Volume 41 - Issue 3

INTRODUCTION: The CHA₂DS₂-VA score, which is used to determine the risk of thromboembolism in patients with atrial fibrillation, has been shown to be a predictor of mortality in many cardiovascular diseases. However, there is no data in the literature on the effect of CHA₂DS₂-VA score on in-hospital mortality in patients with acute aortic dissection (AAD). We aimed to determine the effect of CHA₂DS₂-VA score on in-hospital mortality in patients with AAD.
METHODS: This retrospective cohort study included 113 patients (89 males, 24 females, age 58.7±10.5 years) who underwent surgical treatment for AAD. CHA₂DS₂-VA scores were calculated. All cases of in-hospital mortality during the follow-up period were identified and recorded. Patients were grouped as with and without mortality.
RESULTS: Among patients with AAD, in-hospital mortality was observed in 30 cases (27.5%). Mortality rates in patients with CHA₂DS₂-VA 1, 2, 3 and ≥ 4 were 7%, 13%, 27%, and 53%, respectively. Age, CHA₂DS₂-VA score, and high-sensitivity C-reactive protein serum level independently determined the patients with mortality, and each one unit increase in these parameters predicted 11.3%, 2.19-fold, and 3.2% mortality increase, respectively. In receiver operating characteristic analysis, when the cutoff value of CHA₂DS₂-VA score was taken as 3, it was found to determine the development of mortality due to AAD with 80.5% sensitivity and 78.6% specificity.
CONCLUSION: CHA₂DS₂-VA score is independently associated with the development of in-hospital mortality in patients with AAD. According to the findings of our study, the CHA₂DS₂-VA score may serve as a prognostic marker in patients with AAD.

INTRODUCTION: Public awareness and interest significantly influence research priorities and healthcare advancements. This study investigates the relationship between public interest, represented by Google Trends Relative Search Volume (RSV), and cardiothoracic research outputs over 21 years (2004 – 2024).
METHODS: A total of 26 conditions/surgeries representing eight topics of general cardiothoracic interest were identified from a review of various social media pages, society webpages, and hospital information bulletins. Data on the conditions were collected from Google Trends and PubMed^®. RSV values were calculated annually, and publication counts were extracted for each condition. The study used R (v4.3.3) for all statistical analyses and predictive models.
RESULTS: Trauma-related conditions and extracorporeal membrane oxygenation (ECMO) demonstrated increasing RSV and publication trends, with strong positive correlations (e.g., ECMO: r = 0.88, P < 0.0001). Conditions such as congenital cardiac anomalies (e.g., tetralogy of Fallot: r = -0.74, P < 0.0001) showed a negative correlation, with declining RSV despite ongoing research. Multiple regression revealed a significant positive relationship between RSV and publication counts when conditions were controlled (slope = 16.68, R² = 0.8081, P < 0.0001). Feature importance analysis showed that "Condition" had a slightly greater influence than RSV on publication trends.
CONCLUSION: The study demonstrates variability between public interest and research output across cardiothoracic conditions. While some conditions, such as trauma-related cases and ECMO, show alignment between public awareness and publication activity, others, including congenital anomalies, exhibit divergence.

INTRODUCTION: Women have historically been underrepresented in leadership positions and academia in cardiothoracic surgery, creating barriers to career advancement and limiting role models for trainees. While publications are used to measure success in academia, invited articles such as editorials often represent a formal recognition of expertise. The objective of this study was to identify trends in the gender of editorial authors published in cardiothoracic surgery journals.
METHODS: Editorials published between 2018 and 2022 across 16 peer-reviewed cardiothoracic surgery journals were analyzed. Author gender was estimated using a validated tool (https://gender-api.com/) with additional verification using available institutional profiles.
RESULTS: In total, 806 editorials were published with a total of 1,858 authors (293 women, 16%). Women authors were predominantly from the United States of America (45%) followed by India (9%) and Germany (8%). The percentage of women first authors increased between 2018 and 2022 (P < 0.001); 9% in 2018, 9% in 2019, 17% in 2020, 16% in 2021, and 23% in 2022. A similar trend was observed for women senior authorship (P < 0.0001) (6% in 2018, 9% in 2019, 14% in 2020, 15% in 2021, and 18% in 2022) as well as for editorials with all-women authorship (P < 0.0001), increasing steadily from 9% in 2018 to 20% in 2022.
CONCLUSION: Women authorship in editorials published in cardiothoracic surgery journals has steadily increased in recent years. Despite progress, women still make up less than a quarter of first and senior authors, highlighting a critical gap in gender equity in academic leadership that must be urgently addressed.

