Disturbances of the transfer of cholesterol to high-density lipoprotein (HDL) in patients with peripheral artery disease with or without type 2 diabetes mellitus.

INTRODUCTION: Low high-density lipoprotein (HDL)-cholesterol is frequent in patients with peripheral artery disease (PAD) and also in type 2 diabetes mellitus (T2DM), the major risk factor for PAD. The transfer of cholesterol from the other lipoproteins to HDL is an important aspect of HDL metabolism and function, and may contribute to atherogenic mechanisms that lead to PAD development. OBJECTIVE: The aim of this study was to investigate the status of cholesterol transfers in patients with PAD without or with T2DM. METHODS: Patients with PAD (n = 19), with PAD and T2DM (PAD + DM, n = 19), and healthy controls (n = 20), all paired for age, sex, and BMI were studied. Transfer of both forms of cholesterol, unesterified (UC) and esterified (EC), was performed by incubating plasma with a donor nanoemulsion containing radioactive UC and EC, followed by chemical precipitation and HDL radioactive counting. RESULTS: Low-density lipoprotein (LDL)-cholesterol and triglycerides were similar in the three groups. Compared to controls, HDL-C was lower in PAD + DM (p < 0.05), but not in PAD. Transfer of UC was lower in PAD + DM than in PAD and controls (4.18 ± 1.17%, 5.13 ± 1.44%, 6.59 ± 1.25%, respectively, p < 0.001). EC transfer tended to be lower in PAD + DM than in controls (2.96 ± 0.60 vs 4.12 ± 0.89%, p = 0.05). Concentrations of cholesteryl ester transfer protein (CETP) and lecithin-cholesterol acyltransferase (LCAT), both involved in HDL metabolism, were not different among the three groups. CONCLUSION: Deficient cholesterol transfer to HDL may play a role in PAD pathogenesis. Since UC transfer to HDL was lower in PAD + DM compared to PAD alone, it is possible that defective HDL metabolism may contribute to the higher PAD incidence in patients with T2DM.Keywords.

Prevention of venous thrombosis by warfarin after permanent transvenous leads implantation in high-risk patients.

BACKGROUND: The incidence of venous lesions following transvenous cardiac device implantation is high. Previous implantation of temporary leads ipsilateral to the permanent devices, and a depressed left ventricular ejection fraction have been associated with an increased risk of venous lesions, though the effects of preventive strategies remain controversial. This randomized trial examined the effects of warfarin in the prevention of these complications in high-risk patients. METHOD: Between February 2004 and September 2007, we studied 101 adults who underwent a first cardiac device implantation, and who had a left ventricular ejection fraction < or =0.40, or a temporary pacing system ipsilateral to the permanent implant, or both. After device implantation, the patients were randomly assigned to warfarin to a target international normalized ratio of 2.0-3.5, or to placebo. Clinical and laboratory evaluations were performed regularly up to 6 months postimplant. Venous lesions were detected at 6 months by digital subtraction venography. RESULTS: Venous obstructions of various degrees were observed in 46 of the 92 patients (50.0%) who underwent venography. The frequency of venous obstructions was 60.4% in the placebo, versus 38.6% in the warfarin group (P = 0.018), corresponding to an absolute risk reduction of 22% (relative risk = 0.63; 95% confidence interval = 0.013-0.42). CONCLUSIONS: Warfarin prophylaxis lowered the frequency of venous lesions after transvenous devices implantation in high-risk patients.

[Heart transplantation: the experience of patients with Chagas disease]. / Transplante cardíaco (TC): a experiência do portador da Doença de Chagas.

Successful heart transplantation in patients with Chagas disease depends on special care to be provided during all phases of the transplantation process, and requires specific and rigorous follow-up by the health care team. Recipients must be aware of the permanence of the trypanosome in their organisms as well as of the possibility of infection reactivation after transplantation. Therefore, the patient's knowledge regarding this condition and his active participation in his own treatment are of utmost importance. This study aimed at investigating heart transplantation as experienced by patients with Chagas disease, seeking to understand the meanings that they attribute to such an experience. The methodological procedures included: patient selection; interviews; data analysis, indication of the meaning units and individual analysis; search for discourse convergence; and hermeneutic analysis of convergences. From the data analysis, the following themes emerged: the time lived by recipients with Chagas Disease; the conception of heart transplantation presented by patients with Chagas Disease; and care in the course of heart transplantation.

