ABSTRACT Introduction: Due to Brazilian population aging, prevalence of aortic stenosis, and limited number of scores in literature, it is essential to develop risk scores adapted to our reality and created in the specific context of this disease. Methods: This is an observational historical cohort study with analysis of 802 aortic stenosis patients who underwent valve replacement at Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, from 1996 to 2018. With the aid of logistic regression, a weighted risk score was constructed based on the magnitude of the coeficients β of the logistic equation. Two performance statistics were obtained: area under the receiver operating characteristic curve and the chi-square (χ2) of Hosmer-Lemeshow goodness-of-fit with Pearson’s correlation coeficient between the observed events and predicted as a model calibration estimate. Results: The risk predictors that composed the score were valve replacement surgery combined with coronary artery bypass grafting, prior renal failure, New York Heart Association class III/IV heart failure, age > 70 years, and ejection fraction < 50%. The receiver operating characteristic curve area was 0.77 (95% confidence interval: 0.72-0.82); regarding the model calibration estimated between observed/predicted mortality, Hosmer-Lemeshow test χ2 = 3,70 (P=0.594) and Pearson’s coeficient r = 0.98 (P<0.001). Conclusion: We propose the creation of a simple score, adapted to the Brazilian reality, with good performance and which can be validated in other institutions.

ABSTRACT Introduction: Due to Brazilian population aging, prevalence of aortic stenosis, and limited number of scores in literature, it is essential to develop risk scores adapted to our reality and created in the specific context of this disease. Methods: This is an observational historical cohort study with analysis of 802 aortic stenosis patients who underwent valve replacement at Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, from 1996 to 2018. With the aid of logistic regression, a weighted risk score was constructed based on the magnitude of the coeficients β of the logistic equation. Two performance statistics were obtained: area under the receiver operating characteristic curve and the chi-square (χ2) of Hosmer-Lemeshow goodness-of-fit with Pearson’s correlation coeficient between the observed events and predicted as a model calibration estimate. Results: The risk predictors that composed the score were valve replacement surgery combined with coronary artery bypass grafting, prior renal failure, New York Heart Association class III/IV heart failure, age > 70 years, and ejection fraction < 50%. The receiver operating characteristic curve area was 0.77 (95% confidence interval: 0.72-0.82); regarding the model calibration estimated between observed/predicted mortality, Hosmer-Lemeshow test χ2 = 3,70 (P=0.594) and Pearson’s coeficient r = 0.98 (P<0.001). Conclusion: We propose the creation of a simple score, adapted to the Brazilian reality, with good performance and which can be validated in other institutions.

Abstract Introduction: Stroke is a complication that causes considerable morbidity and mortality during the heart surgery postoperative period (incidence: 1.3 to 5%; mortality: 13 to 41%). Models for assessing the risk of stroke after heart surgery have been proposed, but most of them do not evaluate postoperative morbidity. The aim of this study was to develop a risk score for postoperative stroke in patients who undergo heart surgery with cardiopulmonary bypass. Methods: A cohort study was conducted with data from 4,862 patients who underwent surgery from 1996 to 2016. Logistic regression was used to assess relationships between risk factors and stroke. Data from 3,258 patients were used to construct the model. The model’s performance was then validated using data from the remainder of the patients (n=1,604). The model’s accuracy was tested using the area under the receiver operating characteristic (ROC) curve. Results: The prevalence of stroke during the postoperative period was 3% (n=149); 59% of the patients who exhibited this outcome were male, 51% were aged ≥ 66 years, and 31.5% of the patients died. The variables that remained as independent predictors of the outcome after multivariate analysis were advanced age, urgent/emergency surgery, peripheral arterial occlusive disease, history of cerebrovascular disease, and cardiopulmonary bypass time ≥ 110 minutes. The area under the ROC curve was 0.71 (95% confidence interval 0.66 - 0.75). Conclusion: We were able to develop a risk score for stroke after heart surgery. This score classifies patients as low, medium, high, or very high risk of a surgery-related stroke.

