RESUMO
BACKGROUND: In patients with heart failure secondary to left ventricular (LV) systolic dysfunction, a short deceleration time (DT) successfully predicts clinical outcome. The impact of myocardial viability and revascularization on the mitral inflow velocities, however, is unknown. METHODS AND RESULTS: Forty patients with ischemic cardiomyopathy underwent (201)Tl scintigraphy (SPECT) and 2D, Doppler, and dobutamine echocardiography (DE, to 40 microg. kg(-1). min(-1)) 2 days before CABG. Echocardiography was repeated 3 months after revascularization to determine recovery of function. Significant correlations were present between DT and LV contractile reserve by DE (r=0.72), scar perfusion defect by SPECT (r=-0.69), and the change in ejection fraction (DeltaEF) after surgery (r=0.77) (all P:<0.01). DT >150 ms effectively identified (sensitivity 79%, specificity 81%) patients with DeltaEF >/=5%. The population was divided into 2 groups according to DT: group 1 (DT >150 ms, n=21) and group 2 (DT =150 ms, n=19). At baseline, NYHA class, LV EF, age, and use of cardiovascular drugs were similar between the 2 groups. The number of viable segments by both DE and SPECT, however, was higher in group 1 (both P:<0.01), and only patients in group 1 had an increase in EF (29+/-4.8% to 40+/-8%, P:<0.01) after surgery. Death and heart transplantation occurred in 7 patients from group 2 and 1 patient from group 1 (P:=0.017). CONCLUSIONS: In patients with ischemic cardiomyopathy, the reduced amount of viable myocardium results in a restrictive mitral inflow pattern, which in turn predicts poor survival.
Assuntos
Cardiomiopatias/terapia , Disfunção Ventricular Esquerda/fisiopatologia , Análise de Variância , Velocidade do Fluxo Sanguíneo , Cardiomiopatias/complicações , Cardiomiopatias/fisiopatologia , Ponte de Artéria Coronária , Ecocardiografia Doppler , Humanos , Valva Mitral/fisiologia , Revascularização Miocárdica , Tomografia Computadorizada de Emissão de Fóton Único , Resultado do Tratamento , Disfunção Ventricular Esquerda/etiologia , Função VentricularRESUMO
BACKGROUND: Alterations in adrenergic receptor densities can potentially contribute to myocardial dysfunction. Their relevance to myocardial hibernation in humans is unknown. METHODS AND RESULTS: Accordingly, 22 transmural myocardial biopsies were obtained in 11 patients with ischemic ventricular dysfunction during bypass surgery, guided by transesophageal echocardiography. Patients underwent dobutamine echocardiography (DE) and rest scintigraphic studies before revascularization and DE at 3 to 4 months. alpha- and ss-receptor density (ARD and BRD) and extent of fibrosis were quantified from the myocardial biopsies. Of the 22 segments, 16 had abnormal rest function and 6 were normal. Severely hypokinetic or akinetic segments showed a 2.4-fold increase in ARD with a concomitant 50% decrease in BRD compared with normal segments. An increase in ARD, a decrease in BRD to a lesser extent, and thus an increase in ARD/BRD ratio were seen in dysfunctional segments with contractile reserve compared with normal segments and were most pronounced in those without contractile reserve (P:<0.001). Similar findings were observed if recovery of function or scintigraphic uptake was analyzed as a marker for viability. No significant relation between either ARD or BRD and percent myocardial fibrosis was noted (r=0.37 and -0.39, respectively). CONCLUSIONS: Thus, graded and reciprocal changes in alpha- and ss-adrenergic receptor densities occur in viable, hibernating myocardium and may account in part for the observed depression in resting myocardial function and preserved contractile reserve in this entity.
