Digital periarterial sympathectomy in the management of post-traumatic Raynaud syndrome.

OBJECTIVE: Among Basque handball players, the repeated impact of a ball on the palms of their hands hundreds of thousands of times throughout their sporting careers produces Raynaud syndrome. Treating this patient group is complex. Our objective was to assess the efficacy of digital periarterial sympathectomy in this patient group. METHODS: The study included all of the federated amateur and professional Basque handball patients who presented with Raynaud syndrome assessed in the vascular surgery service between January 2005 and December 2012. The postoperative assessment included a physical examination, basal photoplethysmography and photoplethysmography after heat hyperemia, and arteriography or magnetic resonance angiography. RESULTS: All 182 digital periarterial sympathectomies in the 114 fingers of 60 patients were in Porter functional class III or IV. All patients were discharged within the first 48 hours. Follow-up results, with a mean of 2 years ± 5 months, were 100%. All patients presented immediate pain remission, recovery of comfort, normal nail growth, rapid healing of all ulcers, distal anhidrosis, and return to active sport participation. The results remain steady in 58 patients (93.5%). Mean time until return to sports activity was 9.95 ± 1.61 weeks. CONCLUSIONS: Digital periarterial sympathectomy is a simple, relatively nonaggressive technique without adverse side effects and with excellent medium-term results. In patients with Raynaud syndrome refractory to medical treatment and with threat to the viability of one or several fingers, digital periarterial sympathectomy can be the first treatment option, especially in cases of arteritis associated with very severe spasms.

Timing of renal replacement therapy after cardiac surgery: a retrospective multicenter Spanish cohort study.

BACKGROUND: The optimal time to initiate renal replacement therapy (RRT) in cardiac surgery-associated acute kidney injury (CSA-AKI) is unknown. Evidence suggests that the early use of RRT in critically ill patients is associated with improved outcomes. We studied the effects of time to initiation of RRT on outcome in patients with CSA-AKI. METHODS: This was a retrospective observational multicenter study (24 Spanish hospitals). We analyzed data on 203 patients who required RRT after cardiac surgery in 2007. The cohort was divided into 2 groups based on the time at which RRT was initiated: in the early RRT group, therapy was initiated within the first 3 days after cardiac surgery; in the late group, RRT was begun after the 3rd day. Multivariate nonconditional logistic and linear regression models were used to adjust for potential confounders. RESULTS: In-hospital mortality was significantly higher in the late RRT group compared with early RRT patients (80.4 vs. 53.2%; p < 0.001; adjusted odds ratio of 4.1, 95% CI: 1.6-10.0). Also, patients in the late RRT group had longer adjusted hospital stays by 11.6 days (95% CI: 1.4-21.9) and higher adjusted percentage increases in creatinine at discharge compared with baseline by 67.7% (95% CI: 28.5-106.4). CONCLUSIONS: Patients who undergo early initiation of RRT after CSA-AKI have improved survival rates and renal function at discharge and decreased lengths of hospital stay.

Early and late troponin T determination after elective cardiac surgery. Two different meanings.

AIM: Although Troponins are demonstrated to be better predictors than CK-MB in quantification of myocardial damage, the relation between cut-off values for the diagnosis of perioperative myocardial infarction (PMI) and sample time is still not clear. In the present study we sought to analyse the clinical consequence of an early and late cTnt determinations after elective cardiac surgery. MATERIAL OF STUDY: Data of 117 patients undergone elective open heart surgery between January 2006 and June 2007 were prospectively collected. PMI was detected on the basis of postoperative electrocardiography/echocardiography and hemodynamic state. RESULTS: The in-hospital mortality was 1.7%. Eight patients (6.8%) presented PMI. Receiver-operating characteristic (ROC) analyses showed a cTnt cut-off of 1.22 mg/L (CI 0.94 to 0.99, P = 0.0001, 100% sensitivity and 96% specificity) on arrival to ICU for the diagnosis of PMI. On the second post-operative day the cut-off value was 2.8 mg/L (CI 95% 0.84 to 0.98, P = 0.0001) (sensitivity 66% and specificity 100%). At this time the Pearson's test revealed the best correlation to ICU (P = 0.008) and in-hospital (P = 0.01) length of stay (LOS). DISCUSSION: A better sensibility of cTnt in diagnosis of PMI in the early postoperative period has been demonstrated to be associated to an increasing specificity in the late post-operative period. CONCLUSIONS: PMI must be suspected in patients with a cTnt > 1.22 mg/L. A second later assessment on the 2nd post-operative can exclude false positives and significantly predict the ICU and the in-hospital length of stay.