Abstract Background Prolonged mechanical ventilation (MV) after cardiac surgery imposes a significant burden on the patient in terms of morbidity and financial hospital costs. Objective To develop a risk score model to predict prolonged MV in patients undergoing coronary artery bypass grafting (CABG) surgery. Methods This was a historical cohort study of 4165 adult patients undergoing CABG between January 1996 and December 2016. MV for periods ≥ 12 hours was considered prolonged. Logistic regression was used to examine the relationship between risk predictors and prolonged MV. The variables were scored according to the odds ratio. To build the risk score, the database was randomly divided into 2 parts: development data set (2/3) with 2746 patients and internal validation data set (1/3) with 1419 patients. The final score was validated in the total database and the model's accuracy was tested by performance statistics. Significance was established at p < 0.05. Results Prolonged MV was observed in 783 (18.8%) patients. Predictors of risk were age ≥ 65 years, urgent/emergency surgery, body mass index ≥ 30 kg/m2, chronic kidney disease, chronic obstructive pulmonary disease, and cardiopulmonary bypass time ≥ 120 minutes. The area under the ROC curve was 0.66 (95% CI, 0.64-0.68; p<0.001), the Hosmer-Lemeshow chi-square test was χ2: 3.38 (p=0.642), and Pearson's correlation was r = 0.99 (p<0.001), indicating the model’s satisfactory ability to predict the occurrence of prolonged MV. Conclusion Selected variables allowed the construction of a simplified risk score for daily practice, which may classify the patients as having low, moderate, high, and very high risk. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

OBJECTIVES: To describe the prevalence of the reduced ankle-brachial index (ABI) in patients with heart failure (HF) with preserved ejection fraction (HFpEF) attended at a HF clinic in the metropolitan region of Porto Alegre, and to compar the patients to those with reduced ejection fraction (HFrEF). METHODS: A descriptive observational study, included patients referred to the heart failure clinic in HU-Ulbra with HFpEF or HFrEF and diastolic dysfunction, and measurements of ABIs using vascular Doppler equipment were performed in both groups. RESULTS: The sample consisted of 106 patients with HF, 53.9% of the patients had HFpEF, and 19.4% had a diagnosis of peripheral arterial disease (PAD) (ABI less than 0.9). PAD was identified in 24.1% of the patients with HFpEF, while15.8% of patients in the HFrEF group were diagnosed with PAD. CONCLUSION: Our results did not identify a significantly different prevalence of altered and compatible PAD values in patients with HFpEF. However, we showed a prevalence of 19.4%, a high value if we consider similar populations.

ResumoIntrodução:Os distúrbios do sistema de condução cardíaca são frequentes no pós-operatório de cirurgia de revascularização do miocárdio. Majoritariamente reversíveis, estão associados com alguma injúria do tecido de condução, causada pela própria cardiopatia isquêmica ou por fatores perioperatórios.Objetivo:Primário: investigar a associação entre fatores perioperatórios com o surgimento de bloqueio atrioventricular no pós-operatório de cirurgia de revascularização do miocárdio. Secundários: determinar a necessidade de estimulação cardíaca artificial temporária e de marca-passo definitivo no pós-operatório de cirurgia de revascularização do miocárdio e seu impacto na permanência e na mortalidade hospitalar.Métodos:Análise de Coorte retrospectiva de pacientes submetidos à cirurgia de revascularização do miocárdio, do banco de dados da unidade de Pós-Operatório de Cirurgia Cardíaca do Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, pelo método de regressão logística.Resultados:No período de janeiro de 1996 a dezembro de 2012, foram realizadas 3532 cirurgias de revascularização do miocárdio. Duzentos e oitenta e oito (8,15%) pacientes apresentaram bloqueio atrioventricular durante o pós-operatório de cirurgia de revascularização do miocárdio, necessitando de estimulação cardíaca artificial temporária. Oito dos que apresentaram bloqueio atrioventricular evoluíram para implante de marcapasso definitivo (0,23% do total da amostra). A análise multivariada evidenciou associação significativa de bloqueio atrioventricular com idade acima de 60 anos (OR=2,34; IC 95% 1,75-3,12; P<0,0001), sexo feminino (OR=1,37; IC 95% 1,06-1,77; P=0,015), doença renal crônica (OR=2,05; IC 95% 1,49-2,81; P<0,0001), fibrilação atrial (OR=2,06; IC 95% 1,16-3,66; P=0,014), classe funcional III e IV da New York Heart Association (OR=1,43; IC 95% 1,03-1,98; P=0,031), infarto agudo do miocárdio perioperatório (OR=1,70; IC 95% 1,26-2,29; P<0,0001) e com o uso do balão intra-aórtico no pós-operatório de cirurgia de revascularização do miocárdio (OR=1,92; IC 95% 1,21-3,05; P=0,006). A presença de bloqueio atrioventricular acarretou um aumento significativo da mortalidade (17,9% vs. 7,3% nos que não desenvolveram bloqueio atrioventricular) (OR=2,09; IC 95% 1,46-2,99; P<0,0001) e um tempo mais prolongado de permanência hospitalar (12,75 dias vs. 10,53 dias nos que não desenvolveram bloqueio atrioventricular) (OR=1,01; IC 95% 1,00-1,02; P=0,01).Conclusão:O bloqueio atrioventricular, no pós-operatório de cirurgia de revascularização do miocárdio, é, na maioria dos casos, transitório, sendo associado a diversos fatores perioperatórios: idade acima de 60 anos, sexo feminino, doença renal crônica, fibrilação atrial, classe funcional III e IV da New York Heart Association, infarto agudo do miocárdio perioperatório e uso do balão intra-aórtico. Sua ocorrência prolonga a internação hospitalar e, sobretudo, duplica o risco de mortalidade.