Assuntos
Miocárdio Atordoado/metabolismo , Miocárdio Atordoado/patologia , Miocárdio/metabolismo , Miocárdio/patologia , Receptores Adrenérgicos alfa/metabolismo , Receptores Adrenérgicos beta/metabolismo , Idoso , Biópsia , Ponte de Artéria Coronária , Dobutamina , Ecocardiografia , Feminino , Fibrose/patologia , Coração/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Contração Miocárdica/efeitos dos fármacos , Radiografia , Cintilografia , Recuperação de Função Fisiológica , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/cirurgiaRESUMO
BACKGROUND: Although dobutamine echocardiography (DE) is widely used to assess myocardial viability in humans, little is known about the relation between contractile reserve and myocardial structure. METHODS AND RESULTS: We evaluated 20 patients with coronary disease (64+/-13 years old, ejection fraction 28+/-7.5%) with DE (up to 40 micrograms . kg(-1). min(-1)), rest-redistribution (201)Tl single photon emission CT, and quantitative angiography before bypass surgery. During surgery, patients underwent transmural myocardial biopsies (n=37) guided by transesophageal echocardiography to determine the extent of interstitial fibrosis and intracellular and interstitial proteins by histopathology and immunohistochemistry. Among the 37 segments biopsied, 16 recovered function as assessed 2 to 3 months later. Segments with postoperative functional recovery had more wall thickening at low-dose DE (28% versus 3%, P<0.001), higher thallium uptake (69% versus 48%, P=0.03), and less interstitial fibrosis (2% versus 28%, P<0.001). Quantitative angiographic parameters did not predict recovery of function. Segments with DE viability (contractile reserve and/or ischemia) had less fibrosis (2.7% versus 28%, P<0.001), less vimentin and fibronectin (both P<0.01), more glycogen (P=0.016), and higher thallium uptake (64% versus 35.5%, P<0.05) than those without viability. Viable segments by both DE and thallium had less fibrosis (1%) than those viable by 1 of the 2 techniques (9%) or not viable by both (28%, P=0.005). Thickening at low-dose DE correlated well with the extent of interstitial fibrosis (r=-0.83, P<0.01). CONCLUSIONS: Contractile reserve during DE correlates inversely with the extent of interstitial fibrosis and the amount of fibronectin and vimentin and directly with rest-redistribution thallium uptake.
Assuntos
Doença das Coronárias/patologia , Doença das Coronárias/fisiopatologia , Coração/fisiopatologia , Contração Miocárdica , Miocárdio/patologia , Agonistas Adrenérgicos beta , Adulto , Idoso , Angiografia Coronária , Ponte de Artéria Coronária , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/cirurgia , Dobutamina , Ecocardiografia/métodos , Feminino , Fibronectinas/análise , Fibrose , Coração/diagnóstico por imagem , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Miocárdio/química , Miocárdio/metabolismo , Radioisótopos de Tálio , Tomografia Computadorizada de Emissão de Fóton Único , Vimentina/análiseRESUMO
Although involvement of the aorta and its large branches is more common, Takayasu's arteritis involving the pulmonary arteries is well recognized. This report describes an adolescent girl with an uncommonly severe form of Takayasu's arteritis involving the pulmonary arteries. A successful surgical treatment is presented.
Assuntos
Síndromes do Arco Aórtico/cirurgia , Arterite/cirurgia , Artéria Pulmonar/cirurgia , Arterite de Takayasu/cirurgia , Adolescente , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/cirurgia , Arterite/diagnóstico por imagem , Cateterismo Cardíaco , Feminino , Humanos , Artéria Pulmonar/diagnóstico por imagem , Radiografia , Arterite de Takayasu/diagnóstico por imagemRESUMO
A patient is described with an unruptured aneurysm of the noncoronary sinus of Valsalva that occupied the right ventricular inflow tract and caused dynamic tricuspid stenosis and insufficiency. Results of two-dimensional echocardiography delineated the anatomy of the aneurysm and pulsed Doppler examination provided evidence that the aneurysm was unruptured. The unruptured aneurysm was resected successfully.
