Volume 41 - Issue 1

INTRODUCTION: Coronary artery bypass grafting remains the preferred method for surgical myocardial revascularization. The use of extracorporeal circulation during surgery has been linked to myocardial damage and a systemic inflammatory response. To mitigate these adverse effects, off-pump coronary artery bypass grafting was introduced as an effective and safe alternative. However, the comparison between these two procedures has yielded ambiguous results. The aim of our study was to determine the differences in myocardial damage and the intensity of the inflammatory response by measuring concentrations of troponin, cardiac isoenzyme of creatine kinase, leukocytes, and C-reactive protein at multiple time points within the first 24 hours postoperatively.
METHODS: This single-center, prospective study involved 61 patients diagnosed with coronary artery disease and divided into two groups based on the type of surgery performed.
RESULTS: Our results indicated that coronary artery bypass grafting with extracorporeal circulation is associated with greater myocardial damage, as evidenced by higher levels of troponin and cardiac isoenzyme of creatine kinase. Additionally, extracorporeal circulation was linked to a more pronounced increase in leukocyte count postoperatively. Unexpectedly, C-reactive protein levels were higher in the off-pump coronary artery bypass grafting group. There were no significant differences in hospital stay or in-hospital mortality between the two groups.
CONCLUSION: Further research is necessary to clarify these controversies regarding the differences in systemic inflammatory responses between the two surgical approaches.

INTRODUCTION: Type A aortic dissections are pathologies with high mortality rates. Although ascending aortic aneurysms are typically planned for elective surgery, they are significant conditions in cardiovascular surgery due to their potential to cause type A aortic dissection. This study, which is the first to examine sirtuin 1 (SIRT1) in human ascending aortic tissues, aims to elucidate the relationship between ascending aortic pathologies and the SIRT1 protein.
METHODS: A case-control study was conducted using aortic tissues and demographic data from patients who underwent surgery for ascending aortic aneurysm and type A aortic dissection. Coronary artery bypass patients were selected as the control group. The groups were compared in terms of SIRT1 levels.
RESULTS: The study included a total of 46 patients (16 in the aneurysm group, 14 in the dissection group, and 16 in the control group). The SIRT1 protein level was the highest in the ascending aortic aneurysm group (214, interquartile range [IQR] 79 - 270), followed by the dissection group (172, IQR 148 - 224), and the lowest in the control group (104, IQR 78 - 123) (P = 0.014). SIRT1 level was found to be low in patients with coronary artery disease (P = 0.001), peripheral artery disease (P = 0.008), and hypertension (P = 0.023).
CONCLUSIONS: Type A aortic dissections are associated with elevated SIRT1 levels in the tissue. Systemic atherosclerotic diseases, such as coronary and peripheral artery diseases, are associated with decreased SIRT1 levels. There is also a relationship between hypertension and sirtuin1 levels.

OBJECTIVE: This study investigated whether blood groups are predictive factors for the severity and postoperative mortality in patients with coronary artery disease (CAD) undergoing bypass surgery with extracorporeal circulatory support
METHODS: A retrospective cohort study examined data from 4,002 patients who had coronary surgery for CAD between January 1^st, 2014, and December 30^th, 2020. The study recorded blood groups, demographic information, and and SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) scores for patients who died within the first month post-operation.
RESULTS: Multiple regression analysis showed significant associations with the SYNTAX score (P < 0.001). Individuals with blood group O had a 2.970 times decrease in their SYNTAX score, while those with blood group A showed a 0.260 times increase, and those with blood group B had a 1.895 times decrease. Analyzing the effect of blood groups on mortality, the risk of death was significantly higher compared to blood group O; in group A the risk of death was 2.65 times higher than in group O (P = 0.005, odds ratio [OR]: 2.65, 95% confidence interval [CI]: 1.35 − 5.19). In group B the risk of death was 2.29 times higher than in group O (P = 0.048, OR: 2.29, 95% CI: 1.01 − 5.23). The Rh factor did not affect either mortality or CAD severity.
CONCLUSION: In patients undergoing coronary surgery, the SYNTAX score was found to be significantly lower in blood groups O and B. However, regarding mortality, both blood groups A and B carried a higher risk of death when compared to group O.

