EDITORIAL
IFaculdade Estadual de Medicina de S.J. Rio Preto, S.J. Rio Preto, SP - Brazil
IIFaculdade de Ciências Médicas Unicamp, Campinas, SP - Brazil
IIIEscola Paulista de Medicina Unifesp, São Paulo, SP - Brazil
Mailing address
Key Words: Cardiovascular surgical procedures/history/trends.
The cardiovascular surgery was and has been intensely scrutinized and evaluated. Cardiac surgeons have, in turn, consistently directed the efforts in collecting, analyzing and applying the surgical results in order to improve quality and reassess conducts and procedures1. In this context, the Brazilian cardiac surgery is one of the most respected in the world, with 116,821 procedures in 2008 according to DATASUS2, allowing an renowned institution, such as The Heart Institute (InCor), to have performed more than 71,000 procedures only between 1984 and 2007, as reported by Lisboa et al3, at "Evolution of Cardiovascular Surgery at the Instituto do Coração: Analysis of 71,305 Surgeries", published on page 162.
Few medical specialties have contributed so much to the development of knowledge as the Brazilian cardiac surgery. Thus, in the field of myocardial revascularization surgery, the two contributions that best improved surgical results worldwide were introduced by Brazilian surgeries, i.e., the beating-heart myocardial revascularization technique (known as off-pump myocardial revascularization surgery) and the use of Double Internal Mammary Grafting. The currently used techniques for the surgical treatment of heart failure were developed by Brazilian cardiovascular surgeons.
This abundance is not an accidental feat, but the result of hard work developed during decades by pioneering doctors such as Euryclides Zerbini, Adib Jatene and Hugo Felipozzi, who endeavored to obtain national technology that would allow open-heart surgery, almost simultaneously with the experience carried out in North-American Centers by Gibbon, Kirklin and Lillehei. Only two years after John Gibbon had developed the first extracorporeal circulation (ECC) equipment in the USA, Dr. Felipozzi and his team were able to perform, on October 15, 1955, an open-heart surgery in Brazil using equipment that had been developed in our country, at the Institute of Cardiology Sabbado D'Angelo. In the following year, the first procedure with total ECC was carried out4.
In 1958, Zerbini, Jatene and team also developed the ECC equipment, using it in surgeries carried out in Hospital das Clinicas. In 1968, Zerbini performed the first heart transplant in Brazil, only one year after Christiaan Barnard.
Decades later, the Brazilian cardiovascular surgery has a solid establishment, with professionals and centers that are respected inside and outside the country, national industries that export equipment such as ECC machines, oxygenators and biological and mechanical valves worldwide, saving us dollars and generating jobs. Considering this picture, it is crucial to constantly take stock of the number of operations, the successes, the shortages, in order to implement more efficient public policies that will shorten the way to universalized health care, the objective of SUS (the Brazilian Public Health System).
Therefore, studies like these are extremely important. This one, in particular, has the merit of taking into account the evolution of the number of cardiovascular surgeries performed at InCor during a 24-year period. The total number is an remarkable one, after all, the mean is of 2,971 procedures/year - or more than 8 procedures a day. It is noteworthy the fact that the number has been increasing. If we take myocardial revascularization as an example, the 856 procedures/year in the 80s have currently increased to 1,106/year. This increase is also seen in valvular operations and the correction of congenital cardiopathies.
A decrease in the mortality rate occurs in these procedures (in myocardial revascularization surgery, the current mean mortality rate is 4.8%; in valvular operations, 8.5% and in the correction of congenital cardiopathies, 5.3%). The mean mortality, which in the start was 7.5%, decreased to 7.0% in recent years, of which 4.9% were elective procedures. Interesting figures, but which, as pointed out by the authors themselves, could be even lower.
Several factors lead to the decrease in mortality, among them, the improvement of the professionals, the development of new drugs and the improvement in the quality of life of the population. The matter has been the object of discussion in several studies and among them the study by Brown et al5, which analyzed 108,687 patients submitted to valvular replacement between 1997 and 2006, to conclude that there was a decrease in the morbimortality in spite of the gradual increase in patients' age range5. Other studies have addressed the subject, also showing a trend towards improved survival6-9.
In 2007, the study carried out by Antonio Luiz Ribeiro, a cardiologist and Professor at the Federal University of Minas Gerais, Brazil, generated controversy. Containing data from the years 2000 and 2003, the study showed that 8% of the patients died before being discharged from the hospital. Reference hospitals for cardiovascular surgery in the United States and England, for instance, present a mean mortality rate of 4%.