In vivo assessment of a new method of pulsatile perfusion based on a centrifugal pump.

The aim of this study was to assess platelet dysfunction and damage to organs after extracorporeal circulation using a pump based on a new method that adds a pulsatile flow to the continuous flow provided by a centrifugal pump. The continuous component of the total flow (2-3 L/min) is created by a Bio-Pump centrifugal pump, while the pulsatile component is created by the pulsating of an inner membrane pneumatically controlled by an intra-aortic counterpulsation balloon console (systolic volume of 37.5 mL in an asynchronous way with a frequency of 60 bpm). Six pigs were subjected to a partial cardiopulmonary bypass lasting 180 min and were sacrificed 60 min after extracorporeal circulation was suspended. The hematological study included the measurement of hematocrit, hemoglobin, leukocytes, and platelet function. The new pump did not significantly alter either platelet count or platelet function. In contrast, hematocrit and hemoglobin were significantly reduced during extracorporeal circulation (approximately 5% P = 0.011, and 2 g/dL P = 0.01, respectively). The leukocyte count during extracorporeal circulation showed a tendency to decrease, but this was not significant. In general, the short-term use of the new pump (4 h) did not cause any serious morphological damage to the heart, lung, kidney, or liver. The results suggest that the hemodynamic performance of the new pump is similar to a conventional centrifugal pump and could therefore be appropriate for use in extracorporeal circulation.

A new method of providing pulsatile flow in a centrifugal pump: assessment of pulsatility using a mock circulatory system.

Previous studies have demonstrated the potential advantages of pulsatile flow as compared with continuous flow. However, to date, physiologic pumps have been technically complex and their application has therefore remained in the experimental field. We have developed a new type of centrifugal pump, which can provide pulsatile as well as continuous flow. The inner wall of a centrifugal pump is pulsed by means of a flexible membrane, which can be accurately controlled by means of either a hydraulic or pneumatic driver. The aim of this study was to assess the hydraulic behavior of the new pump in terms of surplus hemodynamic energy (SHE). We conducted experiments using a mock circulatory system including a membrane oxygenator. No differences were found in the pressure-flow characteristics between the new pump and a conventional centrifugal pump, suggesting that the inclusion of the flexible membrane does not alter hydraulic performance. The value of SHE rose when systolic volume was increased. However, SHE dropped when the percentage of ejection time was reduced and also when the continuous flow (programmed by the centrifugal console) increased. Mean flow matched well with the continuous flow set by the centrifugal console, that is, the pulsatile component of the flow was exclusively controlled by the pulsatile console, and was therefore independent of the continuous flow programmed by the centrifugal console. The pulsatility of the new pump was approximately 25% of that created with a truly pulsatile pump.

A comparison between percutaneous and surgical transplantation of autologous skeletal myoblasts in a swine model of chronic myocardial infarction.

