Guidelines and Expert Consensus Documents aim to present management recommendations based on all of the relevant evidence on a particular subject in order to help physicians select the best possible management strategies for the individual patient suffering from a specific condition, taking into account the impact on outcome and also the risk–benefit ratio of a particular diagnostic or therapeutic procedure. Numerous studies have demonstrated that patient outcomes improve when guideline recommendations, based on the rigorous assessment of evidence-based research, are applied in clinical practice.

A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and also by other organizations or related societies. The profusion of documents can put at stake the authority and credibility of guidelines, particularly if discrepancies appear between different documents on the same issue, as this can lead to confusion in the minds of physicians. In order to avoid these pitfalls, the ESC and other organizations have issued recommendations for formulating and issuing Guidelines and Expert Consensus Documents. The ESC recommendations for guidelines production can be found on the ESC website.1 It is beyond the scope of this preamble to recall all but the basic rules.

In brief, the ESC appoints experts in the field to carry out a comprehensive review of the literature, with a view to making a critical evaluation of the use of diagnostic and therapeutic procedures and assessing the risk–benefit ratio of the therapies recommended for management and/or prevention of a given condition. Estimates of expected health outcomes are included, where data exist. The strength of evidence for or against particular procedures or treatments is weighed according to predefined scales for grading recommendations and levels of evidence, as outlined in what follows.

The Task Force members of the writing panels, …

Guidelines on the management of valvular heart disease The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology

Authors/Task Force Members, Alec Vahanian (Chairperson) Paris (France)*, Helmut Baumgartner, Vienna (Austria), Jeroen Bax, Leiden (The Netherlands), Eric Butchart, Cardiff (UK), Robert Dion, Leiden (The Netherlands), Gerasimos Filippatos, Athens (Greece), Frank Flachskampf, Erlangen (Germany), Roger Hall, Norwich (UK), Bernard Iung, Paris (France), Jaroslaw Kasprzak, Lodz (Poland), Patrick Nataf, Paris (France), Pilar Tornos, Barcelona (Spain), Lucia Torracca, Milan (Italy), Arnold Wenink, Leiden (The Netherlands)

Guidelines on the Management of Valvular Heart disease (Version 2012)

The incidence of coronary artery disease (CAD) in women of child-bearing age is low, and acute myocardial infarction (AMI) is uncommon.1,2 Pregnancy, however, has been shown to increase the risk of AMI ≈3-fold compared with the risk in nonpregnant women of similar age.2–5 Although previous studies have provided some data related to the incidence of pregnancy-associated MI (PAMI), clinical characteristics, risk factors, and outcome1,2,4 more information is needed on the mechanisms of AMI, the efficacy and safety of standard therapy, and the applicability of guideline recommendations designed for the general AMI population, to women with PAMI.

The aim of this study was therefore to review contemporary data on PAMI in an attempt to provide recommendations for the management of this condition.

A literature search for cases with AMI related to pregnancy was performed using PubMed and Google Scholar. References from these studies were cross-checked to obtain additional studies that may have been missed by the original search.

All original articles were obtained online or by interlibrary communication. Articles published in languages other than English were translated by medical translators. A total of 134 cases published in the literature from 2006 to 2011 not included in a previous review4 were included in this study.6–124 In addition, 7 cases presented at the First International Congress on Cardiac Problems in Pregnancy in 2010 (Valencia, Spain) and 9 patients treated or consulted by the authors were also included in the analysis. Recommendations were made on the basis of available clinical information, with the understanding that the cases published in the literature and reviewed by us do not represent all the patients who developed PAMI during the period of the study and that reporting may therefore be incomplete and biased. …

Pregnancy-Associated Acute Myocardial Infarction A Review of Contemporary Experience in 150 Cases Between 2006 and 2011

Today, most female children born with congenital heart disease will reach childbearing age. For many women with complex congenital heart disease, carrying a pregnancy carries a moderate to high risk for both the mother and her fetus. Many such women, however, do not have access to adult congenital heart disease tertiary centers with experienced reproductive programs. Therefore, it is important that all practitioners who will be managing these women have current information not only on preconception counseling and diagnostic evaluation to determine maternal and fetal risk but also on how to manage them once they are pregnant and when to refer them to a regional center with expertise in pregnancy management.

Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association

Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996.

Risk factors associated with cardiac surgery during pregnancy.

INTRODUCAO: A endocardite e uma doenca de tratamento dificil e que frequentemente necessita da participacao cirurgica. CASUISTICA E METODOS: Entre janeiro de 1987 e janeiro de 1999, 159 pacientes foram operados em nosso Servico, sendo 64,7% do sexo masculino. Este grupo apresentou idade media de 39,2 anos (2 a 78 anos), com peso medio de 57,1 kg. O acometimento valvar aortico foi o mais frequente (66 pacientes), sendo na valva nativa em 47 casos e em proteses em 19 (8 metalicas e 11 biologicas): a lesao mitral verificou-se em 53 pacientes, sendo mais comum em portadores de protese (28 biologicas e 2 metalicas). O comprometimento das duas valvas esteve presente em 28 casos. Os demais pacientes eram portadores de defeitos congenitos ou de marcapasso definitivo. A operacao foi indicada por refratariedade ao tratamento clinico, insuficiencia cardiaca, quadro infeccioso levando a disfuncao valvar ou de protese, vazamento periprotetico, ou ainda por arritmia. RESULTADOS: O estudo microbiologico evidenciou maior prevalencia de infeccao por Streptococcus viridans e Staphilococcus aureus. A operacao realizada nos portadores de endocardite infecciosa em valva nativa propiciou a conservacao da valva em 3 pacientes do grupo mitral e em 1 do grupo aortico; nos demais pacientes empregaram-se proteses (a maioria metalica em aorticos e biologica em mitrais). As reoperacoes foram frequentes, tendo pacientes com ate quarta operacao. A lesao congenita responsavel pela maioria dos casos foi a comunicacao interventricular (3 casos) e 4 pacientes apresentavam a endocardite em eletrodo de marcapasso. A mortalidade global foi de 16,3%, com maior incidencia em portadores de protese mitral e aortica submetidos a reoperacao. A presenca de abscesso como complicacao da endocardite infecciosa verificou-se em 18,2% dos pacientes, utilizando-se pericardio bovino na reconstrucao da maioria, com mortalidade de 17,2%. CONCLUSAO: Concluimos que o tratamento cirurgico da endocardite infecciosa representa um desafio para o cirurgiao, apesar de todo o progresso adicionado ao arsenal diagnostico e terapeutico desta patologia.

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Endocardite infecciosa: 12 anos de tratamento cirúrgico

OBJECTIVE: To assess the short- and long-term results of the use of streptokinase (SK) for the treatment of thromboses in cardiac valvular prostheses. METHODS: Seventeen patients with cardiac prosthetic thrombosis diagnosed by clinical, echocardiographic, and radioscopic findings underwent fibrinolytic treatment with a streptokinase bolus of 250,000 U followed by 100.000 U/hour. Short- and long-term results were assessed by radioscopy and echocardiography. RESULTS: Of the 17 patients, 12 had mechanical double-disk prostheses (4 aortic, 6 mitral, 2 tricuspid), 4 had single-disk prostheses (2 aortic, 1 mitral, and 1 tricuspid), and 1 had a tricuspid bioprosthesis. The success rate was 64.8%, the partial success rate was 17.6%, and the nonsuccess rate was 17.6%. All patients with a double-disk prosthesis responded, completely or partially, to the treatment. None of the patients with a single-disk prosthesis had complete resolution of the thrombosis. The time of streptokinase infusion ranged from 6 to 80 hours (mean of 56 h). The mortality rate due to the use of streptokinase was 5.8% and was secondary to cerebral bleeding. During streptokinase infusion, 3 (17.6%) embolic episodes occurred as follows: 1 cerebral, 1 peripheral, and 1 coronary. The rethrombosis index was 33% in a mean follow-up of 42 months. CONCLUSION: The use of fibrinolytic agents was effective and relatively safe in patients with primary thrombosis of a double-disk prosthesis. A fatal hemorrhagic complication occurred in 1 (5.8%) patient, and embolic complications occurred in 3 (17.6%) patients. In a mean 42-month follow-up, 67% of the patients were free from rethrombosis.