INTRODUCTION: David procedure has shown to be a low-risk perioperative procedure even in challenged scenarios cases, with favorable long-term outcomes and additional benefits linked to the avoidance of prosthetic valves, including freedom from anticoagulation and reintervention, reduced risk of thromboembolic complications and endocarditis. Furthermore, an aortic valve preservation program in Colombia confers probably specific advantages to our population, considering the sociodemographic factors of middle-income countries.
METHODS: A retrospective analysis was conducted on the clinical and perioperative results, as well as short-term follow-up data of patients who underwent David procedure at one clinical center from Colombia between November 2021 and June 2024.
RESULTS: One hundred and three patients were treated, with a mean age of 60 years, of whom 82.3% were male. In most cases, the preoperative diagnosis was aortic root dilation, with 80% presenting severe aortic insufficiency. Also 11.6% were initially diagnosed with type A acute dissection. The 30-day mortality was 0.9%. There were no cases of perioperative myocardial infarction nor dialysis requirement. Other complications were atrial fibrillation in 29.13% and acute renal failure in 9.7%. Follow-up was completed in 97.08% of cases, with survival rates at one year of 99%. Freedom from reintervention, endocarditis, and freedom from anticoagulation at one year were 100%, 100%, and 67%, respectively.
CONCLUSION: In our study, David procedure emerged as an effective procedure, offering potential benefits that could be particularly relevant in middle-income countries. Perioperative and follow-up outcomes were comparable to those reported in large series from high-income countries.

INTRODUCTION: Median sternotomy is the gold standard for cardiac surgery but carries a significant risk of wound complications, including sternal dehiscence and wound infections.
OBJECTIVE: This study aimed to compare the early efficacy and complication rates of three distinct steel-wire sternal closure techniques and identify potential risk factors of complications.
METHODS: We conducted a randomized controlled study on patients undergoing cardiac surgery. Patients were randomly allocated into three groups of sternal closure techniques: simple interrupted (Group A), figure-of-eight (Group B), or a modified combined technique (Group C). Baseline characteristics, intraoperative parameters, postoperative recovery outcomes, and sternal wound complications including sternal dehiscence and superficial and deep wound infections were evaluated. Binomial logistic regression was performed to determine independent risk factors for complications.
RESULTS: One hundred sixty-five adult cardiac patients were finally included in the study. All three intervention groups (n = 55) were well-matched regarding baseline characteristics and intraoperative parameters. The incidence of sternal dehiscence (6.1%) and superficial (7.9%) and deep wound infections (3.6%) did not differ significantly among the three wire closure techniques (P > 0.05). However, logistic regression identified numerous factors associated with superficial sternal wound infections including old age, obesity (body mass index > 30), comorbidities, elevated C-reactive protein and HbA1C, prolonged cardiopulmonary bypass time, extended operative time, and longer intensive care unit stay (P < 0.05 for all).
CONCLUSION: The three steel-wire closure techniques demonstrated comparable early postoperative stability and similar rates of sternal wound complications. Technique choice may be based on surgeon preference.