OBJECTIVE: Our aim was to compare the efficacy of surgical versus percutaneous administration of skeletal myoblasts (SkM) in a swine model of chronic myocardial infarction and to determine the mechanism(s) involved in their beneficial effect. METHODS: Two months after induction of myocardial infarction (MI), Goettingen miniature pigs underwent autologous SkM transplant either by direct surgical injection (n=6) or percutaneous access and intramyocardial delivery under fluoroscopic and echocardiographic guidance (n=6). Control animals received media alone (n=4). Functional analysis was performed by 2D echocardiography. Myoblast engraftment, in vivo cell differentiation, vessel formation, fibrosis, and the ratio between collagen type I/III deposition were analyzed in the infarct (IA) and non-infarct area (NIA) by immunohistochemistry. RESULTS: Animals received a median of 407.55+/-115x10(6) BrdU-labeled autologous SkM. Myoblast transplant was associated with a statistically significant increase in left ventricular ejection fraction (p<0.01), increased vasculogenesis and decreased fibrosis (p<0.05), and reduced collagen type I/III ratio in the IA and NIA areas as compared with control animals. No differences were found between groups receiving SkM by percutaneous or surgical access. CONCLUSIONS: Our results indicate that increased vasculogenesis and changes in matrix remodeling with decreased fibrosis are associated with the beneficial effect of SkM transplant in chronic MI. The equivalent benefit observed from surgical and percutaneous delivery has important clinical implications.

[Coronary surgery. Developments in the last decade. Indications and results]. / Cirugía coronaria. Evolución en la última década. Indicaciones y resultados actuales.

Coronary artery bypass surgery is endorsed by the excellent, well-documented, long-term results that follow complete revascularization and the use of 1 or 2 mammary artery grafts. This article contains a review of the current indications for and the results of such surgery and an evaluation of new challenges and opportunities, including the implementation of safer and less aggressive surgery, and surgery associated with other operative procedures. The aim was to develop a strategy linked to a cycle of innovation that could be used to adapt surgery to the needs of the population, to new technologies, and to pioneering developments.

Cellular cardiomyoplasty: clinical application.

Myocardial regeneration can be induced with the implantation of a variety of myogenic and angiogenic cell types. More than 150 patients have been treated with cellular cardiomyoplasty worldwide, 18 patients have been treated by our group. Cellular cardiomyoplasty seems to reduce the size and fibrosis of infarct scars, limit postischemic remodelling, and restore regional myocardial contractility. Techniques for skeletal myoblasts culture and ex vivo expansion using autologous patient serum (obtained from plasmapheresis) have been developed by our group. In this article we propose (1) a total autologous cell culture technique and procedures for cell delivery and (2) a clinical trial with appropriate endpoints structured to determine the efficacy of cellular cardiomyoplasty.

Bicaval anastomosis in a heart transplant recipient with left superior vena cava.

We describe the surgical procedure of orthotopic heart transplantation (OHT) in a recipient with persistent left superior vena cava (LSVC) and isolated noncompaction of the left ventricle. The bicaval anastomosis technique was performed using and isolating his native coronary sinus to let the left superior vena cava drain into his own inferior vena cava through the native coronary sinus.

Autologous human serum for cell culture avoids the implantation of cardioverter-defibrillators in cellular cardiomyoplasty.

BACKGROUND: Current clinical experience with cellular cardiomyoplasty (using serum bovine-cultivated myoblasts) has demonstrated significant malignant ventricular arrhythmias and sudden deaths in patients. In some ongoing clinical trials the implantation of cardioverter-defibrillator is mandatory. We have hypothesized that contact of human cells with fetal bovine serum results after 3-week fixation of animal proteins on the cell surface, representing an antigenic substrate for immunological and inflammatory adverse events. METHODS AND RESULTS: Autologous myoblasts were transplanted into infarcted LV in 20 patients (90% males, mean age 62+/-8 years). Cells were cultivated in a complete human medium during 3 weeks, using the patients' own serum obtained from a blood sample or from plasmapheresis. Injections were performed during CABG (2.1 grafts/pt). All patients had an uneventful recovery. At a mean follow-up of 14 +/- 5 months without mortality, no malignant cardiac arrhythmias are reported. LV ejection fraction improved from 28 +/- 3% to 52 +/- 4.7% (p = 0.03), and regional wall motion score index (WMSI) from 3.1 to 1.4 (p = 0.04) in the cell-treated segments. Myocardial viability tests showed areas of regeneration. Patients moved from mean NYHA class 2.5 to class 1.2. CONCLUSIONS: A total autologous cell culture procedure was used in cellular cardiomyoplasty reducing the risk of arrhythmia. Human-autologous-serum cell expansion avoids the risk of prion, viral or zoonoses contamination. Since patients treated with noncultivated bone marrow cells are free of arrhythmia, the bovine-culture medium seems to be responsible for this complication. Cellular cardiomyoplasty may be efficient to avoid progression of ventricular remodeling and subsequent heart failure in ischemic heart disease.