AbstractIntroduction:Disturbances of the cardiac conduction system are frequent in the postoperative period of coronary artery bypass surgery. They are mostly reversible and associated with some injury of the conduction tissue, caused by the ischemic heart disease itself or by perioperative factors.Objective:Primary: investigate the association between perioperative factors and the emergence of atrioventricular block in the postoperative period of coronary artery bypass surgery. Secondary: determine the need for temporary pacing and of a permanent pacemaker in the postoperative period of coronary artery bypass surgery and the impact on hospital stay and hospital mortality.Methods:Analysis of a retrospective cohort of patients submitted to coronary artery bypass surgery from the database of the Postoperative Heart Surgery Unit of the Sao Lucas Hospital of the Pontifical Catholic University of Rio Grande do Sul, using the logistic regression method.Results:In the period from January 1996 to December 2012, 3532 coronary artery bypass surgery were carried out. Two hundred and eighty-eight (8.15% of the total sample) patients had atrioventricular block during the postoperative period of coronary artery bypass surgery, requiring temporary pacing. Eight of those who had atrioventricular block progressed to implantation of a permanent pacemaker (0.23% of the total sample). Multivariate analysis revealed a significant association of atrioventricular block with age above 60 years (OR=2.34; CI 95% 1.75-3.12; P<0.0001), female gender (OR=1.37; CI 95% 1.06-1.77; P=0.015), chronic kidney disease (OR=2.05; CI 95% 1.49-2.81; P<0.0001), atrial fibrillation (OR=2.06; CI 95% 1.16-3.66; P=0.014), functional class III and IV of the New York Heart Association (OR=1.43; CI 95% 1.03-1.98; P=0.031), perioperative acute myocardial infarction (OR=1.70; CI 95% 1.26-2.29; P<0.0001) and with the use of the intra-aortic balloon in the postoperative period of coronary artery bypass surgery (OR=1.92; CI 95% 1.21-3.05; P=0.006). The presence of atrioventricular block resulted in a significant increase in mortality (17.9% vs. 7.3% in those who did not develop atrioventricular block) (OR=2.09; CI 95% 1.46-2.99; P<0.0001) and a longer hospital stay (12.75 days x 10.53 days for those who didn't develop atrioventricular block) (OR=1.01; CI 95% 1.00-1.02; P=0.01).Conclusions:In most cases, atrioventricular block in the postoperative period of coronary artery bypass surgery is transient and associated with several perioperative factors: age above 60 years, female sex, chronic kidney disease, atrial fibrillation, New York Heart Association functional class III or IV, perioperative acute myocardial infarction and use of an intra-aortic balloon. Its occurrence prolongs hospitalization and, above all, doubles the risk of mortality.

