Coronary Artery Bypass Surgery in Brazil: Analysis of the National Reality Through the BYPASS Registry

Rodrigo Pereira Paez Nelson Américo Hossne Junior José Amalth do Espírito Santo Otavio Berwanger Renato Hideo Nakagawa Santos Renato Abdala Karam Kalil Fabio B. Jatene Alexandre Biasi Cavalcanti Alexandre Cabral Zilli Luiz Carlos Bettiati Jr Fernando Augusto Marinho dos Santos Figueira Stephanie Steremberg Pires D'Azevedo Marcelo José Ferreira Soares Marcio Pimentel Fernandes Roberto Vito Ardito Renata Andrea Barberio Bogdan Valquíria Pelisser Campagnucci Diana Nakasako Clarissa Garcia Rodrigues Anilton Bezerra Rodrigues Junior Marcelo Matos Cascudo Fernando Antibas Atik Elson Borges Lima Vinicius José da Silva Nina Renato Albuquerque Heluy Lisandro Gonçalves Azeredo Odilon Silva Henrique Junior José Teles de Mendonça Katharina Kelly de Oliveira Gama Silva Marcelo Pandolfo José Dantas de Lima Júnior Renato Max Faria Jonas Gonçalves dos Santos Guilherme Henrique Biachi Coelho Sergio Nunes Pereira Roberta Senger Enio Buffolo Guido Marco Caputi Juliana Aparecida Borges de Oliveira Walter J. Gomes BYPASS Registry Study GroupAbout the authors

Abstract

Introduction:

Coronary artery bypass grafting (CABG) is the most frequently performed heart surgery in Brazil. Recent international guidelines recommend that national societies establish a database on the practice and results of CABG. In anticipation of the recommendation, the BYPASS Registry was introduced in 2015.

Objective:

To analyze the profile, risk factors and outcomes of patients undergoing CABG in Brazil, as well as to examine the predominant surgical strategy, based on the data included in the BYPASS Registry.

Methods:

A cross-sectional study of 2292 patients undergoing CABG surgery and cataloged in the BYPASS Registry up to November 2018. Demographic data, clinical presentation, operative variables, and postoperative hospital outcomes were analyzed.

Results:

Patients referred to CABG in Brazil are predominantly male (71%), with prior myocardial infarction in 41.1% of cases, diabetes in 42.5%, and ejection fraction lower than 40% in 9.7%. The Heart Team indicated surgery in 32.9% of the cases. Most of the patients underwent cardiopulmonary bypass (87%), and cardioplegia was the strategy of myocardial protection chosen in 95.2% of the cases. The left internal thoracic artery was used as a graft in 91% of the cases; the right internal thoracic artery, in 5.6%; and the radial artery in 1.1%. The saphenous vein graft was used in 84.1% of the patients, being the only graft employed in 7.7% of the patients. The median number of coronary vessels treated was 3. Operative mortality was 2.8%, and the incidence of cerebrovascular accident was 1.2%.

Conclusion:

CABG data in Brazil provided by the BYPASS Registry analysis are representative of our national reality and practice. This database constitutes an important reference for indications and comparisons of therapeutic procedures, as well as to propose subsequent models to improve patient safety and the quality of surgical practice in the country.

Keywords:
Registries; Database, Cardiovascular Surgical Procedures; Cardiac Surgical Procedures; Coronary Artery Bypass Grafts; Myocardial Revascularization

Abbreviations, acronyms & symbols ADA = Anterior descending artery GCP = Good Clinical Practices ARDS = Adult respiratory distress syndrome ITA = Internal thoracic artery BYPASS = Brazilian Registry of Adult Patients UndergoingCardiovascular Surgery LAD = Left anterior descending CABG = Coronary artery bypass grafting LITA = Left internal thoracic artery CAD = Coronary artery disease LVEF = Left ventricular ejection fraction COPD = Chronic obstructive pulmonary disease MI = Myocardial infarction CPB = Cardiopulmonary bypass NYHA = New York Heart Association classification for heart failure EACTS = European Association for Cardio-Thoracic Surgery PCI = Percutaneous coronary intervention EAPC = European Association of Percutaneous Cardiovascular Interventions RITA = Right internal thoracic artery ESC = European Society of Cardiology SBCCV = Sociedade Brasileira de Cirurgia Cardiovascular FREEDOM = Future Revascularization Evaluation in Patients withDiabetes Mellitus: Optimal Management of Multivessel Disease STS = Society of Thoracic Surgeons SVG = Saphenous vein grafts SYNTAX = Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery

INTRODUCTION

The Brazilian Registry of Adult Patients Undergoing Cardiovascular Surgery - the BYPASS Project - is an ongoing database established in 2015 by the Sociedade Brasileira de Cirurgia Cardiovascular (SBCCV) and aimed to collect perioperative and postoperative data from patients undergoing cardiac surgery in Brazil.