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Fibrinolytic therapy for thrombosis in cardiac valvular prosthesis short and long term results

Ha trinta anos tem sido empregada a tecnica descrita por Lower e Shumway para o transplante cardiaco ortotopico, com bons resultados. Complicacoes, como estase venosa, formacao de trombos, arritmias atriais e insuficiencia das valvas tricuspide e mitral, estao presentes no pos-operatorio tardio. A partir de 1995, passamos a utilizar a tecnica bicaval em todos os casos (6 pacientes). Cinco eram do sexo masculino e a media de idades dos receptores era de 50,6 anos. A cardiomiopatia era dilatada e isquemica em 2 casos cada, e chagasica e reumatica nos demais. Tres pacientes apresentavam operacoes previas, sendo que um deles havia sido submetido a tres operacoes de protese valvar aortica, o segundo a implante de marcapasso epimiocardico definitivo, e o ultimo a duas operacoes de revascularizacao do miocardio associada a aneurismectomia de ventriculo esquerdo. A tecnica cirurgica consistiu, na maioria dos casos, na anastomose das veias pulmonares, em conjunto com o atrio esquerdo do coracao a ser implantado e, a seguir, a da cava superior, inferior, do tronco pulmonar e aorta. Todos os doadores estavam em hospitais da cidade e com retirada multipla de orgaos. Nao tivemos obito hospitalar e todos os pacientes estao vivos para um periodo de um a quinze meses de pos-operatorio. Nao houve diferenca significativa quando se comparou as duas tecnicas para o tempo de anoxia, tempo de C E C, tempo de implante, presenca de taquiarritmias atriais, sangramento e permanencia hospitalar. Houve diferenca significativa (p<0,05) para a utilizacao de marcapasso temporario e presenca de insuficiencia tricuspide. Acreditamos que a tecnica bicaval, alem de reduzir o tamanho das cavidades atriais, e uma tecnica simples, com indice menor de complicacoes e que podera ser empregada com mais frequencia.

Transplante cardíaco ortotópico pela técnica bicaval

No periodo de dezembro de 1987 a dezembro de 1989, 906 pacientes foram submetidos a cirurgia cardiaca com circulacao extracorporea, no Instituto Dante Pazzanese de Cardiologia, sendo 43% coronarianos, 37% valvares, 17% congenitos e 3% outros. Dentre eles, observou-se, na fase intra-hospitalar de pos-operatorio, a ocorrencia de 19 casos de deiscencia parcial ou total da toracotomia mediana (2%), que ocorreu, em media, ao redor da 1o semana de pos-operatorio, tendo sido a reintervencao cirurgica por volta da 3o semana. As culturas mostraram predominio de germes gram positivos e poucos casos de gram negativos e fungos. Em apenas um caso nao foi isolado qualquer agente infeccioso. Neste grupo de pacientes, constatou-se a presenca de fatores predominantes, tais como diabetes, obesidade, doenca pulmonar obstrutiva cronica (DPOC) e tempo prolongado de cirurgia (media de 6 horas). Houve predominio de pacientes adultos, cujas idades variaram de 40 a 67 anos, media de 53 anos (89%). Constatou-se que, em 84% dos pacientes, a arteria mamaria interna foi utilizada como enxerto na revascularizacao cirurgica do miocardio. Alem das medidas gerais de terapeutica local e sistemica com antibioticos especificos, visando ao combate dos agentes infecciosos e a consequente esterilizacao da ferida, os pacientes eram conduzidos a sala de operacao, procedendo-se a limpeza e desbridamento dos planos cirurgicos, incluindo o esterno, deixando-se, em alguns casos, irrigacao continua com solucao de povidine. Em dois pacientes foi realizada rotacao de retalho miocutâneo, devido a refratariedade ao tratamento. De cinco casos de mediastinite, tres faleceram por falencia de multiplos orgaos e sepsis. O grupo restante apresentou boa evolucao, tendo obtido alta hospitalar apos a 3o semana da reintervencao, com boa cicatrizacao da ferida operatoria.

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Antoninho S Arnoni

Papers

Risk factors associated with cardiac surgery during pregnancy.

Endocardite infecciosa: 12 anos de tratamento cirúrgico

Fibrinolytic therapy for thrombosis in cardiac valvular prosthesis short and long term results

Transplante cardíaco ortotópico pela técnica bicaval

Manuseio da deiscência do esterno no pós-operatório de cirurgia cardíaca