Assuntos
Aneurisma/complicações , Cardiopatias/complicações , Seio Aórtico , Insuficiência da Valva Tricúspide/etiologia , Estenose da Valva Tricúspide/etiologia , Adulto , Aneurisma/diagnóstico , Aneurisma/cirurgia , Ecocardiografia , Cardiopatias/diagnóstico , Cardiopatias/cirurgia , Neoplasias Cardíacas/diagnóstico , Hemodinâmica , Humanos , Masculino , Mixoma/diagnóstico , Ruptura Espontânea , Insuficiência da Valva Tricúspide/diagnóstico , Insuficiência da Valva Tricúspide/cirurgia , Estenose da Valva Tricúspide/diagnóstico , Estenose da Valva Tricúspide/cirurgiaRESUMO
OBJECTIVES: We sought to evaluate the relation of segmental tissue Doppler (TD) velocities to both the regional amount of interstitial fibrosis and the myocyte beta-adrenergic receptor density in humans. BACKGROUND: The systolic myocardial velocity (Sm) and early diastolic myocardial velocity (Em) acquired by TD are promising new indexes of left ventricular function. However, their structural and functional correlates in humans are still unknown. METHODS: Ten patients with coronary artery disease underwent echocardiographic examination including TD imaging, along with transmural endomyocardial biopsy at the time of coronary bypass surgery (two biopsies per patient for a total of 20 specimens). The specimens were analyzed for percent interstitial fibrosis and beta-adrenergic receptor density. RESULTS: Normal segments (n = 8) had a higher beta-adrenoceptor density (2,280 +/- 738 vs. 1,373 +/- 460, p = 0.03) and a lower amount of interstitial fibrosis (13 +/- 3.3% vs. 28 +/- 11.5%, p = 0.002) than dysfunctional segments (n = 12). Myocardial systolic velocity and Em were also significantly higher (9.5 +/- 2.7 vs. 5.9 +/- 1.8 cm/s, p = 0.025 and 11.3 +/- 2.8 vs. 6.4 +/- 2.1 cm/s, p = 0.002, respectively) in normal segments. A significant relationship was present between Em and the beta-adrenergic receptor density (r = 0.78, p < 0.001) and percent interstitial fibrosis (r = -0.7, p = 0.0026), which together accounted for 81% of the variance observed in Em. Likewise, a significant relationship was present between Sm and the beta-adrenergic receptor density (r = 0.68, p < 0.001) and the percent interstitial fibrosis (r = -0.66, p = 0.004) and together accounted for 62% of the variance observed in Sm. CONCLUSIONS: Systolic myocardial velocity and Em are strongly dependent on both the number of myocytes and the myocardial beta-adrenergic receptor density.
Assuntos
Velocidade do Fluxo Sanguíneo , Circulação Coronária , Doença das Coronárias/fisiopatologia , Ecocardiografia , Miocárdio/metabolismo , Receptores Adrenérgicos beta/metabolismo , Idoso , Biópsia , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/patologia , Diástole , Endocárdio/patologia , Feminino , Fibrose , Humanos , Masculino , Pessoa de Meia-Idade , Miocárdio/patologiaRESUMO
BACKGROUND: Laparoscopic techniques used to manage asymptomatic splenic artery aneurysms have been reported infrequently. METHODS: A laparoscopic splenic artery aneurysm resection was attempted for six consecutive patients. RESULTS: One patient underwent conversion to laparotomy because of a tear in the splenic vein. Among the five successful laparoscopic splenic artery aneurysm resections, the mean estimated blood loss was 37 +/- 12.6 ml, the mean operative time was 187.6 +/- 79.2 min, and the mean postoperative length of hospital stay was 1.8 +/- 1.3 days. The mean time to a clear liquid diet was 5.3 +/- 0.5 h, and the mean time to a regular diet was 1 +/- 0 day. The mean duration of narcotic analgesic use was 5.4 +/- 1.5 days, and the mean time to resumption of regular activities was 12.7 +/- 1.6 days. CONCLUSIONS: These cases illustrate the benefit of a laparoscopic approach with brief hospitalizations, early resumption of diet and regular activity, and minimal use of postoperative narcotic analgesics.