A estimulação cardíaca artificial (ECA) é o tratamento mais seguro e eficaz para a bradicardia sintomática irreversível. Nas indicações propícias, pode trazer grande benefício clínico. Contudo, as evidências mostram que a ação da ECA geraria, em alguns casos, efeitos deletérios à estrutura e fisiologia cardíacas. Este potencial efeito negativo da ECA convencional poderia ser mais acentuado principalmente em pacientes com comprometimento prévio da função ventricular esquerda e, sobretudo, quando o eletrodo é colocado em posição apical do ventrículo direito (VD). Intrigante é, contudo, que após quase 6 décadas de ECA do VD, apenas uma reduzida parcela de pacientes apresenta esta condição clinicamente manifesta. Os determinantes do surgimento ou não da cardiopatia por ECA não estão totalmente esclarecidos. Ainda é motivo de debate a existência de uma relação de causalidade entre o padrão de BRE artificial secundário à ativação antifisiológica ventricular, alterações da dinâmica contrátil ventricular, e condições clínicas (disfunção sistólica prévia, cardiopatia estrutural preexistente, tempo desde o implante) ou elétricas (duração do intervalo QRS, dose percentual de estimulação ventricular). Esta revisão aborda dados contemporâneos sobre esta nova entidade e discute alternativas de como utilizar a ECA neste contexto, com ênfase na terapia de ressincronização cardíaca.

Implantable cardiac pacing systems are a safe and effective treatment for symptomatic irreversible bradycardia. Under the proper indications, cardiac pacing might bring significant clinical benefit. Evidences from literature state that the action of the artificial pacing system, mainly when the ventricular lead is located at the apex of the right ventricle, produces negative effects to cardiac structure (remodeling, dilatation) and function (dissinchrony). Patients with previously compromised left ventricular function would benefit the least with conventional right ventricle apical pacing, and are exposed to the risk of developing higher incidence of morbidity and mortality for heart failure. However, after almost 6 decades of cardiac pacing, just a reduced portion of patients in general would develop these alterations. In this context, there are not completely clear some issues related to cardiac pacing and the development of this cardiomyopathy. Causality relationships among QRS widening with a left bundle branch block morphology, contractility alterations within the left ventricle, and certain substrates or clinical (previous systolic dysfunction, structural heart disease, time from implant) or electrical conditions (QRS duration, percentage of ventricular stimulation) are still subjecte of debate. This review analyses contemporary data regarding this new entity, and discusses alternatives of how to use cardiac pacing in this context, emphasizing cardiac resynchronization therapy.

OBJETIVOS: Determinar os preditores de risco relacionados ao desenvolvimento de acidente vascular cerebral em pacientes que realizaram cirurgia cardíaca. Métodos: Estudo de coorte histórico. Incluímos 4626 pacientes com idade > 18 anos submetidos à cirurgia de revascularização do miocárdio, cirurgia cardíaca valvar isolada ou cirurgia valvar associada com revascularização do miocárdio, de janeiro de 1996 e dezembro de 2011. A relação entre os preditores de risco e o acidente vascular cerebral foi avaliada por modelo de regressão logística com nível de significância de 0,05. Resultados: A incidência de acidente vascular cerebral foi 3% na amostra total. A análise multivariada identificou como preditores de risco para o acidente vascular cerebral: idade 50-65 anos (OR=2,11 - 95% IC 1,05-4,23 - P=0,036) e idade > 66 anos (OR=3,22 - 95% IC 1,6-6,47 - P=0,001), cirurgia de urgência/emergência (OR=2,03 - 95% IC 1,20-3,45 - P=0,008), valvulopatia aórtica (OR=2,32 - 95% IC 1,18-4,56 - P=0,014), fibrilação atrial (OR=1,88 - 95% IC 1,05-3,34 - P=0,032), doença arterial obstrutiva periférica (OR=1,81 - 95% IC 1,13-2,92 - P=0,014), história de doença cerebrovascular (OR=3,42 - 95% IC 2,19-5,35 - P<0,001) e tempo de circulação extracorpórea >110 minutos (OR=1,71 - 95% IC 1,16-2,53 - P=0,007). A mortalidade foi 31,9% nos pacientes que sofreram AVC e 8,5% nos sem AVC (OR=5,06 - 95% IC 3,5-7,33 - P<0,001). Conclusão: Idade, cirurgia de urgência/emergência, doença de valva aórtica, história de fibrilação atrial, doença arterial obstrutiva periférica, história de doença cerebrovascular e tempo de circulação extracorpórea > 110 minutos foram preditores independentes para o desenvolvimento de AVC intra-hospitalar, em pacientes submetidos à cirurgia cardíaca.