INTRODUCTION: Frailty increases the risk of adverse outcomes after cardiac surgery. However, there is no consensus on how to best assess it.
OBJECTIVE: To verify the prevalence of frailty in patients undergoing elective valve surgery or coronary artery bypass grafting (CABG) and if a more comprehensive assessment of the physical, psychological, and nutritional domains would better discriminate the frailty phenotype and its association with in-hospital mortality.
METHODS: Besides the criteria proposed by Fried, the Mini Nutritional Assessment, gait speed, Duke Activity Status Index, Dutch Exertion Fatigue Scale, and screening for depressive symptoms (Patient Health Questionnaire-9) were used.
RESULTS: Overall, considering Fried's criteria, 43.6% of the patients were frail, and 49.6% were pre-frail. Of those considered frail, 51% were under 60 years old. Fried's frailty phenotype showed no association with postoperative in-hospital mortality. Using additional variables to characterize frailty domains, it was possible to distinguish two groups (clusters) of patients. In cluster 1, 84.8% were frail according to Fried's criteria (vs. 27.4% in cluster 2, P < 0.001), the rate of postoperative infection was higher (24.2% vs. 7.1%, P = 0.022), and in-hospital mortality was significantly higher (27.3% vs. 9.5%, P = 0.020).
CONCLUSION: We observed a considerable proportion of patients with Fried frailty phenotype in patients undergoing CABG or valve surgery, many of them under 60 years old, but those frailty phenotypes were not associated with postoperative hospital outcomes. However, the association of frailty phenotype with higher rates of postoperative in-hospital mortality was evident when additional criteria were used to assess the domains associated with frailty.

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) has become a viable option for patients with severe aortic valve stenosis across a broad range of surgical risk in recent years. The Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) score, a novel indicator of malnutrition and inflammation, has been discovered to be inversely linked with prognosis in several cancer types. The purpose of this study is to examine the performance of the HALP score in predicting one-month major adverse cardiac events and one-year mortality in patients treated with TAVI.
METHODS: This study included 395 consecutive patients treated with TAVI, separated into two groups based on their HALP scores: low and high. Our study's primary endpoint was all-cause death within a year after discharge following the TAVI operation. The secondary endpoint was a composite endpoint that included periprocedural complications and events in one month.
RESULTS: Patients with a low median HALP score had a higher risk of one-month composite events and one-month death. In multivariate analysis, chronic kidney disease (odds ratio [OR]: 4.67, 95% confidence interval [CI]: 2.36 - 9.25, P < 0.001) and HALP score < 3.4 (OR: 1.235, 95% CI: 1.091 - 1.397, P < 0.001) were independent predictors of first-year mortality. Kaplan-Meier analysis for computing cumulative survival found that patients with low HALP scores based on a receiver operating characteristic curve cutoff of 3.4 had increased mortality rates throughout short-term follow-up.
CONCLUSION: The HALP score may be a significant independent predictor of short-term prognosis and mortality in patients treated with TAVI, beyond conventional risk-scoring tools for better disease management.

INTRODUCTION: Acute Physiologic and Chronic Health Evaluation (APACHE) II is an effective tool to predict outcomes in cardiac surgery recovery. The present study aimed to evaluate the efficacy and compare the performance of the APACHE II and Simplified Acute Physiology Score (SAPS 3) scoring tools as predictive indices of mortality in cardiac surgery patients.
METHODS: This was a retrospective observational study, evaluating patients over 18 years of age who underwent cardiac surgeries between 2020 and 2023. A receiver operating characteristic curve analysis was conducted to evaluate the sensitivity and specificity of the APACHE II and SAPS 3 tools in detecting intensive care unit (ICU) mortality in critically ill patients. Binary logistic regression was performed to assess the odds of mortality between groups (primary outcome) using data on comorbidities.
RESULTS: APACHE II was efficient in predicting mortality in cardiac surgery (sensitivity = 81%; specificity = 75%) as was SAPS 3 (sensitivity = 75%; specificity = 64%). Binary logistic regression revealed that mortality was significantly associated with comorbidities (chronic obstructive pulmonary disease and non-dialysis-dependent chronic kidney disease) and the type of surgery, with a higher risk in emergency procedures compared to elective ones.
CONCLUSION: In conclusion, APACHE II and SAPS 3 proved to be efficient tools for predicting mortality in cardiac surgery patients admitted to the ICU. This study contributes to understanding these tools in a regional context and specifically in cardiac surgeries, as well as assessing other predictors that may be important for identifying risk groups and predicting mortality after cardiac surgeries.