[Future perspectives in the treatment of heart failure: from cell transplantation to cardiac regeneration]. / Perspectivas futuras de tratamiento en la insuficiencia cardíaca: del trasplante de células a la regeneración cardíaca.

The last few years have witnessed growing interest in regenerative therapy for the failing heart by cell transplantation. Although initial studies with skeletal myoblasts are more than 10 years old, the potential of bone marrow-derived cells has led to a flurry of experimental studies generating generally positive but occasionally contradictory results. This has given rise on not a few occasions to conflicting viewpoints regarding the ethics of initiating clinical trials. We feel it is appropriate to offer a critical view of the use of stem cells for heart failure. Perhaps the thorniest question to answer at this time is whether clinical trials are justified or not in the light of current knowledge, or whether we should acquire deeper knowledge of the possible efficacy and safety of this type of treatment, and of the mechanisms that account for its efficacy, before we so much as initiate studies in humans. We feel there is now sufficient evidence to justify the performance of clinical trials despite the undoubtedly numerous questions that remain to be answered with experimental studies in animals.

Bicaval versus standard technique in orthotopic heart transplant: assessment of atrial performance at magnetic resonance and transthoracic echocardiography.

Despite a more physiological morphology of atrial anastomosis in the bicaval technique with respect to standard biatrial anastomosis in orthotopic heart transplantation (OHT), the impact on the long-term outcome is still not clear. In this retrospective study, we sought to investigate the morphology and function of the atria through magnetic resonance imaging (MRI) and transthoracic echocardiography (TTE). Moreover, we aimed to analyse the accuracy of TTE with respect to MRI. Cox regression analysis of 216 consecutive patients receiving OHT between August 1987 and January 2010 identified only recipient age at the time of transplant to be an independent predictor of mortality (P = 0.048, odds ratio = 1.04). After a mean follow-up of 96.6 ± 77.7 months, 108 patients were alive, of which 35 were found to be eligible for MRI assessment. In this analysis, left and right atrial volumes were found to be significantly larger in the standard group in comparison with the bicaval group (P = 0.001), and no significant difference between the two techniques was observed in left and right atrio-ventricular output. Moreover, a significantly reduced accuracy was observed (CCC < 0.3) when TTE results were compared with MRI assessment in evaluating atrial dimensions. Although left and right atrial volumes are significantly larger in the standard group in comparison with the bicaval group, we concluded that no significant difference in the atrial output and survival between the two techniques could be demonstrated.

Myocardial regeneration in heart failure: integrated development of biological therapeutic approaches.

Heart failure currently constitutes one of the greatest health problems in the Western world. Its incidence, far from diminishing or even remaining stable, is actually still increasing in association with the aging of the population and its lifestyle. A better knowledge of physiopathological mechanisms has allowed for the development of new therapeutic focal points and lines of research. Nevertheless, its treatment is complex and encompasses a multidisciplinary approach. Patients in an advanced stage still have a very high mortality rate in spite of receiving optimum medical care. The development of new therapeutic techniques that afford a better prognosis has therefore been essential. Of these, and leaving aside surgical treatments, myocardial regeneration by means of cellular therapy, new concepts in tissue engineering and their results, and the applications of new advances in the field of immunomodulation have all recently experienced development. In this article, the aim is to bring the latest concepts in the physiopathology and humoral response of cardiac failure up to date as well as doing the same with the therapeutic approaches in this area.

Alternatives to heart transplantation: integration of biology with surgery.