Assuntos
Aneurisma/cirurgia , Laparoscopia/métodos , Artéria Esplênica/cirurgia , Adulto , Idoso , Analgésicos Opioides/uso terapêutico , Aneurisma/diagnóstico por imagem , Dieta , Feminino , Seguimentos , Humanos , Complicações Intraoperatórias/cirurgia , Laparoscopia/efeitos adversos , Laparotomia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Cuidados Pós-Operatórios , Complicações Pós-Operatórias , Radiografia , Estudos Retrospectivos , Veia Esplênica/lesões , Resultado do TratamentoRESUMO
The surgical approach to aneurysms involving the transverse aortic arch usually requires either techniques for perfusion or hypothermic circulatory arrest. A simplified approach may be warranted when the aneurysmal process begins in the distal aortic arch and spares the innominate artery. Between November, 1975, and January, 1984, 32 patients (22 men, 10 women; median age 61 years) underwent repair of aneurysms of the distal aortic arch by simple cross-clamping of the diseased aortic segment. In each, the aneurysm arose distal to the innominate artery and involved the arch at the origin of the left subclavian or left common carotid artery. Proximal control was achieved by cross-clamping the aortic arch between the innominate and left carotid arteries. No shunts or extracorporeal bypass circuits were employed. Proximal hypertension was controlled by sodium nitroprusside infusion. All patients were heparinized. A mean aortic cross-clamp time of 27 +/- 10 minutes was required for Dacron graft replacement in 28 patients and Dacron patch repair in three patients. Surgical repair was accomplished successfully in 32 patients. The 30 day mortality was 3% with an in-hospital mortality of 6%. There were no complications as a result of myocardial infarction or stroke. Paraplegia (three patients) was related to cross-clamp time (less than 30 minutes, 0/18; greater than 30 minutes, 3/13 [p less than 0.001]) and distal extent of the aneurysm (localized, 0/22; extensive, 3/9 [p less than 0.001]). Transient renal failure (two patients) was related to cross-clamp time (less than 30 minutes, 0/18; greater than 30 minutes, 2/13 [p less than 0.001]). This experience supports the use of simple aortic cross-clamping for aneurysms of the distal aortic arch, especially if an expeditious repair can be accomplished.
Assuntos
Aneurisma Aórtico/cirurgia , Revascularização Miocárdica , Injúria Renal Aguda/etiologia , Adulto , Idoso , Aorta Torácica/cirurgia , Ponte Cardiopulmonar/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/métodos , Paraplegia/etiologia , Complicações Pós-Operatórias , Fatores de TempoRESUMO
Uteroglobin/CCSP is expressed specifically in the Clara cells. This allows the gene to be used as a marker to identify the elements regulating the physiologic and cell-specific expression of this gene. The regulation of UG/CCSP by IFN-gamma was shown to be at the level of the proximal promoter by the upregulation of HNF3 beta. This has allowed the determination of the factors responsible for the expression of UG/CCSP.
Assuntos
Regulação da Expressão Gênica/fisiologia , Pulmão/metabolismo , Proteínas/genética , Mucosa Respiratória/metabolismo , Uteroglobina/genética , Animais , Humanos , Pulmão/citologia , Camundongos , Proteínas/metabolismo , Mucosa Respiratória/citologia , Uteroglobina/metabolismoRESUMO
The prophylactic and therapeutic efficacies of IA-4 N-oxide against Schistosoma mansoni in rhesus monkeys (Macaca mulatta) have been evaluated. Ten monkeys were divided into 5 groups of 2 monkeys each. All monkeys were exposed to S. mansoni cercariae on day 0 and treatment groups were established as follows: untreated controls, oral prophylactic administration, intramuscular prophylactic administration, oral therapeutic administration, and intramuscular therapeutic administration. Analysis of parasitologic and pathologic criteria indicate that the compound is most effective when administered as a therapeutic regimen. Complete cures were effected in these monkeys. Prophylactic treatments resulted in a delay in onset of patency and reductions in fecal egg excretion, worm burdens, and tissue damage.
Assuntos
Hicantone/análogos & derivados , Esquistossomose/tratamento farmacológico , Tioxantenos/análogos & derivados , Animais , Colo/parasitologia , Colo/patologia , Granuloma , Haplorrinos , Hicantone/administração & dosagem , Hicantone/uso terapêutico , Indazóis/administração & dosagem , Indazóis/uso terapêutico , Fígado/parasitologia , Fígado/patologia , Macaca mulatta , Contagem de Ovos de Parasitas , Schistosoma mansoni , Esquistossomose/patologia , Esquistossomose/prevenção & controleRESUMO
A case of traumatic right lung herniation to an area of anterior costal sternal separation and right hemothorax is presented. Application of a thoracoscopic approach to a traumatic lung hernia of the chest wall in this case is discussed.