Objective: To determine the risk factors related to the development of stroke in patients undergoing cardiac surgery. Methods: A historical cohort study. We included 4626 patients aged > 18 years who underwent coronary artery bypass surgery, heart valve replacement surgery alone or heart valve surgery combined with coronary artery bypass grafting between January 1996 and December 2011. The relationship between risk predictors and stroke was assessed by logistic regression model with a significance level of 0.05. Results: The incidence of stroke was 3% in the overall sample. After logistic regression, the following risk predictors for stroke were found: age 50-65 years (OR=2.11 - 95% CI 1.05-4.23 - P=0.036) and age >66 years (OR=3.22 - 95% CI 1.6-6.47 - P=0.001), urgent and emergency surgery (OR=2.03 - 95% CI 1.20-3.45 - P=0.008), aortic valve disease (OR=2.32 - 95% CI 1.18-4.56 - P=0.014), history of atrial fibrillation (OR=1.88 - 95% CI 1.05-3.34 - P=0.032), peripheral artery disease (OR=1.81 - 95% CI 1.13-2.92 - P=0.014), history of cerebrovascular disease (OR=3.42 - 95% CI 2.19-5.35 - P<0.001) and cardiopulmonary bypass time > 110 minutes (OR=1.71 - 95% CI 1.16-2.53 - P=0.007). Mortality was 31.9% in the stroke group and 8.5% in the control group (OR=5.06 - 95% CI 3.5-7.33 - P<0.001). Conclusion: The study identified the following risk predictors for stroke after cardiac surgery: age, urgent and emergency surgery, aortic valve disease, history of atrial fibrillation, peripheral artery disease, history of cerebrovascular disease and cardiopulmonary bypass time > 110 minutes.

INTRODUÇÃO: A cirurgia de revascularização do miocárdio muitas vezes é o tratamento de escolha de pacientes que sofrem angina instável. Não sabemos se essa condição acresce morbimortalidade nesse cenário. OBJETIVO: Comparar os desfechos dos pacientes submetidos a cirurgia de revascularização do miocárdio com quadro de angina instável com os pacientes submetidos a cirurgia de revascularização do miocárdio que não apresentaram angina instável. MÉTODOS: Coorte retrospectiva. A angina instável foi definida como síndrome coronariana aguda sem supradesnivelamento de ST e sem alteração enzimática e/ou angina classe IV. RESULTADOS: No período entre fevereiro de 1996 a julho de 2010, de 2.818 a cirurgia de revascularização do miocárdio isoladas realizadas, 1.016 (36,1%) pacientes apresentaram angina instável. A análise multivariada demonstrou que os pacientes com angina instável no pré-operatório utilizaram mais medicações como ácido acetilsalicílico, betabloqueador, heparina (anticoagulação plena), nitrato e menor necessidade de diureticoterapia, do que pacientes sem angina instável. Pacientes com angina instável utilizaram maior monitorização com Swan-Ganz e suporte com balão intra-aórtico do que os pacientes estáveis. Sobre os desfechos, necessitaram de maior tempo de internação (P=0,030) e apresentaram menor taxa de óbito (P=0,018) no pós-operatório de cirurgia de revascularização do miocárdio isolada. CONCLUSÃO: Submeter pacientes a cirurgia de revascularização do miocárdio isolada na vigência de síndrome coronariana aguda como angina instável não elevou a taxa de mortalidade.

INTRODUCTION: Coronary artery bypass graft is often the treatment of choice for patients who suffer from unstable angina. We do not know whether this condition adds morbidity in this scenario. OBJECTIVE: To compare the outcomes of patients undergoing coronary artery bypass graft with unstable angina framework with patients who underwent coronary artery bypass graft showed no unstable angina. METHODS: Retrospective cohort study. Unstable angina was defined as acute coronary syndrome without ST elevation and without enzymatic alteration and/or class IV angina. RESULTS: Between February 1996 and July 2010, to 2,818 isolated coronary artery bypass graft performed, 1,016 (36.1%) patients had unstable angina. Multivariate analysis showed that patients with preoperative unstable angina used more medications such as acetylsalicylic acid, beta-blocker, heparin (anticoagulation), nitrate and less need for diuretics than patients without unstable angina. Patients with unstable angina used increased monitoring with Swan-Ganz and support with intra-aortic balloon than stable patients. On outcomes, required longer hospitalization (P=0.030) and had a lower death rate (P=0.018) in the post-coronary artery bypass graft alone. CONCLUSION: Submit patients to coronary artery bypass graft in the presence of acute coronary syndrome such as unstable angina did not increase the mortality rate.