The first report of the BYPASS revealed that coronary artery bypass grafting (CABG) is the most frequently performed cardiac surgery in Brazil, encompassing 54.1% of the cases[11 Gomes WJ, Moreira RS, Zilli AC, Bettiati LC, Jr., Figueira F, SSP DA, et al. The Brazilian Registry of Adult Patient Undergoing Cardiovascular Surgery, the BYPASS Project: Results of the First 1,722 Patients. Braz J Cardiovasc Surg. 2017;32(2):71-6. doi: 10.21470/1678-9741-2017-0053.
https://doi.org/10.21470/1678-9741-2017-...
]. CABG remains the standard of care for management of patients with coronary artery disease, particularly in high-risk patients with multivessel disease, diabetics, aged 65 years or more, with left main stem or with impaired left ventricular function.

Previous analyses of results of CABG patients in Brazil were derived from single centers, a group of hospitals or defective databases, failing to reach national representativeness. Recent international guidelines recommend that national societies establish their own database on the practice and results of CABG and, in anticipation of this, the BYPASS registry was introduced in 2015[22 Sousa-Uva M, Neumann FJ, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur J Cardiothorac Surg. 2019;55(1):4-90. doi: 10.1093/ejcts/ezy289.
https://doi.org/10.1093/ejcts/ezy289...
,33 Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019;40(3):237-69. doi: 10.1093/eurheartj/ehy462.
https://doi.org/10.1093/eurheartj/ehy462...
].

To provide a comprehensive understanding of the scenario of cardiovascular surgery in Brazil, this analysis presents the clinical profile and outcomes of patients undergoing CABG and enrolled in the BYPASS project, assessing the data harvested from the initial cohort of patients included.

METHODS

This study was approved by the Research Ethics Committee of the Universidade Federal de São Paulo (UNIFESP - Registration number 1143/2017) and compiled data from the Bypass Registry, an observational and prospective study, with longitudinal follow-up. This report comprises a cross-sectional study, evaluating patients undergoing first-time isolated CABG.

Population and Locations

The participation of cardiovascular centers in this project was voluntary and involved 17 institutions throughout the country and located in the following regions: Southeast[44 Kennedy MW, Kaplan E, Hermanides RS, Fabris E, Hemradj V, Koopmans PC, et al. Clinical outcomes of deferred revascularisation using fractional flow reserve in patients with and without diabetes mellitus. Cardiovasc Diabetol. 2016;15:100. doi: 10.1186/s12933-016-0417-2.
https://doi.org/10.1186/s12933-016-0417-...
], Northeast[55 Mansur Ade P, Favarato D. Mortality due to cardiovascular diseases in Brazil and in the metropolitan region of São Paulo: a 2011 update. Arq Bras Cardiol. 2012;99(2):755-61. doi: 10.1590/S0066-782X2012005000061.
https://doi.org/10.1590/S0066-782X201200...
], South[33 Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019;40(3):237-69. doi: 10.1093/eurheartj/ehy462.
https://doi.org/10.1093/eurheartj/ehy462...
], and Central-West[11 Gomes WJ, Moreira RS, Zilli AC, Bettiati LC, Jr., Figueira F, SSP DA, et al. The Brazilian Registry of Adult Patient Undergoing Cardiovascular Surgery, the BYPASS Project: Results of the First 1,722 Patients. Braz J Cardiovasc Surg. 2017;32(2):71-6. doi: 10.21470/1678-9741-2017-0053.
https://doi.org/10.21470/1678-9741-2017-...
].

The project is partnered with the HCor Research Institute, responsible for collecting, analyzing and auditing the data.

A total of 2292 patients were analyzed, included until November 2018. The population consisted of patients older than 18 years of age, submitted to first-time isolated CABG, without other associated procedures. The informed consent form was signed by every patient included in the study and the data collection followed the National Clinical Research regulation standards as well as the Document of the Americas and Good Clinical Practice (GCP). The Bypass Registry was approved by the Ethics and Research Committee of the coordinating center and each participating institution.