INTRODUCTION: Postoperative bleeding increases morbidity and mortality. We aimed to review the scoring systems used to predict massive bleeding after isolated coronary artery bypass grafting in diabetic patients and determine the parameters of the new scoring system — the Optimum Risk Score for Bleeding (ORS).
METHODS: Two hundred ninety-seven diabetic patients who underwent isolated coronary artery bypass operation between 2017 and 2019 were reviewed. The patients were grouped according to amount of drainage (> 850 mL/day) and the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) bleeding severity grade. Previously identified risk factors and scoring systems (Papworth, WILL-BLEED, Association of Cardiothoracic Anesthetists perioperative risk of blood transfusion [ACTA-PORT], Transfusion Risk and Clinical Knowledge [TRACK], and Transfusion Risk Understanding Scoring Tool [TRUST]) were analyzed.
RESULTS: Papworth was better predictive for E-CABG bleeding grades 2 - 3. WILL-BLEED, ACTA-PORT, TRACK, and TRUST had no discriminatory value in terms of E-CABG bleeding grades 2 - 3. Among the parameters in the scoring systems, gender, preoperative hemoglobin (or hematocrit) value, preoperative platelet count, use of antiplatelets until less than five days prior to the operation, and preoperative creatinine (or estimated glomerular filtration rate) values should be included in the scoring system we aim to establish in the future, the ORS.
CONCLUSION: The current scoring systems do not provide satisfactory results in predicting postoperative bleeding. Female gender, lower body mass index, and preoperative platelet count were associated with increased postoperative bleeding. There is a need for an ORS which gives more precise results in predicting postoperative bleeding.

INTRODUCTION: Heart transplantation is a crucial therapeutic modality for patients with advanced heart failure. For satisfactory results, acceptable ischemic times are essential. This study aims to investigate the relationship between cold ischemic time > 4 hours and mortality in the first month after heart transplantation.
METHODS: Retrospective and observational analysis of medical records of patients who underwent heart transplantation between January 2019 and December 2023. The inclusion criteria were patients who underwent heart transplantation using the histidine-tryptophan-ketoglutarate preservation solution during organ retrieval and immediately before organ implantation. Recipient variables, etiology of heart failure, procedural variables, and 30-day mortality were studied.
RESULTS: During the study period, 62 patients underwent heart transplantation. There were a predominance of males (79%) and an average age of 51 years. Seven patients had a cold ischemic time ≥ 4 hours, with three dying (43%) before 30 days. Among the 55 patients with cold ischemic times < 4 hours, 17 died (31%) before 30 days. Statistical analysis using the chi-square test revealed no statistically significant association between cold ischemia and mortality in the first 30 days after transplantation (P = 0.835).
CONCLUSION: The study found no difference in 30-day mortality between patients who underwent heart transplantation with cold ischemic times > 4 hours and those with cold ischemic times < 4 hours. Thus, there may be new strategies to increase the number of donors with a safe rebalance of the relationship between the number of available allografts and patients on the waiting list.

INTRODUCTION: The Charlson Comorbidity Index (CCI) is used for assessing comorbidities and estimating risk of adverse outcomes in surgical patients. In cardiac surgery, the burden of comorbidities can significantly influence incidence of postoperative complications and mortality. This study evaluates the utility of CCI in predicting perioperative complications in patients undergoing cardiac surgery.
METHODS: Observational cross-sectional study with retrospective data including 483 adult patients who underwent cardiac surgery with cardiopulmonary bypass at the Instituto Nacional de Cardiología Ignacio Chávez from June 2022 to December 2023. Patients were grouped by preoperative CCI: mild (0 – 1), moderate (2), and severe (≥ 3). Statistical analyses (chi-square, Mann-Whitney U, logistic regression) assessed the association between CCI and postoperative complications, adjusting for age and sex.
RESULTS: Patients with severe comorbidity had higher rates of postoperative complications, including delirium (27.3% vs. 9.4%, P = 0.00), stroke (P = 0.03), transfusion (69.7% vs. 47.2%, P = 0.04), and renal replacement therapy (18.2% vs. 5.3%, P = 0.02). Median Sequential Organ Failure Assessment scores at 24 hours were significantly higher (P = 0.00). Logistic regression adjusted for age, sex, and coronary artery bypass grafting identified delirium (odds ratio [OR]: 3.13), nosocomial pneumonia (OR: 3.10), acute kidney injury (OR: 2.28), and renal replacement therapy (OR: 4.10) as independent predictors of severe comorbidity.
CONCLUSIONS: The CCI is a valuable tool for predicting postoperative complications in patients undergoing cardiac surgery. Early identification of comorbidities is essential for perioperative planning and optimizing clinical outcomes. Integrating the CCI into routine clinical practice is recommended to enhance patient management.

