and percutaneous coronary artery procedures at Dr. Siyami Ersek Heart Hospital between 2015 and 2022 were retrospectively analyzed using hospital electronic records without selection bias. Demographic information, such as age, sex, height, weight, and body mass index, cardiac surgery type, and preoperative laboratory findings were recorded.
Results: Renal transplant recipients and hemodialysis patients undergoing heart surgery showed no significant differences in age, sex, or comorbidities (P > 0.05). Both groups had a high percentage of patients with elevated fasting blood glucose, triglycerides, and low-density lipoprotein levels. Additionally, body mass index and the triglyceride-glucose index were elevated, indicating insulin resistance. Renal transplant recipients with low preoperative glomerular filtration rate and hemoglobin levels < 10 g/dL had a higher risk of developing acute kidney injury. Four patients (9%) experienced graft loss after acute kidney injury, requiring hemodialysis. Mortality rates did not differ significantly between the groups (P > 0.56).
Conclusion: Cardiovascular surgery can be safely performed in both renal transplant recipients with functional allografts and end-stage kidney disease patients on hemodialysis. Identifying and managing risk factors in these patients, who frequently experience cardiovascular complications, will lead to better outcomes.
Keywords: Cardiac surgical procedures; Renal dialysis; Acute kidney injury; Selection Bias; Insulin Resistance;

Introduction: Previous studies suggest that the location of coronary artery disease cannot independently predict atrial fibrillation after coronary artery bypass grafting, but with little information, it has also been thought that simultaneous right coronary endarterectomy may cause this rhythm problem.
Objective: In this study, we aimed to evaluate the effect of right coronary artery bypass grafting on early postoperative atrial fibrillation.
Methods: Patients who underwent elective on-pump coronary artery bypass grafting operations in our hospital were included in the study, and patients who underwent a different open-heart surgery or those who had previously undergone open-heart surgery were not included. Patients included in the study were divided into Group 1 (patients who developed postoperative atrial fibrillation) and Group 2 (patients who did not develop postoperative atrial fibrillation) and compared in terms of right coronary artery bypass grafting and other follow-up parameters.
Results: The mean age of a total of 158 patients included in the study was determined as 63.25 ± 10.07 years (range 44 - 85 years), 120 were male, and 96% of them had hypertension. Postoperative atrial fibrillation developed in 43 patients, and right coronary artery bypass grafting was performed in 123 patients.
Conclusion: We think that the frequency of postoperative atrial fibrillation development may be higher in cases where right coronary artery bypass grafting is performed, as it may play a role in processes related to the conduction system and right ventricular dysfunction, and multicenter studies with a large number of patients would be beneficial on this subject.

Keywords: Coronary Artery Disease; Coronary artery bypass; Atrial fibrillation; Cardiac Conduction System Disease;

Introduction: Randomized controlled trials (RCTs) provide evidence of efficacy, while real-world data (RWD) demonstrate effectiveness in real-world practice. We designed a systematic review and meta-analysis of reconstructed time-to-event (RTE) data from propensity score matching studies comparing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) to compare their effectiveness and evaluate the generalizability of TAVI indications.
Methods: Systematic review of literature between 2007 and 2023 including propensity score matching studies comparing TAVI or SAVR that reported at least one-year Kaplan-Meier curves of endpoints.
Results: Twenty-one studies were included (39538 participants). TAVI shows a higher all-cause mortality (hazard ratio [HR] 1.41; 95% confidence interval [CI] 1.34-1.47, P-value < 0.001), with a significant heterogeneity. The analysis of HR trend over time shows that TAVI superiority is limited to the first month with a steep reversal afterwards, when SAVR becomes clearly superior. All-cause mortality is significantly higher in TAVI in low-risk (HR 1.35; 95% CI 1.08-1.69, P-value < 0.001) as well as in intermediate (HR 1.73; 95% CI 1.35-2.22, P-value < 0.001) and high-risk (HR 1.61; 95% CI 1.38-1.88, P-value < 0.001) patients. The HR trend in the subgroups of risk confirms the data from the whole mixed population.
Conclusion: In a real-word setting, TAVI is associated with higher incidence of all-cause death and maintains a survival benefit only in the first month after implantation. These results show that TAVI effectiveness may not reflect the efficacy demonstrated by RCTs and pose a threat to their external validity.
Keywords: Transcatheter Aortic Valve Replacement; Aortic valve; Meta-analysis; Systematic Review