Assuntos
Endoscopia , Pneumopatias/cirurgia , Traumatismos Torácicos/complicações , Toracoscopia , Ferimentos não Penetrantes/complicações , Acidentes de Trânsito , Adulto , Seguimentos , Hemotórax/etiologia , Hemotórax/cirurgia , Hérnia/etiologia , Herniorrafia , Humanos , Pneumopatias/etiologia , Masculino , Costelas , Esterno , Traumatismos Torácicos/cirurgia , Gravação em Vídeo , Ferimentos não Penetrantes/cirurgiaRESUMO
Because of their anatomic location, cardiac sarcomas often interfere with cardiac function. Excision is considered to palliate the cardiac defect, but complete excision is often difficult owing to access, particularly in left atrial tumors. Incomplete resection results in tumor recurrence. To achieve complete resection of a large left atrial sarcoma, we used the technique of cardiac explantation, extracorporeal resection of the tumor with cardiac reconstruction, and cardiac autotransplantation.
Assuntos
Neoplasias Cardíacas/cirurgia , Histiocitoma Fibroso Benigno/cirurgia , Transplante Autólogo/métodos , Adulto , Humanos , MasculinoRESUMO
A 4-year-old boy presented with a single seizure following a viral syndrome. He had a pericardial effusion on admission, and this increased suddenly on the third day of hospitalization, producing cardiac tamponade. After blood was aspirated from the child's pericardial cavity, the father revealed that he performed cardiac massage on his son following the seizure. A laceration of the right atrium was repaired at operation, and the boy made a good recovery. Cardiopulmonary resuscitation by lay persons is not without hazard, and patients with such a history should be watched carefully for the possibility of damage to intrathoracic structures.
Assuntos
Traumatismos Cardíacos/etiologia , Ressuscitação/efeitos adversos , Tamponamento Cardíaco/diagnóstico , Tamponamento Cardíaco/etiologia , Tamponamento Cardíaco/cirurgia , Pré-Escolar , Átrios do Coração/lesões , Traumatismos Cardíacos/diagnóstico , Traumatismos Cardíacos/cirurgia , Humanos , Masculino , Derrame Pericárdico/diagnóstico , Derrame Pericárdico/etiologia , Derrame Pericárdico/cirurgiaRESUMO
Aortoesophageal fistula, secondary to thoracic aortic aneurysm, is an uncommon cause of gastrointestinal bleeding that is uniformly fatal without surgical intervention. These may be primary fistulas, in cases of thoracic aortic aneurysm without previous repair, or secondary fistulas occurring after surgical repair of thoracic aortic aneurysm. Surgical treatment has been successful in a small number of cases of primary aortoesophageal fistula, secondary to thoracic aortic aneurysm, but techniques used have varied. We report a successful repair of primary aortoesophageal fistula, secondary to descending thoracic aortic aneurysm, and review the evolution of management since the three previously reported successful repairs at our institution.
Assuntos
Aneurisma da Aorta Torácica/complicações , Doenças da Aorta/cirurgia , Fístula Esofágica/cirurgia , Fístula Vascular/cirurgia , Aorta Torácica , Doenças da Aorta/etiologia , Fístula Esofágica/etiologia , Feminino , Humanos , Pessoa de Meia-Idade , Fístula Vascular/etiologiaRESUMO
For many years, pleural effusions have been recognized as a complication of cirrhosis, occurring in approximately 5.5% of patients. Recent studies have confirmed that small defects in the diaphragm allow for passage of ascitic fluid into the pleural space. Successful management of these patients is challenging, as many of the treatment options can be associated with increased morbidity. The initial treatment should focus on eliminating and preventing the recurrence of ascites with diuretics and water and salt restriction. For those patients who do not respond medically, more invasive techniques have been used including serial thoracentesis, chest tube placement, chemical pleurodesis, and peritoneovenous shunts. We present a patient with recurrent pleural effusions secondary to hepatic cirrhosis who was unsuccessfully treated medically, and subsequently treated with thoracentesis, chest tube drainage and pleurodesis, with ultimate resolution after transjugular intrahepatic portosystemic shunt placement.