Fibroelastoma papilífero é um tumor benigno, raro e de crescimento lento, que geralmente tem origem no endocárdio das valvas cardíacas. Este tumor representa uma causa potencial de embolia sistêmica, infarto agudo do miocárdio, acidente vascular cerebral e morte súbita. O diagnóstico precoce é fundamental, já que a excisão cirúrgica pode evitar complicações cerebrovasculares e cardiovasculares. O diagnóstico geralmente é feito pelo ecocardiograma transesofágico. Neste trabalho, são descritos dois casos de pacientes com fibroelastoma papilífero de valva aórtica, causando eventos cerebrais cardioembólicos, que foram submetidos com sucesso a tratamento cirúrgico. Apresenta-se, ainda, uma sucinta revisão da literatura.

Papillary fibroelastomas of the heart valves are benign, slow-growing, rare tumors of the heart. This tumor represents a potential cause of systemic embolism, stroke, myocardial infarction and sudden death. Early diagnosis is very important, as surgical excision of these tumors can prevent cerebrovascular and cardiovascular complications. Diagnosis is usually made by transesophageal echocardiogram. We describe two cases of patients with papillary fibroelastomas causing cardioembolic cerebral events, which underwent successful surgical treatment. The authors present a brief review of the literature.

FUNDAMENTO: Os inibidores da enzima conversora de angiotensina (IECA) reduzem o risco de óbito, infarto agudo do miocárdio (IAM) e acidente vascular encefálico (AVE) em portadores de doença coronariana. No entanto, não há consenso quanto à sua indicação em pacientes que serão submetidos à cirurgia de revascularização miocárdica (CRM). OBJETIVO: Avaliar a relação entre uso pré-operatório de IECA e eventos clínicos após realização da CRM. MÉTODOS: Estudo de coorte retrospectivo. Foram incluídos dados de 3.139 pacientes consecutivos submetidos à CRM isolada em hospital terciário brasileiro, entre janeiro de 1996 e dezembro de 2009. O seguimento dos pacientes foi realizado até a alta hospitalar ou óbito. Desfechos clínicos no pós-operatório foram analisados entre os usuários e os não-usuários de IECA no pré-operatório. RESULTADOS: Cinquenta e dois por cento (1.635) dos pacientes receberam IECA no pré-operatório. O uso de IECA foi preditor independente da necessidade de suporte inotrópico (RC 1,24, IC 1,01-1,47; P=0,01), de insuficiência renal aguda (IRA, RC 1,23, IC 1,01-1,73; P=0,04) e de evolução para fibrilação atrial (FA, RC 1,32, IC 1,02-1,7; P=0,03) no pós-operatório. A mortalidade entre os pacientes que receberam ou não IECA no pré-operatório foi semelhante (10,3 vs. 9,4%, P=0,436), bem como a incidência de IAM e AVE (15,6 vs. 15,0%, P=0,694 e 3,4 vs. 3,5%, P=0,963, respectivamente). CONCLUSÃO: O uso pré-operatório de IECA foi associado a maior necessidade de suporte inotrópico e maior incidência de IRA e FA no pós-operatório, não estando associado ao aumento das taxas de IAM, AVE ou óbito

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors reduce the chance of death, myocardial infarction (MI) and cerebrovascular accident (CVA) in patients with coronary disease. However there is no consensus as to its indication in patients undergoing coronary artery bypass grafting (CABG). OBJECTIVE: To assess the relationship between preoperative use of ACE inhibitors and clinical outcomes after CABG. METHODS: Retrospective cohort study. We included data from 3,139 consecutive patients undergoing isolated CABG in Brazilian tertiary care hospital between January 1996 and December 2009. Follow-up was until discharge or death. Clinical outcomes after surgery were analyzed between users and nonusers of ACE inhibitors preoperatively. RESULTS: Fifty-two percent (n=1,635) of patients received ACE inhibitors preoperatively. The use of ACE inhibitors was an independent predictor of need for inotropic support (OR 1.24, 95% CI 1.01 to 1.47, P = 0.01), acute renal failure (OR 1.23, 95% CI 1.01 to 1.73, P = 0.04) and progression to atrial fibrillation (OR 1.32, 95% CI 1.02 to 1.7, P = 0.03) postoperatively. The mortality rate among patients receiving or not preoperative ACE inhibitors was similar (10.3% vs. 9.4%, P = 0.436), as well as the incidence of myocardial infarction and stroke (15.6% vs. 15.0%, P = 0.694 and 3.4% vs. 3.5%, P = 0.963, respectively). CONCLUSION: The use of preoperative ACE inhibitors was associated with increased need for inotropic support and higher incidence of acute renal failure and postoperative atrial fibrillation, not associated with increased rates of myocardial infarction, stroke or death

