Letters to the editor

SPECIAL

Letters to the editor

Editorial

My dear friend Domingo:

I want to thank you for publishing this editorial (Cardiovascular Surgery Outcomes - Oportunity to rediscuss medical and cardiological care in the Brazilian Public Health System. Walter J. Gomes, José Teles de Mendonça, Domingo M. Braile). The editorial enhanced the journal, and I must also thank the Brazilian editors for the sensible, dedicated and serious contextualization of the theme. This editorial captures the sense of feeling and the medical humanism that is dying out today.

After reading the editorial, I felt satisfied to know that, in our countries, people work with accuracy, bravery and honesty, emphasizing that the outcomes come not only from the perfectionism and the skill of surgeons, but also from their working conditions and improper social conditions that often are the cause of pathologies the doctors are treating. Because of this, improper statistics can be calculated because this data was not taken into account.

If you have the chance, please send W. J Gomes and JT Mendonça a friendly hug from me, as well as congratulations for this achievement. Be sure that I have sent it to many fellow Argentinian surgeons.

Your editorial delighted me, particularly because I read it soon after a very unpleasant argument I had regarding the topic of "research" for multinational laboratories that is performed in Public Hospitals by doctors who charge in dollars without reporting it. Again, please accept my congratulations and my respect as a humanist physician.

My warmest congratulations,

Adolfo Saadia - Buenos Aires/Argentina

Medline

Dear Domingo,

I have received the journal and I have read the editorial celebrating the indexation of RBCCV/BJCVS in Medline. After seeing your enthusiasm and methodical determination for so many years, I was not surprised by the outcome. However, I know this was a difficult battle, which could not have been won without persistence and trust in the justice of the cause. These have always distinguished you during your career. I was not only enthusiastic about but also extremely moved by your dedication, knowing you engaged in this effort during your personal fight for life, and seeing that you were fortunately successful in both. Once again, God was fair to you, allowing for the pleasure of achieving this victory alive.

He and all of us know that this mission was yours. We also know, as you said, that this battle does not finish here. This is only the first step of a new journey. It's up to the editor, his team, and all of us, to continue this journal using the same model that got it chosen for Medline in the first place.

I believe God will give you a long life-- not only to enjoy the laurels of this victory with your family, but also to carry on, exemplifying your persistence and your dedication to the things you believe in. This serves as an example-- not only for Brazilian cardiac surgeons, but also for Brazil as a country, which nowadays is in need of more people like you.

Congratulations once again. This remarkable date will definitely go down in history as a victory of persistence, humility, and determination!

Sergio Nunes Pereira - Santa Maria/RS-Brazil

Scientific Bulletin

Dear Dr. Walter Gomes,

The scientific bulletins issued by our society have been significantly helping in my training as a cardiovascular surgeon, as well as in the advancement of the up-to-date information about our specialty, largely from the unquestionable support from you and Professor Braile -- people who, for your knowledge and constant development, I strongly admire.

As was to be expected, the vast majority of the studies refer to coronary artery disease; however, I believe current subjects about surgical treatment of cardiac insufficiency would be enjoyed by the readers of this bulletin.

Congratulations in advance to the whole team for your hard work, which has greatly contributed to keeping Brazilian cardiovascular surgery in the world spotlight.

Luiz Renato Dias Daroz - Cardiovascular Surgeon of the Service of Hospital Marcio Cunha - Ipatinga/MG-Brazil

Risk Score

Dear Mr. Editor,

We have intently reviewed the article, "Is the RACHS-1 (Risk Adjustment in Congenital Heart Surgery) a useful tool in our scenario?" (RBCCV 22.4)[1]. The high variability in presentation of congenital cardiopathies associated with their low frequency restricts the outcomes analysis in institutional isolated studies. The RACH allows us to determine the complexity of the operated cases and to estimate the prognosis, and it is also an improvement tool for this service [2]. The RACHS-1 was created through a consensus of specialists and validated by service outcomes in developed countries [3,4]. What could be debatable is its applicability within our spectrum of assistance.

However, we do not agree with the author's statement that RACHS1 could not be applied to our environment. Apart from being a retrospective study, the number of patients is limited to analysis. Because it is an institutional study, it does not represent the reality of the country, therefore invalidating its conclusion. For a low-risk population, three categories with higher complexity were not analyzed due to the limited number of patients. The score validation-attempting to incorporate score into the Brazilizan reality - must include a more expressive denominator in all categories. The analysis of mortality risk factors should include a complex logistic regression model and should also include in the outcomes the p-value and the calculation of the odds ratio with the appropriate confidence intervals. The RACHS-1 categories should be included in this model, along with the other variables that were implied to be high mortality causes in the discussion of this study but that were not evaluated by the authors in the results. Continuous variables, such as cardiopulmonary bypass and anoxia duration, were analyzed as ordinal variables, which is inadequate. Table 1 shows a proportionality between the higher mortality and the RACHS-1 category; however, there is not a statistical analysis of this data, even though the results are higher than expected and are higher than the services that have validated this data [3-5]. There is no doubt that the Brazilian reality is different from the centers that have validated the RACHS-1; however, it would be irresponsible to discard the tool based on the study in question.