Profile and Outcomes

The main variables assessed were demographic data, clinical presentation, risk factors, medications in use, left ventricular ejection fraction (LVEF), evaluated by echocardiography, and laboratory tests. Intraoperative data recorded operative time, use of cardiopulmonary bypass (CPB) and cardioplegia, type of grafts harvested, and preferred anastomotic techniques (direct, sequential or Y-composite grafts). Postoperative data included incidence of the following complications: stroke, major bleeding requiring reoperation, utilization of blood products, vasoplegia, arrhythmia, myocardial infarction, low cardiac output, use of vasoactive drugs, mechanical ventilation longer than 24 hours, kidney failure, need for transfusion, infection, and hospital mortality.

Statistical Analysis

The quantitative variables were described by mean ± standard deviation, and the qualitative variables were presented in form of absolute and relative frequency. Statistical analyses were performed with the Statistical Package R version 3.3.2 (R Foundation for Statistical Computing).

RESULTS

Epidemiological data and relative risk factors for heart disease are presented in Table 1. Patients referred to CABG in Brazil were predominantly male (71%), mean age 63.5±9.6 years, with recent myocardial infarction (MI) in 41.1% of the cases.

Table 1
Demographics data.

Table 2 depicts the reimbursement source, whether public or private, and the setting in which the patients were operated on; i.e., elective or urgent surgery. Most of the patients were admitted through the public healthcare system (84.4%) and operated under elective conditions (77.7%).

Table 2
Reimbursement source and preoperative conditions.

Intraoperative variables regarding surgical access, use of cardiopulmonary bypass, myocardial protection, use of internal thoracic artery and other arterial grafts, Y- or sequential grafts were collected according to Table 3.

Table 3
Intraoperative characteristics.

Intraoperative clinical events, such as bleeding, vasoplegia, arrhythmias, infarction [defined as an elevation of more than 10 times the upper limit of troponin T], use of vasopressors and intraoperative death are shown in Table 4. Postoperative follow-up was also analyzed in view of the main indicators and complications that may occur, according to Table 5.

Table 4
Intraoperative complications.
Table 5
Postoperative intra-hospital data.

Most of the patients underwent CPB (87%), and cardioplegia was the strategy of myocardial protection chosen in 95.2% of the cases.

The left internal thoracic artery (LITA) was used in 91% of the cases; the right internal thoracic artery (RITA), in 5.6%; and radial artery in only 1.1%. Total arterial revascularization was performed in 15.9%, and a significant portion (13.1%, 300 of 2289 patients) received an isolated internal thoracic artery graft to the left anterior descending (LAD) artery.

Saphenous vein grafts (SVG) were used in up to 84.1% of patients. There were 7.7% of patients revascularized with vein grafts only, without arterial grafts. The median number of vessels treated was 3[22 Sousa-Uva M, Neumann FJ, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur J Cardiothorac Surg. 2019;55(1):4-90. doi: 10.1093/ejcts/ezy289.
https://doi.org/10.1093/ejcts/ezy289...
,33 Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019;40(3):237-69. doi: 10.1093/eurheartj/ehy462.
https://doi.org/10.1093/eurheartj/ehy462...
].

The in-hospital mortality rate was 2.8%, and the incidence of clinically relevant cerebrovascular accident was 1.2%.

DISCUSSION

Coronary artery disease is one of the leading causes of mortality and morbidity in the 21st century[44 Kennedy MW, Kaplan E, Hermanides RS, Fabris E, Hemradj V, Koopmans PC, et al. Clinical outcomes of deferred revascularisation using fractional flow reserve in patients with and without diabetes mellitus. Cardiovasc Diabetol. 2016;15:100. doi: 10.1186/s12933-016-0417-2.
https://doi.org/10.1186/s12933-016-0417-...
]. In Brazil, approximately 30% of people die from cardiovascular causes according to data from the Unified Health System (DATASUS)[55 Mansur Ade P, Favarato D. Mortality due to cardiovascular diseases in Brazil and in the metropolitan region of São Paulo: a 2011 update. Arq Bras Cardiol. 2012;99(2):755-61. doi: 10.1590/S0066-782X2012005000061.
https://doi.org/10.1590/S0066-782X201200...
].