Chronic heart failure is one of the major health care issues in terms of increasing number of patients, rate of hospitalizations and costs. Heart transplantation is the best established therapy for patients with severe heart failure. However, the number of donors limits the activity to 5000 heart transplants performed annually worldwide. This limitation has generated alternative treatments. The increase of the interest in the reversibility of the heart failure and the application of new biological alternatives has generated therapeutic strategies designed to integrate biology and medical technologies in order to act to the biomechanical, the molecular and the neurohormonal mechanisms of heart failure. These treatments include cellular cardiomyoplasty, tissue engineering, surgical left ventricular restoration as well as passive and active mechanical ventricular assistance as destination therapy, bridge to recovery or bridge to transplantation. The integrated development of these approaches could offer hopeful treatments, although there is still much to be learned regarding the optimal use of these strategies.

Stem cells cardiac differentiation in 3D systems.

Cardiac regeneration requires a complex cascade of events. Stem cell therapy and tissue engineering are newly emerging tools with promising potential for recover or replace of damaged cardiac tissue. There are many factors, most of them still no clarified, that limit the effectiveness of these treatments and their translation to the clinic. Cells should graft, survive and functionally integrate to the target organ in order to have a chance to restore its function. As in original tissues, a complex and well defined set of signals, many of them coming from the extracellular matrix, is required for normal cell physiology. Biomaterials science gives us important tools to build this extracellular matrix. Functionalized 3D systems can provide the correct environment and act as a delivery system for genes or gene products, guiding the therapeutic cells to the functional phenotype.

Allograft morphology and function in heart transplant recipients surviving more than 15 years by magnetic resonance imaging and dual-source computed tomography.

OBJECTIVE: Cardiac allograft vasculopathy and late graft failure are the main limiting factors of long-term success of heart transplantation, and little is known about graft function in the long-term survivors. The aim of this study was to assess the ventricular function and the allograft vasculopathy in long-term survivors (>15 years) with the cardiac magnetic resonance imaging (MRI) and dual-source computed tomography (DSCT) coronary angiogram. METHODS: In our database, 34 cardiac recipients have more than 15 years of follow-up and were evaluated for this study; 22 (65%) of them were enrolled. Mean age at transplant was 46 ± 13.5 years, mean donor age was 28.5 ± 10.1 years, and mean graft ischemic time was 189 ± 58 min. Mean follow-up was 18.5 ± 2.4 years (range 15-22). All patients underwent cardiac MRI and DSCT. RESULTS: Mean left ventricular (LV) volumes indexed to the body surface area (BSA) were within normal range: the end-diastolic volume/BSA was 61 ± 16 ml m(-2), end-systolic volume/BSA was 22 ± 15 ml m(-2), stroke volume/BSA was 38 ± 6 ml m(-2), LV mass/BSA: 72 ± 18 g m(-2), and mean ejection fraction (EF) was 0.59 ± 0.08. Two patients (9%) showed a global cardiac hypokinesia and two other patients (9%) showed akinesia of one segment. At DSCT, 41% of patients had a strictly normal coronary angiogram, 41% had wall thickening and 18% presented a least one >60% stenosis. CONCLUSIONS: Cardiac MRI and DSCT coronary angiogram revealed a normal graft function and morphology after more than 15 years of transplantation. However, a certain number of patients have significant cardiac allograft vasculopathy and another consistent group has initial disease. These patients deserve further follow-up and tailoring of the immunosuppressive regimen.

External validation and comparison of three scores to predict renal replacement therapy after cardiac surgery: a multicenter cohort.

PURPOSE: Cardiac surgery-associated acute kidney injury requiring renal replacement therapy (RRT) is independently associated with mortality. Several risk scores have been developed to predict the need for RRT after cardiac surgery. We have compared and verified the external validity of the three main available scores for RRT prediction after cardiac surgery: the Thakar score, the Mehta tool, and the Simplified Renal Index. METHODS: The risk scores were calculated in a cohort of 1084 adult patients, 248 of whom required RRT, who underwent open-heart surgery in 24 Spanish hospitals in 2007. The performance of the systems was determined by examining their discrimination (areas under the receiver operating characteristic curves (aROC) and calibration (Lemeshow-Hosmer chi-square goodness-of-fit statistics). RESULTS: The aROCs in the Thakar score, the Mehta tool, and the Simplified Renal Index were 0.82, 0.76 and 0.79, respectively. The three scoring systems were poorly calibrated and tended to underestimate the actual need for RRT. CONCLUSIONS: The Thakar score and the Simplified Renal Index discriminated well between low - and high-risk patients in our cohort, and Thakar outperformed the Mehta tool. These best-performing scores may aid in the selection of optimal therapy, facilitate the planning of hospital resource utilization, improve preoperative counseling, select participants for clinical trials of renal-protective therapies and enable an accurate comparison between different institutions or surgeons.