In conclusion, we congratulate the authors for their courage to show their outcomes in a stratified way, and we hope the great centers of our country adopt this initiative. The outcomes published in Brazil thus far are restricted to populations in which it is not possible to identify the complexity grade of the performed procedures [6,7]. Currently, discussing the outcomes in pediatric heart surgery in the absence of risk stratification is highly reprehensible and unproductive.

Luiz Fernando Canêo, Fernando A. Atik

Cardiovasculcar Surgery Department - InCor-DF-Brazil

Answer

Mr. Editor,

We have received the comments of Dr. Luiz Canêo concerning our article entitled, "Is the RACHS-1 (Risk Adjustment in Congenital Heart Surgery) a useful tool in our scenario?" (RBCCV 22.4). We agree with the fact that the article deals with only a small and retrospective experience that allows for variations. It is true that it is about an experience of a new and low-volume service, but it does try to offer the best quality of assistance to its patients; hence, the use of score to attempt to trace the service's initial outcomes.

We understand that we do not have a representative sample of the country, and at no point did the authors intend to extend their conclusions to the national reality; rather, they focused on the possibilities for our state, which the sample of the study represents. Despite being one of the poorest states in the country, our state has been attempting to offer quality assistance in pediatric heart surgery, which has low rates of resolution. We conclude that our study is a regional reference.

As the article section of a Master's degree thesis, it was not possible for the report to contemplate all of the studied aspects of the dissertation. However, some other characteristics of this population were taken into consideration.

In terms of validating the use of score in Brazil, we believe that, if more Brazilian institutions were inclined to show their outcomes using systems that classify the complexity of their patients, it would be more useful; what we have had thus far, as Dr. Canêo emphasized in his letter, are studies that are restricted to populations in which it is impossible to identify the complexity grade of the patients.

In conclusion, we are grateful for the comments, and we hope this letter will inspire other groups in pediatric heart surgery to embrace the idea of discussing outcomes in pediatric heart surgery with risk stratification in order to raise a productive debate and to offer increasingly better care for our pediatric population.

Rachel Vilela de Abreu Haickel Nina - Pediatric Cardiologist. Cardiology and Cardiac Surgery Service HU-UFMA, São Luís/MA-Brazil

REFERÊNCIAS (Cartas ao Editor)/ REFERENCES (Letters to the editor)

REFERÊNCIAS (Reposta)/ REFERENCES (Answer)

• 1. Nina RVAH, et al. O escore de risco ajustado para cirurgia em cardiopatias congênitas (RACHS-1) pode ser aplicado em nosso meio? Rev Bras Cir Cardiovasc. 2007;22(4):425-31.
• 2. Jacobs JP, et al. Nomenclature and databases - the past, the present, and the future : a primer for the congenital heart surgeon. Pediatr Cardiol. 2007; 28(2):105-15.
• 3. Jenkins KJ, et al. Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg. 2002;123(1):110-8.
• 4. Jenkins KJ and Gauvreau K. Center-specific differences in mortality: preliminary analyses using the Risk Adjustment in Congenital Heart Surgery (RACHS-1) method. J Thorac Cardiovasc Surg. 2002;124(1):97-104.
• 5. Larrazabal LA, et al. Improvement in congenital heart surgery in a developing country: the Guatemalan experience. Circulation. 2007;116(17):1882-7.
• 6. Stolf NA. Congenital heart surgery in a developing country: a few men for a great challenge. Circulation. 2007;116(17):1874-5.
• 7. Ribeiro, AL, et al. Mortality related to cardiac surgery in Brazil, 2000-2003. J Thorac Cardiovasc Surg. 2006;131(4):907-9.
• 1. Stolf NAG. Congenital heart surgery in a developing country: a few men for a great challenge. Circulation. 2007;116(17):1874-5.
• 2. Ribeiro ALP, Gagliardi SPL, Nogueira JLS, Silveira LM, Colosimo EA, Nascimento CAL. Mortality related to cardiac surgery in Brazil, 2000-2003. J Thorac Cardiovasc Surg. 2006;131(4):907-9.

Publication Dates

• Publication in this collection
  13 Aug 2008
• Date of issue
  Mar 2008