In 2014, CABG celebrated six decades since Kolesov's direct coronary approach for myocardial revascularization. And the technique continues to evolve at all times, from the onset of the worldwide experience without CPB, to the advent of CPB, returning to new scenarios without the use of CPB[66 Buffolo E, Andrade JC, Succi JE, Leao LE, Cueva C, Branco JN, et al. Direct myocardial revascularization without extracorporeal circulation: technique and initial results. Tex Heart Inst J. 1985;12(1):33-41.]; from the use of the saphenous vein to the use of the internal thoracic artery, including sequential anastomoses, until coronary artery bypass grafting completely performed with arterial grafts[77 Calafiore AM, Teodori G, Di Giammarco G, Vitolla G, Maddestra N, Paloscia L, et al. Multiple arterial conduits without cardiopulmonary bypass: early angiographic results. Ann Thorac Surg. 1999;67(2):450-6.], with graft quality control by Doppler graft flow measurement[44 Kennedy MW, Kaplan E, Hermanides RS, Fabris E, Hemradj V, Koopmans PC, et al. Clinical outcomes of deferred revascularisation using fractional flow reserve in patients with and without diabetes mellitus. Cardiovasc Diabetol. 2016;15:100. doi: 10.1186/s12933-016-0417-2.
https://doi.org/10.1186/s12933-016-0417-...
].

In patients with stable chronic disease, CABG is indicated to relieve symptoms and/or improve prognosis[88 Kolh P, Windecker S, Alfonso F, Collet JP, Cremer J, Falk V, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg. 2014;46(4):517-92. doi: 10.1093/ejcts/ezu366.
https://doi.org/10.1093/ejcts/ezu366...
]. CABG surgery has well established indications and benefits when it comes to left main artery disease, multivessel coronary artery disease, diabetes, proximal LAD occlusion and left ventricular dysfunction[99 Hueb W, Lopes N, Gersh BJ, Soares PR, Ribeiro EE, Pereira AC, et al. Ten-year follow-up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease. Circulation. 2010;122(10):949-57. doi: 10.1161/circulationaha.109.911669.
https://doi.org/10.1161/circulationaha.1...

10 Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet.1994;344(8922):563-70

11 Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961-72. doi: 10.1056/NEJMoa0804626
https://doi.org/10.1056/NEJMoa0804626...
-1212 Kapoor JR, Gienger AL, Ardehali R, Varghese R, Perez MV, Sundaram V, et al. Isolated disease of the proximal left anterior descending artery comparing the effectiveness of percutaneous coronary interventions and coronary artery bypass surgery. JACC Cardiovasc Interv. 2008;1(5):483-91. doi: 10.1016/j.jcin.2008.07.001.
https://doi.org/10.1016/j.jcin.2008.07.0...
].

In recent decades, hospitals and surgeons have been called upon to present their findings to the medical community and society. The European EuroSCORE study showed general mortality in cardiac surgery around 3.1%, while the American multicenter Society of Thoracic Surgeons (STS), around 2.0%[1313 Grant SW, Hickey GL, Dimarakis I, Trivedi U, Bryan A, Treasure T, et al. How does EuroSCORE II perform in UK cardiac surgery; an analysis of 23 740 patients from the Society for Cardiothoracic Surgery in Great Britain and Ireland National Database. Heart. 2012;98(21):1568-72. doi:10.1136/heartjnl-2012-302483.
https://doi.org/10.1136/heartjnl-2012-30...
,1414 Jacobs JP, Shahian DM, Prager RL, Edwards FH, McDonald D, Han JM, et al. Introduction to the STS National Database Series: Outcomes Analysis, Quality Improvement, and Patient Safety. Ann Thorac Surg. 2015;100(6):1992-2000. doi: 10.1016/j.athoracsur.2015.10.060
https://doi.org/10.1016/j.athoracsur.201...
]. Hannan et al.[1515 Hannan EL, Wu C, Smith CR, Higgins RS, Carlson RE, Culliford AT, et al. Off-pump versus on-pump coronary artery bypass graft surgery: differences in short-term outcomes and in long-term mortality and need for subsequent revascularization. Circulation. 2007;116(10):1145-52. doi: 10.1161/circulationaha.106.675595.
https://doi.org/10.1161/circulationaha.1...
], analyzing 49,830 patients undergoing CABG surgery in New York state between 2001 and 2004, found mortality around 1.19%, stroke around 1.2%, transmural infarction 0.5% sternal infection 0.9%, reoperation for bleeding 1.9%, sepsis 1.0%, renal dialysis 1.4%, respiratory failure 3.7%, and reoperation 1.2%.