Propagación eléctrica en los mecanismos de torsión y succión en un corazón de tres tiempos / Electrical Propagation in the Mechanisms of Twist and Suction in a Three-phase Heart

Introducción: La hipótesis de Torrent Guasp plantea que los ventrículos están conformados por una banda muscular continua que nace a nivel de la válvula pulmonar y se extiende hasta la raíz aórtica delimitando las dos cavidades ventriculares. Esta anatomía brindaría la interpretación para dos aspectos fundamentales de la dinámica ventricular izquierda: el mecanismo de torsión y el llenado diastólico rápido por efecto de succión. Objetivos: Investigar la activación eléctrica de las bandeletas endocárdica y epicárdica para comprender la torsión ventricular, el mecanismo de succión activa en la fase isovolumétrica diastólica y el significado del volumen residual. Material y métodos: La investigación se realizó mediante un mapeo electroanatómico tridimensional en cinco pacientes. Al ser la bandeleta descendente endocárdica y la ascendente epicárdica, se utilizaron dos vías de abordaje por punción. Resultados: El mapeo tridimensional endoepicárdico demuestra una activación eléctrica de la zona de la lazada apexiana concordante con la contracción sincrónica de las bandeletas descendente y ascendente. La activación simultánea y contrapuesta de la bandeleta ascendente con punto de partida de su activación radial desde la bandeleta descendente, en la zona de entrecruzamiento de ambas, es coherente con la torsión ventricular. La activación tardía de la bandeleta ascendente se compatibiliza con la persistencia de su contracción durante el período inicial de la fase isovolumétrica diastólica (base del mecanismo de succión); se produce sin necesidad de postular activaciones eléctricas posteriores al QRS. Conclusiones: Este trabajo explica el proceso de la torsión ventricular y el mecanismo de succión. Comprueba que la activación de la bandeleta ascendente completa el QRS anulando el concepto tradicional de relajación pasiva en la fase isovolumétrica diastólica.

Background: The hypothesis of Torrent Guasp considers that the ventricular myocardium consists of a continuous muscular band that begins at the level of the pulmonary valve and ends at the level of the aortic root, limiting both ventricular chambers. This anatomy would provide the interpretation for two fundamental aspects of left ventricular dynamics: the mechanism of left ventricular twist and rapid diastolic filling due to the suction effect. Objectives: The aim of this study was to investigate the electrical activation of the endocardial and epicardial bands to understand ventricular twist, the mechanism of active suction during the diastolic isovolumic phase and the significance of the residual volume. Methods: Five patients underwent three-dimensional electroanatomic mapping. As the descending band is endocardial and the ascending band is epicardial, two sites of puncture were used. Results: Three-dimensional endo-epicardial mapping demonstrates an electrical activation sequence in the area of the apex loop in agreement with the synchronic contraction of the descending and ascending band segments. The simultaneous and opposing radial activation of the ascending band segment, starting in the descending band segment, in the area in which both band segments intertwine, is consistent with the mechanism of ventricular twist. The late activation of the ascending band segment is consistent with its persistent contraction during the initial period of the isovolumic diastolic phase (the basis of the suction mechanism), and takes place without need of postulating further electrical activations after the QRS complex. Conclusions: This study explains the process of ventricular twist and the suction mechanism, and demonstrates that the activation of the ascending band segment completes the QRS, ruling out the traditional concept of passive relaxation during the diastolic isovolumic phase.