INTRODUÇÃO: Distúrbios do sistema de condução cardíaco são complicações potenciais e conhecidas dos procedimentos de cirurgia cardíaca valvar. OBJETIVOS: Investigar a associação entre fatores peri-operatórios com bloqueio atrioventricular (BAV) e a necessidade de estimulação cardíaca artificial temporária (ECAT) e, se necessário, implante de marcapasso definitivo no pós-operatório de cirurgia cardíaca (POCC) valvar. MÉTODOS: Coorte histórica de pacientes submetidos a cirurgia cardíaca valvar, sendo realizada análise de banco de dados por regressão logística. RESULTADOS: No período de janeiro de 1996 a dezembro de 2008, foram realizadas 1102 cirurgias cardíacas valvares: 718 (65,2%) na valva aórtica e 407 (36,9%) na valva mitral; destas, 190 (17,2%) cirurgias de revascularização miocárdica associadas à cirurgia valvar e 23 (2,1%) cirurgias valvares combinadas (aórtica+mitral). Cento e oitenta e sete (17%) pacientes apresentaram quadro clínico e eletrocardiográfico de BAV durante o POCC valvar, necessitando de ECAT. Quatorze (7,5%) pacientes evoluíram para implante de marcapasso definitivo (1,27% do total da amostra). A análise multivariada evidenciou associação significativa de BAV com cirurgia de valva mitral (OR=1,76; IC 95% 1,08-2,37; P=0,002), implante de prótese biológica (OR=1,59; IC 95% 1,02-3,91; P= 0,039), idade maior que 60 anos (OR = 1,99; IC 95% 1,35-2,85; P<0,001), uso prévio de medicações antiarrítmicas (propafenona e amiodarona) (OR = 1,86; IC 95% 1,04-3,14; P=0,026) e uso prévio de betabloqueador (OR = 1,76; IC 95% 1,25-2,54; P=0,002). Embora a presença do BAV e necessidade de ECAT não tenham se associado a aumento de mortalidade, prolongaram a permanência hospitalar significativamente (P<0,0001) e, portanto, o consumo de recursos hospitalares. CONCLUSÃO: Esse estudo evidencia um conjunto de fatores preditivos potenciais a um perfil de pacientes que determinam alto risco de bloqueio atrioventricular e necessidade de estimulação cardíaca artificial temporária no pós-operatório de cirurgia cardíaca valvar

INTRODUCTION: Disturbances of the cardiac conduction system are potential complications after cardiac valve surgery. OBJECTIVES: This study was designed to investigate the association between perioperative factors and atrio-ventricular block, the need for temporary cardiac artificial pacing and, if necessary, permanent pacemaker implantation after cardiac valve surgery. METHODS: Retrospective analysis of the Cardiac Surgery Database - Hospital São Lucas/PUCRS. The data are collected prospectively and analyzed retrospectively. RESULTS: Between January 1996 and December 2008 were included 1102 valve surgical procedures: 718 aortic valves (65.2%), 407 (36.9%) mitral valve and 190 (17.2%) coronar artery bypass grafting combined with valve repair and 23 (2.1%) aortic and mitral combined surgery. 187 patients (17%) showed clinical and electrocardiographic pattern of atrio-ventricular block requiring artificial temporary pacing. Of these, 14 patients (7.5%) required permanent pacemaker implantation (1.27% of the total valve surgery patients). Multivariate analysis showed association of the incidence of atrio-ventricular block and temporary pacing with mitral valve surgery (OR 1,76; CI 95% 1.08-2.37; P=0.002), implantation of bioprosthetic devices (OR 1.59; CI 95% 1.02-3.91; P=0,039), age over 60 years (OR 1.99; CI 95% 1.352.85; P<0.001), prior use of anti-arrhythmic drugs (OR 1.86; CI 95% 1.04-3.14; P=0.026) and previous use of b-blocker (OR 1.76; CI 95% 1.25-2.54; P=0.002). Remarkably the presence of atrio-ventricular block did not significantly show association with increased mortality, but significantly prolonged (P<0.0001) hospital length-of-stay and, therefore, hospital costs. CONCLUSIONS: Our study presents a group of predictive factors referring to a specific patient profile by which high risk of atrio-ventricular block and the need of temporary cardiac pacing after cardiac valve surgery it is determined