In our country, Silva et al.[1616 Silva GSD, Colosimo FC, Sousa AG, Piotto RF, Castilho V. Coronary Artery Bypass Graft Surgery Cost Coverage by the Brazilian Unified Health System (SUS). Braz J Cardiovasc Surg. 2017;32(4):253-9. doi: 10.21470/1678-9741-2016-0069.
https://doi.org/10.21470/1678-9741-2016-...
] showed an operative mortality rate of 4.0% in patients operated by the Unified Health System (SUS) at the Hospital Beneficência Portuguesa in São Paulo, while Fortes et al.[1616 Silva GSD, Colosimo FC, Sousa AG, Piotto RF, Castilho V. Coronary Artery Bypass Graft Surgery Cost Coverage by the Brazilian Unified Health System (SUS). Braz J Cardiovasc Surg. 2017;32(4):253-9. doi: 10.21470/1678-9741-2016-0069.
https://doi.org/10.21470/1678-9741-2016-...
,1717 Fortes JV, Barbosa e Silva MG, Baldez TE, Costa MA, da Silva LN, Pinheiro RS, et al. Mortality Risk After Cardiac Surgery: Application of Inscor in a University Hospital in Brazil's Northeast. Braz J Cardiovasc Surg. 2016;31(5):396-9. doi: 10.5935/1678-9741.20160080.
https://doi.org/10.5935/1678-9741.201600...
] showed an average mortality of 7.4% in patients referred for CABG in a university hospital in northeastern Brazil. TotalCor Hospital, a private hospital focused on cardiology, points to a mortality rate of 1.7%. The profile of the patient operated in this private hospital is also favorable, with an expected mortality rate of 0.7%[1818 Barros e Silva PG, Baruzzi AC, Ramos DL, Okada MY, Garcia JC, Cardoso F de A, et al. Improving Indicators in a Brazilian Hospital Through Quality-Improvement Programs Based on STS Database Reports. Braz J Cardiovasc Surg. 2015;30(6):660-3. doi: 10.5935/1678-9741.20150075.
https://doi.org/10.5935/1678-9741.201500...
].

The BYPASS Registry is the first study of a Brazilian multicenter database with national representativity. The records strengthen that Brazilian patients, in general, have little access to primary prevention and surgery was indicated after heart attacks, heart failure and ventricular dysfunction. Brazilian patients have unsatisfactory outpatient follow-up and are generally poorly medicated, either due to poor adherence or lack of medication in the public healthcare system.

Since it is a voluntary participation, currently 17 Brazilian centers spontaneously provide their data to the BYPASS Registry. It should be remembered that the STS database also started with few centers and still does not reach all centers yet, but around 90%. Over the years, the participation of centers increased due to the benefits of having their results analyzed and receiving advice to improve hospital processes focused on surgical quality and patient safety. Currently, the STS participating center is a recognized center for quality control and continuous improvement. The TotalCor Hospital in São Paulo provides data for the STS since 2011 and has since reached a decrease in the time of mechanical ventilation and hospital stay through the guidelines received[1818 Barros e Silva PG, Baruzzi AC, Ramos DL, Okada MY, Garcia JC, Cardoso F de A, et al. Improving Indicators in a Brazilian Hospital Through Quality-Improvement Programs Based on STS Database Reports. Braz J Cardiovasc Surg. 2015;30(6):660-3. doi: 10.5935/1678-9741.20150075.
https://doi.org/10.5935/1678-9741.201500...
]. Since its first publication in 2018, the BYPASS study has had great adherence of cardiac surgeons, increasing from 945 to 2292 patients undergoing CABG in follow-up. The BYPASS study also seeks to be an evaluator and consultant in the process of improvement in cardiovascular surgery in Brazil.

Diabetes was more prevalent in patients undergoing revascularization in Brazil, when compared to other international registries, such as the SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) trial[1919 Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367(25):2375-84. doi: 10.1056/NEJMoa1211585.
https://doi.org/10.1056/NEJMoa1211585...
]. FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial defined bypass surgery as the standard treatment for diabetic and multivessel patients, mainly directing these patients for surgery.