INTRODUCTION: This study explored the function and molecular mechanism of long non-coding ribonucleic acid taurine up-regulated gene 1 (TUG1) in children with ventricular septal defect (VSD).
METHODS: To establish an in vivo VSD model, 10 pregnant mice were administered valproic acid via intraperitoneal injection (VSD group, n = 10). Another 10 pregnant mice were used as the control group and administered 0.9% sodium chloride solution via intraperitoneal injection. Subsequently, the cardiac function and cardiac tissue histopathological characteristics in both groups were evaluated. TUG1, miR-222-3p, and hypoxia-inducible factor 1-alpha subunit inhibitor (HIF1AN) expression levels in cardiac tissues were tested. P19 cells were chosen to simulate VSD in vitro model, and the cell progression was tested. P19 cells were induced to differentiate into cardiomyocytes with dimethyl sulfoxide, and test of the shape and beating frequency of cardiomyocytes was conducted. Left ventricular fractional shortening, ejection fraction, and systolic and diastolic thickness of the cardiac anterior wall were significantly reduced in VSD fetal mice. VSD formation, aortic overlay, and dysplasia were observed.
RESULTS: TUG1 and HIF1AN were upregulated, and miR-222-3p was downregulated in VSD mice. Silencing TUG1 or HIF1AN or elevating miR-222-3p facilitated P19 cell progression and differentiation, whereas lowering miR-222-3p did the opposite. TUG1 was a molecular sponge of miR-222-3p, which targeted HIF1AN. Elevating HIF1AN reversed the impacts of silencing TUG1 or elevating miR-222-3p on P19 cells.
CONCLUSIONS: The findings of this study could offer a new insight into the molecular basis of VSD and lay the groundwork for new diagnostic techniques.

OBJECTIVE: To evaluate the association between postoperative acute kidney injury (AKI) and outcomes in adults undergoing cardiovascular surgery who required a prolonged intensive care unit (ICU) stay.
METHODS: We conducted a retrospective cohort study of consecutive cardiovascular surgery patients with ICU stay ≥ 72 hours. AKI was defined and staged using creatinine-based Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The primary outcome was in-hospital mortality. Secondary outcomes were time to extubation, ICU days until ward transfer, and perioperative transfusion exposure (red blood cells/fresh frozen plasma/platelet/apheresis); initiation of renal replacement therapy was assessed exploratorily. Multivariable logistic regression examined the association between AKI and mortality, adjusting for age, sex, baseline renal function/chronic kidney disease (estimated glomerular filtration rate category), hypertension, diabetes, chronic obstructive pulmonary disease, ejection fraction (or Age Creatinine Ejection Fraction score), procedure type (coronary artery bypass grafting/valve/combined), cardiopulmonary bypass and cross-clamping times, transfusions, and post-cardiopulmonary bypass vasoactive/inotropic use where available.
RESULTS: AKI was frequent after cardiovascular surgery and was independently associated with higher in-hospital mortality in adjusted analyses. Patients with AKI also had longer time to extubation, greater transfusion requirements, and prolonged ICU stay, with a stepwise worsening across KDIGO stages. Findings were consistent in sensitivity analyses. Incomplete urine-output data were acknowledged as a limitation, as oliguria forms part of KDIGO definitions.
CONCLUSION: Among cardiovascular surgery patients with prolonged ICU stay, postoperative AKI is a strong predictor of in-hospital mortality and adverse resource-related outcomes. Emphasis on prevention, early detection, and optimized perioperative management may improve prognosis in this high-risk population.