Assuntos
Hidrotórax/cirurgia , Cirrose Hepática/complicações , Derrame Pleural/cirurgia , Derivação Portossistêmica Transjugular Intra-Hepática , Humanos , Hidrotórax/etiologia , Hidrotórax/terapia , Masculino , Pessoa de Meia-Idade , Derrame Pleural/etiologia , Derrame Pleural/terapia , RecidivaRESUMO
Mediastinal thymic cysts are usually asymptomatic and found incidentally on a routine chest roentgenogram. Rarely, they may cause symptoms of vascular obstruction. A 55-year-old woman presented with intermittent swelling in her left neck. The swelling was positional and was worse while supine and disappeared while upright. Evaluation revealed a thymic cyst causing extrinsic compression of the left brachiocephalic vein. The cyst was resected with complete resolution of the left neck swelling.
Assuntos
Veias Braquiocefálicas , Cisto Mediastínico/complicações , Doenças Vasculares/etiologia , Feminino , Humanos , Veias Jugulares/diagnóstico por imagem , Cisto Mediastínico/diagnóstico por imagem , Pessoa de Meia-Idade , Fatores de Tempo , Tomografia Computadorizada por Raios X , Insuficiência VenosaRESUMO
Cadaveric dissections were carried out to examine the relationship of the cardiac valve structures to the surface anatomy of the chest as it relates to our approaches to minimally invasive valvular operations. The techniques of upper hemisternotomy and lower hemisternotomy as used at our institution are described.
Assuntos
Doenças das Valvas Cardíacas/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos , Esterno/cirurgiaRESUMO
Chronic traumatic aneurysm of the thoracic aorta is an unusual occurrence. Previously, arteriography was performed on all patients seen in our institution with this entity to allow confirmation of the diagnosis and anatomic delineation for operation. A case of chronic traumatic aneurysm of the distal descending aorta discovered on a routine chest roentgenogram and evaluated with chest computed tomographic scanning with three-dimensional reconstruction is presented. It is our belief that not all thoracic aneurysms require arteriography, and improved methods of computed tomographic scanning allow adequate diagnosis and anatomic delineation with decreased morbidity and cost.
Assuntos
Aorta Torácica/lesões , Aneurisma da Aorta Torácica/diagnóstico por imagem , Processamento de Imagem Assistida por Computador , Tomografia Computadorizada por Raios X , Acidentes de Trânsito , Idoso , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/etiologia , Aneurisma da Aorta Torácica/cirurgia , Doença Crônica , Humanos , MasculinoRESUMO
Left ventricular free wall rupture is the third leading complication and the second most common cause of death after myocardial infarction. Its occurrence has been considered an unpredictable event usually leading to death. An increased appreciation for the clinical presentation of this syndrome and the nearly ubiquitous use of echocardiography have fostered a rise in the antemortem diagnosis of left ventricular free wall rupture, allowing the possibility of operative repair. Despite the increased reporting of left ventricular free wall rupture, the experience of any one surgeon or surgical group tends to be quite small. We review the current status of rupture prediction, clinical presentation, diagnosis, and treatment options. A recent case of left ventricular free wall rupture referred to the Baylor Cardiothoracic Surgery Group with the misdiagnosis of ruptured dissection of the ascending thoracic aorta is presented to illustrate our approach to this clinical situation.
Assuntos
Ruptura Cardíaca Pós-Infarto/diagnóstico , Ruptura Cardíaca Pós-Infarto/terapia , Humanos , Fatores de RiscoRESUMO
Esophagectomy after pneumonectomy has been reported rarely, and the surgical approach presents a challenge. We report a case of a transthoracic esophagectomy in a 54-year-old man who had undergone right pneumonectomy for non-small cell lung cancer 16 years previously.