Less than one-third of the reported patients undergoing revascularization surgery were female. Approximately 12% of the patients who underwent surgery had previously undergone percutaneous coronary interventions, an issue that deserves further investigation regarding the quality of the revascularization provided to these patients.

The vast majority of patients (84.4%) were operated in the public healthcare system, which draws attention since approximately 30% of Brazilians have private health insurance[2020 Bocchini B. Pesquisa mostra que quase 70% dos brasileiros não têm plano de saúde particular. Brasília: Empresa Brasil de Comunicação; 2018 [cited 2019 Feb 22]. Available from: http://agenciabrasil.ebc.com.br/geral/noticia/2018-02/pesquisa-mostra-que-quase-70-dos-brasileiros-nao-tem-plano-de-saude-particular.
http://agenciabrasil.ebc.com.br/geral/no...
]. Such information suggests that many patients with access to private health care are operated on public hospitals, or that patients who have access to private health care initially avoid being referred to surgery.

The analysis showed that operative mortality in CABG in Brazil was slightly higher compared to North American and European centers. This finding is remarkable, given the limited budget, resources and infrastructure of the health system, both private and public, as well as operating rooms and intensive care units, both in basic equipment and human resources.

Brazilian surgeons currently prefer to perform on-pump CABG, the technique employed in 87% of the cases. In this scenario, cardioplegia has been the preferred strategy for myocardial protection (95.2%). This is an amazing finding in a country that pioneered the development of off-pump coronary surgery. Minimally invasive or robotic revascularization is not routinely performed in Brazil.

Major complications such as death, cerebrovascular accident, and myocardial infarction were similar to those of international studies. Major bleeding requiring reoperation, arrhythmias, kidney failure, infection and heart failure were also similar.

Vasoplegia was uncommon (0.7%) in this study. It is a well-known complication in the postoperative period of cardiovascular surgery, defined by hemodynamic collapse similar to septic shock, characterized by decreased systemic vascular resistance, increased cardiac index and severe hypotension, despite the use of vasoactive drugs, occurring in the first postoperative hours[2121 Hossne Junior NA, Miranda M, Monteiro MR, Branco JN, Vargas GF, Pestana JO, et al. Cardiopulmonary bypass increases the risk of vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure. Rev Bras Circ Cardiovasc. 2015;30(4):482-8. doi: 10.5935/1678-9741.20140092.
https://doi.org/10.5935/1678-9741.201400...
].

The use of sequential anastomoses is a strategy to minimize aortic manipulation, but also to reduce CPB time and aortic cross-clamping.

Bilateral internal thoracic arteries (ITA) were used only in 4.8% of the patients, a practice more frequent than that reported by the STS database (4.1%), but fair below the European practice (10%)[2222 Schwann TA, Tatoulis J, Puskas J, Bonnell M, Taggart D, Kurlansky P, et al. Worldwide Trends in Multi-arterial Coronary Artery Bypass Grafting Surgery 2004-2014: A Tale of 2 Continents. Semin Thorac Cardiovasc Surg. 2017;29(3):273-80. doi: 10.1053/j.semtcvs.2017.05.018
https://doi.org/10.1053/j.semtcvs.2017.0...
,2323 Deutsch O, Gansera L, Wunderlich M, Eichinger W, Gansera B. Does Bilateral ITA Grafting Increase Perioperative Complications? Outcome of 6,476 Patients with Bilateral versus 5,020 Patients with Single ITA Bypass. Thorac Cardiovasc Surg. 2016;64(3):188-94. doi: 10.1055/s-0035-1558992.
https://doi.org/10.1055/s-0035-1558992...
]. Only 16.9% of the patients had total arterial graft, of which 69% of the patients received only one ITA graft.

The radial artery was seldom used (1.1%); and 7.7% of the patients received only the saphenous vein as a graft. The saphenous vein graft was widely used (84.1%), similar to Europe (84.4%) and the United States (95.1%)2222 Schwann TA, Tatoulis J, Puskas J, Bonnell M, Taggart D, Kurlansky P, et al. Worldwide Trends in Multi-arterial Coronary Artery Bypass Grafting Surgery 2004-2014: A Tale of 2 Continents. Semin Thorac Cardiovasc Surg. 2017;29(3):273-80. doi: 10.1053/j.semtcvs.2017.05.018
https://doi.org/10.1053/j.semtcvs.2017.0...