INTRODUÇÃO: Escores para avaliação de risco cirúrgico em pacientes submetidos à cirurgia de revascularização miocárdica são amplamente utilizados. OBJETIVO: Construir um escore capaz de predizer mortalidade em pacientes submetidos à cirurgia de revascularização miocárdica. MÉTODOS: No período entre janeiro de 1996 e dezembro de 2007, foram coletados dados de 2809 pacientes submetidos à cirurgia de revascularização miocárdica no Hospital São Lucas da PUC-RS. Em cerca de 2/3 da amostra (n=1875), foi construído o escore, após análises uni e multivariada. No restante (n=934), o escore foi validado. O escore final foi construído com a amostra total, utilizando as mesmas variáveis (n=2809). A acurácia do modelo foi testada utilizando-se a área sob a curva ROC. RESULTADOS: A idade média foi 61,3 ± 10,1 anos (desvio padrão) e 34% eram mulheres. Os fatores de risco identificados como preditores independentes de mortalidade cirúrgica e utilizados para montagem do escore (parênteses) foram: idade > 60 anos (2), sexo feminino (2), vasculopatia extracardíaca (2), insuficiência cardíaca classe funcional III e IV (3), fração de ejeção < 45% (2), fibrilação atrial (2), doença pulmonar obstrutiva crônica (3), estenose aórtica (3), creatinina 1,5-2,4 (2), creatinina > 2,5 ou diálise (4) e cirurgia de emergência/urgência (16). A área sob a curva ROC obtida foi de 0,86 (IC 0,81-0,9). CONCLUSÃO: O escore desenvolvido por meio de variáveis clínicas de fácil obtenção (idade, sexo, vasculopatia extracardíaca, classe funcional, fração de ejeção, fibrilação atrial, doença pulmonar obstrutiva crônica, estenose aórtica, creatinina e cirurgia de emergência/urgência) mostrou-se capaz de predizer mortalidade em pacientes submetidos à cirurgia de revascularização miocárdica no nosso Hospital.

INTRODUCTION: Scores to predict surgical risk in patients submitted to myocardial revascularization surgery are broadly used. OBJECTIVE: To develop a score capable to predict mortality in patients submitted to myocardial revascularization surgery. METHODS: From January 1996 to December 2007, data were collected from 2809 patients submitted to myocardial revascularization surgery at PUC-RS São Lucas Hospital. In 2/3 of the sample (n=1875), the score was developed, after uni and mutivariated analyses. In the remaining 1/3 (n =934) the score was validated. The final score was developed with the total sample, using the same variables (n=2809). The accuracy of the model was tested using the area under the ROC curve. RESULTS: The mean age was 61.3 ±10.1 years and 34% were women. The risk factors identified as independent predictors of surgical mortality and used for score development (parentheses) were: age > 60 years (2), female (2), extracardiac vasculopathy (2), heart failure functional class III and IV (3), ejection fraction<45% (2), atrial fibrillation (2), chronic obstructive pulmonary disease (3), aortic stenosis (3), creatinine 1.5-2.4 (2), creatinine > 2.5 or dialysis (4), emergency/urgency surgery (16). The area obtained under the ROC curve was 0.86 (CI 0.81-0.9). CONCLUSION: The score developed, using clinical variables easy to obtain (age, sex, extracardiac vasculopathy, functional class, ejection fraction, atrial fibrillation, chronic obstructive pulmonary disease, aortic stenosis, creatinine and emergency/urgency surgery) showed capability to predict mortality in patients submitted to myocardial revascularization surgery in our Hospital.