Mortality rates have been compared among databases from several countries and continents. The mortality outcomes after cardiovascular surgeries carried out in SUS hospitals in Brazil have shown to be higher when compared to the data from databases of the Society for Thoracic Surgeons (STS) in the United States of America. However, it necessary to consider the fact that the North-American database is voluntary, encompasses the outcomes of reference hospitals that receive patients with better socioeconomic indicators and represents less than 10% of the total surgeries carried out annually in the USA.
Gomes et al10 emphasized that it would be interesting to make the comparison based on more "comparable" data, such as those from the Public Health System of European countries, which are divergent. In the United Kingdom, the Cardiac Surgery Registry shows a myocardial revascularization surgery mortality rate of around 3%, whereas in Spain, it increases to 7.3%10,11.
The conclusion of the article remains extremely valid, both at the institutional and national levels. Cardiac surgeries remain on the rise and the patient demand should increase in the following years, with the improved access of the population to the healthcare system and also due to the acceleration of global population aging, with the consequent increase in the incidence of cardiovascular diseases. The healthcare policies created for this area must be necessarily capable of tending to these needs.
Surgical procedures in septuagenarian and octogenarian patients have been increasingly more common. If the InCor data are available, a new study could be carried out, showing the evolution in the number of surgeries per age range throughout the assessed period.
References
- 1. Shahian DM, Silverstein T, Lovett AF, Wolf RE, Normand SL. Comparison of clinical and administrative data sources for hospital coronary artery bypass graft surgery report cards. Circulation. 2007; 115(12): 1518-27.
-
2Ministério da Saúde. Datasus. Dados fornecidos diretamente pelo Datasus sob pedido formal. Brasília; 2009.
- 3. Lisboa LAF, Moreira LF, Dallan LA, Pomerantzeff P, Costa R, Puig LB, et al. Evolução da cirurgia cardiovascular no Instituto do Coração: análise de 71.305 operações. Arq Bras Cardiol. 2009 [94(2):174-81.
- 4. Gomes WJ, Saba JC, Buffolo E. 50 anos de circulação extracorpórea no Brasil: Hugo J. Felipozzi, o pioneiro da circulação extracorpórea no Brasil. Rev Bras Cir Cardiovasc. 2005; 20 (4): 1-6.
- 5. Brown JM, O'Brien SM, Wu C, Sikora JAH, Griffith BP, Gammie JS. Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons National Database. J Thorac Cardiovasc Surg. 2009; 137 (1): 82-90.
- 6. Puskas JD, Kilgo PD, Lattouf OM, Thourani VH, Cooper WA, Thomas A, et al. Off-Pump coronary bypass provides reduced mortality and morbidity and equivalent 10-year survival. Ann Thorac Surg. 2008; 86 (4): 1139-46.
- 7. Miyahara K, Matsuura A, Takemura H, Saito S, Sawaki S, Yoshioka T, et al. On-pump beating-heart coronary artery bypass grafting after acute myocardial infarction has lower mortality and morbidity. J Thorac Cardiovasc Surg. 2008; 135 (3): 521-6.
- 8. Liakopoulos OJ, Choi YH, Haldenwang PL, Strauch J, Wittwer T, Dörge H, et al. Impact of preoperative statin therapy on adverse postoperative outcomes in patients undergoing cardiac surgery: a meta-analysis of over 30000 patients. Eur Heart J. 2008; 29 (12): 1548-59.
- 9. Tahir SM, Price LL, Shah PB, Welt FGP. Eighteen year (1985-2002) analysis of incidence, mortality, and cardiac procedure outcomes of acute myocardial infarction in patients > 65 years of age. Am J Cardiol. 2008; 101 (7): 930-6.
- 10. Gomes WJ, Mendonça JT, Braile DM. Resultados em cirurgia cardiovascular: oportunidade para rediscutir o atendimento médico e cardiológico no sistema público de saúde do país. Rev Bras Cir Cardiovasc. 2007; 22 (4): III-VI.
- 11. Palma-Ruiz M, García de Dueñas L, Rodríguez-González A, Sarría-Santamera A. Analysis of in-hospital mortality from coronary artery bypass grafting surgery. Rev Esp Cardiol. 2003; 56 (7): 687-94.
Evolution of cardiovascular surgery. The Brazilian saga. A history of work, pioneering experience and success
Publication Dates
-
Publication in this collection
05 May 2010 -
Date of issue
Feb 2010