23 Deutsch O, Gansera L, Wunderlich M, Eichinger W, Gansera B. Does Bilateral ITA Grafting Increase Perioperative Complications? Outcome of 6,476 Patients with Bilateral versus 5,020 Patients with Single ITA Bypass. Thorac Cardiovasc Surg. 2016;64(3):188-94. doi: 10.1055/s-0035-1558992.
https://doi.org/10.1055/s-0035-1558992...
-2424 ElBardissi AW, Aranki SF, Sheng S, O'Brien SM, Greenberg CC, Gammie JS. Trends in isolated coronary artery bypass grafting: an analysis of the Society of Thoracic Surgeons adult cardiac surgery database. J Thorac Cardiovasc Surg. 2012;143(2):273-81. doi: 10.1016/j.jtcvs.2011.10.029.
https://doi.org/10.1016/j.jtcvs.2011.10....
. The time spent for preparation of the grafts can influence surgical teams with high volume to prefer the saphenous vein use instead of harvesting the second internal thoracic artery. Injury of the LITA during the preparation may also induce the surgeon to perform saphenous surgery instead of preparing the RITA.

Only 32.9% of the patients had their procedures indicated by the Heart Team, being a growing trend and demands of medical guidelines that patients have indication for cardiac procedures discussed and based on scientific evidence. Since the first report, the BYPASS study has seen a large increase in the participation of the Heart Team in the indication of cardiac surgeries[11 Gomes WJ, Moreira RS, Zilli AC, Bettiati LC, Jr., Figueira F, SSP DA, et al. The Brazilian Registry of Adult Patient Undergoing Cardiovascular Surgery, the BYPASS Project: Results of the First 1,722 Patients. Braz J Cardiovasc Surg. 2017;32(2):71-6. doi: 10.21470/1678-9741-2017-0053.
https://doi.org/10.21470/1678-9741-2017-...
].

Understanding the differences between the surgical strategy of the Brazilian surgeon and that of other countries, even with regional differences, may guide and suggest improvements in the routines adopted by different centers[2525 Gomes WJ, Mendonca JT, Braile DM. Cardiovascular surgery outcomes opportunity to rediscuss medical and cardiological care in the Brazilian public health system. Rev Bras Cir Cardiovasc. 2007;22(4):iii-vi. doi: 10.1590/S0102-76382007000400002.
https://doi.org/10.1590/S0102-7638200700...
,2626 Rao C, Zhang H, Gao H, Zhao Y, Yuan X, Hua K, et al. The Chinese Cardiac Surgery Registry: Design and Data Audit. Ann Thorac Surg. 2016;101(4):1514-20. doi: 10.1016/j.athoracsur.2015.09.038.
https://doi.org/10.1016/j.athoracsur.201...
].

The experience of international databases shows that its continuous data management brings long-term benefits, optimizing hospital practices and directing preventive policies. The dissemination of the BYPASS Registry and the invitation to surgeons to provide their data have contributed to the growth of the database. The adherence of several Brazilian centers to provide their data to the BYPASS Registry should be encouraged as part of a process of continuous medical improvement and patient safety. Policies should be designed to help fund national registries and stimulate surgeons to provide their data.

CONCLUSION

The CABG data in Brazil provided by the BYPASS Registry analysis are, so far, the most representative of our national reality and practice. This database constitutes an important reference for indications and comparisons of therapeutic procedures, as well as to propose subsequent models to improve patient safety and the quality of surgical practice in the country.

Authors' roles & responsibilities WJG, JAES, JABO, OB, ABC, FBJ Conception and study design; data management; manuscript redaction or critical review of its content; final manuscript approval Other authors Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final manuscript approval

  • This study was carried out at the Universidade Federal de São Paulo (UNIFESP/EPM), São Paulo, SP, Brazil.
  • No financial support.

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Publication Dates

  • Publication in this collection
    Mar-Apr 2019

History

  • Received
    02 Oct 2018
  • Accepted
    27 Jan 2019
Sociedade Brasileira de Cirurgia Cardiovascular Rua Afonso Celso, 1178 Vila Mariana, CEP: 04119-061 - São Paulo/SP Brazil, Tel +55 (11) 3849-0341, Tel +55 (11) 5096-0079 - São Paulo - SP - Brazil
E-mail: bjcvs@sbccv.org.br