INTRODUCTION: Several clinical trials have demonstrated the non-inferiority of transcatheter aortic valve replacement compared with surgical aortic valve replacement in patients with severe aortic stenosis and low to intermediate surgical risk. However, mid-term results are still contentious. We performed this meta-analysis to compare the safety and efficacy of transcatheter vs. surgical aortic valve replacement in the mid-term in patients with aortic stenosis at low to moderate surgical risk.
METHODS: We searched Embase, PubMed^®, and Cochrane databases for randomized clinical trials that compared transcatheter with surgical aortic valve replacement in patients with symptomatic severe aortic stenosis with a follow-up of at least four years. Outcomes of interest were all-cause mortality and disabling stroke.
RESULTS: We included six randomized clinical trials encompassing 6,444 patients with severe aortic stenosis, of whom 3,282 (50.9%) underwent transcatheter aortic valve replacement. There was no difference in all-cause mortality (risk ratio [RR] 1.08; 95% confidence interval [CI] 0.94 - 1.25; P = 0.30) and disabling stroke (RR 0.95; 95% CI 0.75 - 1.21; P = 0.67) between groups. In the subgroup analysis, five-year mortality (RR 1.28; 95% CI 1.10 - 1.49) was higher in the transcatheter group. The new pacemaker implantation (RR 2.22; 95% CI 1.42 - 3.45) rate was higher in the transcatheter group. However, the new atrial fibrillation (RR 0.40; 95% CI 0.31 - 0.52) rate was higher in the surgical group.
CONCLUSION: Mid-term mortality and disabling stroke rates in patients with severe aortic stenosis treated with either transcatheter or surgical aortic valve replacement were similar.

The rising cardiovascular disease burden in Africa necessitates a strengthened healthcare system including enhanced access to cardiac surgery, the definitive treatment for several surgical cardiovascular diseases. Though open-heart surgery, the most invasive type of cardiac surgery, was already possible in Africa over five decades ago, with pioneering surgeons performing atrial septal defect repairs via surface cooling in Ghana as early as 1964, its development across the continent has been hindered by significant challenges. This study highlights the challenges faced by both established and nascent open-heart surgery programs across Africa. We further identify key areas for sustaining and expanding open-heart surgery programs, including robust training for surgeons and support staff, resource allocation, and enhanced capacity building. By systematically analyzing the landscape of open-heart surgery in Africa, this paper proposes a multifactorial approach to overcome these limitations and ensure equitable access to this life-saving intervention for a vastly underserved population.

INTRODUCTION: N-terminal pro-brain natriuretic peptide (NT-proBNP) is a biomarker for heart stress and heart failure, with its production triggered by the stretching of cardiac fibers. This study investigates if elevated NT-proBNP levels can independently predict poor outcomes for patients undergoing heart surgery.
METHODS: A systematic review was performed in the PubMed^®, Latin American and Caribbean Health Sciences Literature (or LILACS), Physiotherapy Evidence Database (PEDro), Web of Science, and Embase databases, with the following descriptors: "NT-proBNP" OR "NTproBNP" OR "N- terminal pro-B-type natriuretic peptide" OR "N- terminal pro brain natriuretic peptide" OR "amino terminal pro brain natriuretic peptide" AND "Cardiovascular Surgical Procedures" NOT "Pediatric" OR "children" NOT "cancer" OR "oncology" NOT "animal*". Articles that evaluated NT-proBNP and adverse outcomes in cardiac surgical patients were chosen. The levels of evidence and the strength of recommendation were assessed considering the Grading of Recommendations, Assessment, Development and Evaluation (or GRADE) system and validity by the PEDro scale. For systematic review, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (or PRISMA) criteria and the Population, Intervention, Comparison, Outcome (or PICO) strategy were followed.
RESULTS: Forty-seven articles were included, of which 17 were related to serious complications, including mortality.
CONCLUSION: Preoperative NT-proBNP is a prognostic marker for mortality, length of stay in the postoperative intensive care unit, postoperative acute kidney injury, postoperative atrial fibrillation, postoperative low cardiac output, postoperative prolonged mechanical ventilation time, prolonged hospitalization time, unscheduled hospital readmission related to heart problems, and postoperative heart failure.

Our technique described below offers a reproducible, cost-effective approach for no-touch saphenous vein harvesting that can be adopted by well-trained surgical teams. The hybrid no-touch technique, incorporating LigaSure™, small incisions, and pressurized closure, achieves excellent results with minimal major and local complications. Given the robust evidence supporting improved patency and outcomes, the no-touch approach should be considered a reliable and superior option for the second conduit in coronary artery bypass grafting procedures.

The neocuspidization technique using autologous pericardium (AVNeo^®) is a recent alternative for aortic valve replacement in selected patients. Between 2019 and 2023, we applied it in 56 patients, evaluating surgical outcomes, survival, reintervention rates, and clinical and echocardiographic results. We analyzed its advantages, patient selection criteria, limitations, and management of bicuspid valves. We also assessed whether it is suitable for all patients and discussed the midterm outcomes observed. AVNeo^® may offer a promising option, especially for younger patients, by preserving native anatomy and avoiding prosthetic materials, though long-term data and further research are still needed.