OBJECTIVE: To compare the clinical efficacy and safety of intra-aortic balloon pump (IABP) and levosimendan in coronary artery bypass grafting (CABG).
METHODS: A systematic search of PubMed^®, Embase, Cochrane Library, and Google Scholar was conducted through July 2024. Outcomes analyzed included atrial fibrillation, postoperative mediastinitis, the requirement for inotropic support, in-hospital mortality, postoperative intensive care unit (ICU) stay, postoperative length of stay, ventilation time, and mean arterial pressure (MAP) levels.
RESULTS: The analysis included nine studies with 681 patients. Levosimendan presented advantage over IABP in CABG patients in terms of postoperative ICU stay, postoperative length of stay, and reduction in MAP levels, with effect sizes: mean difference (MD) = -0.83, 95% confidence interval (CI) -0.97 to -0.68, P < 0.00001 = -1.14, 95% CI: -1.33 to -0.95, P < 0.00001, and MD = -4.55, 95% CI: -6.14 to -2.96, P < 0.00001, respectively. Levosimendan had an advantage on subgroup analyses in terms of postoperative ICU stay and postoperative length of stay, with effect sizes: MD = -0.83, 95% CI: -0.93 to -0.72, P < 0.00001 and MD = -1.14, 95% CI: -1.28 to -1.01, P < 0.00001, respectively. However, the incidence of postoperative mediastinitis was higher in the levosimendan group (relative risk = 1.45, 95% CI: 0.88 to 2.38), though not statistically significant.
CONCLUSION: Levosimendan may improve recovery and hemodynamic outcomes in high-risk CABG patients compared to IABP but may be associated with a higher, though non-significant, risk of mediastinitis. Further high-quality studies are warranted.

INTRODUCTION: Cycle ergometer in the postoperative period of open-heart surgery is a safe and economical exercise option. However, its specific effects, whether or not associated with conventional physiotherapy, are not well established in current literature. The objective of this study was to evaluate the effects of cycle ergometer exercise associated or not with conventional physical therapy, compared with only conventional physical therapy, on functional capacity, hospitalization time, peripheral muscle strength, and pulmonary complications of patients after open-heart surgery.
METHODS: MEDLINE, Cumulative Index to Nursing & Allied Health Literature, Latin American and Caribbean Health Sciences Literature, Web of Science, Scopus, Embase, Physiotherapy Evidence Database, and Cochrane Library were searched; manual searches were also conducted in the references of the included studies. Randomized controlled trials that analyzed the effects of cycle ergometer exercise associated or not with conventional physical therapy compared with only conventional physical therapy in adult patients after an open-heart surgery were included. Methodological quality was assessed by Cochrane risk-of-bias tool, and the meta-analysis was undertaken using RevMan 5.3.
RESULTS: Mean difference in the six-minute walk test (31 meters, 95% confidence interval [CI]: 1.59 to 60.3 meters, P = 0.04) was higher and in intensive care unit stay was lower (-0.5 days, 95% CI: -0.86 to -0.14 days, P = 0.007) in the intervention group. The total hospitalization time (-0.18 days, 95% CI: -0.73 to 0.38 days, P = 0.53) didn't change between groups.
CONCLUSION: Cycle ergometer exercises improved functional capacity but with no clinically relevant effects on hospitalization time after open-heart surgeries.

Surgical left atrial appendage occlusion (S-LAAO) is increasingly performed during cardiac surgery, but perioperative outcomes remain uncertain. Using a nationwide Japanese inpatient database, we analyzed 25,059 adults undergoing valve or coronary bypass surgery (2020 – 2022). After propensity score matching (n = 2,543 each), addition of S-LAAO was not associated with differences in in-hospital mortality, transfusion, reoperation, or 30-day readmission compared to non-S-LAAO group. However, prolonged inotropic support (≥ 2 days) was more frequent with S-LAAO (40.8% vs. 34.7%; odds ratio 1.29, 95% confidence interval: 1.13 – 1.47). Addition of S-LAAO did not increase mortality but was linked to greater inotrope use, warranting further investigation.

We present a clinical case of mitral insufficiency in a 59-year-old patient with dextrocardia and complete transposition of the viscera. The patient underwent mitral valve posterior leaflet repair and annuloplasty. During the operation, a "mirror inversion” of the equipment and surgery team position was carried out. The special feature of the operation was due to the fact that the aorta and great vessels in the wound were mirror-image. The postoperative period proceeded without complications. Being aware of the patient's dextrocardia and hence organizing the surgical procedure appropriately, we could achieve good results in radical surgery for valvular heart disease.