Introduction: Extracorporeal membrane oxygenation (ECMO) has emerged as a life-saving therapy for patients with severe respiratory and cardiac failure. However, the management of infections and circuit sequestration remains a significant challenge in ECMO patients. This narrative review aims to provide a comprehensive overview of current strategies and evidence related to antibiotics therapy and circuit management in ECMO.
Methods: A systematic search was conducted in medical databases including PubMed® and Google Scholar to identify relevant studies published up to January 2022. Keywords such as "antibiotics therapy ECMO", "circuit sequestration ECMO", and related terms were used to retrieve articles. Studies focusing on infections acquired during ECMO, antibiotic dosing, circuit optimization, and outcomes were included.
Results: The search yielded a total of 20 relevant studies encompassing various aspects of antibiotics therapy and circuit sequestration in ECMO patients. Key findings include the epidemiology of infections acquired during ECMO, optimal antibiotic dosing strategies, risk factors for circuit-related complications, and the impact of circuit changes on patient outcomes. Effective management of infections and circuit sequestration is essential to improve outcomes in ECMO patients.
Conclusion: This review highlights the importance of tailored antibiotic therapy, vigilant circuit monitoring, and evidence-based practices to mitigate complications and optimize patient care during ECMO support. Further research is needed to refine existing strategies and enhance the overall management of ECMO-associated infections and circuit issues.
Keywords: Extracorporeal membrane oxygenation; Antibiotics Therapy; Circuit Sequestration; Infections; Antibiotic Dosing

This review highlights the pivotal milestones in the development of cardiac transplantation and related techniques. Beginning with Alexis Carrel's pioneering work on vascular anastomosis and organ preservation, the narrative progresses through groundbreaking achievements such as John Gibbon's invention of the heart-lung machine in 1953 and James Hardy's daring chimpanzee-to-human heart transplant in 1964. The story culminates in Christiaan Barnard’s historic human heart transplant in 1967 and Euryclides Zerbini's leadership in bringing this innovation to Brazil in 1968. Key advancements include the development of orthotopic heart transplantation techniques by Richard Lower and Norman Shumway and the resurgence of heart transplants following the introduction of cyclosporine in 1983, which revolutionized organ rejection management. The collaborative Programa Nordeste de Transplante Cardíaco, initiated in 1986, exemplifies regional innovation in overcoming logistical and financial barriers in Brazil. Recent progress, such as the first successful xenotransplantation using a genetically modified pig heart in 2022, underscores ongoing efforts to address donor shortages and improve transplant outcomes. This narrative is a testament to human ingenuity and perseverance in offering life-saving solutions to end-stage heart disease.

Keywords: Surgery; Pioneer; Heart transplantation; Historical Article

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Various techniques of conduit repair have been employed during valve reconstruction. While Ozaki conduits have streamlined the procedure, their limited availability poses concerns. This case report presents 14-year-old patient with pulmonary atresia and an anomalous left anterior descending artery arising from the right sinus. A right ventricle-to-pulmonary artery conduit was created using Dacron^® graft and a trileaflet valve employing Duran's technique of pericardial valve reconstruction, elucidating surgical methodology. In developing countries, the implementation of Duran's technique presents noteworthy advantage allowing for utilization of autologous tissue, addressing challenges associated with PTFE conduits. Unlike PTFE conduits, the results of Duran’s technique at the pulmonary position needs to be followed up in a large number of cases.

Keywords: Pulmonary atresia; Pulmonary artery; Congenital Heart Defects; Polyethylene Terephthalates; Adolescent;

A 79-year-old man with severe aortic valve stenosis and atrial fibrillation was referred to our department for surgery. Computed tomography revealed persistent left superior vena cava. Lower mini-sternotomy was performed. The left atrial appendage was amputated before ablation of the persistent left superior vena cava. The jaw of the ablation device was passed behind the pulmonary veins using a tip-lighted articulating dissector. Finally, aortic valve replacement was completed. Aortic valve replacement with concomitant pulmonary vein and persistent left superior vena cava ablation via lower mini-sternotomy is a safe and less invasive alternative.

Keywords: Superior Vena Cava; Persistent Left Superior Vena Cava; Sternotomy; Aortic valve stenosis; Atrial Appendage; Tomography;

The incidence of sternal wound complications, such as dehiscences, infections, and sternocutaneous fistulas, can reach 10%. Sternocutaneous fistulas are extremely rare, and the only definite therapy is surgical repair. Our experience taught us that combining a traditional approach with an extracellular matrix patch might be a step forward in therapy. We described three examples of surgically reconstructing sternocutaneous fistulas with an extracellular matrix patch (ProxiCor^®).

Keywords: Incidence; Sternum/surgery; Surgical wound infection; Cutaneous Fistula; Cardiac Surgical Procedures;

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