Collagen is reduced and disrupted in human aneurysms and dissections of ascending aorta.

In ascending aorta aneurysms, there is an enlargement of the whole vessel, whereas aortic dissections (ADs) are characterized by the cleavage of the wall into 2 sheets at the external half. We searched if alterations in collagen could be related to these diseases. Sections of aortas from 14 case patients with acute dissections, 10 case patients with aneurysms, and 9 control subjects were stained with picrosirius. Slides were analyzed under polarized microscopy to evaluate the structure of collagen fibers. The proportion of collagen was calculated in each half of the medial layer by color detection in a computerized image analysis system. Collagen appearance under polarized light was consistent with collagenolysis. The mean collagen proportions at the inner and outer halves, respectively, were 0.50 +/- 0.13 and 0.40 +/- 0.08 in the control group, 0.20 +/- 0.10 and 0.18 +/- 0.12 in the AD group, and 0.33 +/- 0.12 and 0.19 +/- 0.12 in the aneurysm group. The AD (P < .01) and control (P = .04) groups had less collagen at the external half; no difference was found in the aneurysm group (P = .71). In both halves, there was less collagen in the case patients than in the control subjects (all P < .01), but at the internal half, the decrease was significantly greater in the case patients with aneurysms than in those with dissections (P = .03; at the external half, P = .99). Aortic dissections and aneurysms show a decrease in collagen content that could be related to a weakness of the wall underlying the diseases, but the locations of the decrease differ: in dissections, it is situated mostly at the external portion of the media (site of cleavage), whereas in aneurysms, it is more diffuse, consistent with the global enlargement.

Heart transplantation experiences: a phenomenological approach.

AIM: The aim of this study was to understand the heart transplantation experience based on patients' descriptions. BACKGROUND: To patients with heart failure, heart transplantation represents a possibility to survive and improve their quality of life. Studies have shown that more quality of life is related to patients' increasing awareness and participation in the work of the healthcare team in the post-transplantation period. Deficient relationships between patients and healthcare providers result in lower compliance with the postoperative regimen. METHOD: A phenomenological approach was used to interview 26 patients who were heart transplant recipients. Patients were interviewed individually and asked this single question: What does the experience of being heart transplanted mean? Participants' descriptions were analysed using phenomenological reduction, analysis and interpretation. RESULTS: Three categories emerged from data analysis: (i) the time lived by the heart recipient; (ii) donors, family and caregivers and (iii) reflections on the experience lived. Living after heart transplant means living in a complex situation: recipients are confronted with lifelong immunosuppressive therapy associated with many side-effects. Some felt healthy whereas others reported persistence of complications as well as the onset of other pathologies. However, all participants celebrated an improvement in quality of life. Health caregivers, their social and family support had been essential for their struggle. Participants realised that life after heart transplantation was a continuing process demanding support and structured follow-up for the rest of their lives. CONCLUSION: The findings suggest that each individual has unique experiences of the heart transplantation process. To go on living participants had to accept changes and adapt: to the organ change, to complications resulting from rejection of the organ, to lots of pills and food restrictions. RELEVANCE TO CLINICAL PRACTICE: Stimulating a heart transplant patients spontaneous expression about what they are experiencing and granting them the actual status of the main character in their own story is important to their care.

Predictors of Adamkiewicz artery and anterior spinal artery detection through computerized tomographic angiography.

BACKGROUND: The detection of the Adamkiewicz artery and the anterior spinal artery has been associated with the ability to prevent adverse spinal cord outcomes after aortic surgical procedures. Yet, to our knowledge, no previous studies have attempted to use modern predictive models to identify the most important variables in determining artery detectability. AIMS: To develop a model to predict the odds of visualizing the Adamkiewicz artery or anterior spinal artery in patients undergoing computerized tomographic angiography. METHODS: We conducted a prospective, cross-sectional study. Outcomes of interest were the non-detection of the Adamkiewicz artery and anterior spinal artery, and their corresponding level of origin. Axial images were inspected in high definition in search of two dense spots characterizing the Adamkiewicz artery and anterior spinal artery. A multiplanar three-dimensional reconstruction was then performed using the OsiriX® software. RESULTS: A total of 110 participants were part of this analysis. When evaluating risks for the Adamkiewicz artery being undetectable, significant factors could be classified into three broad categories: risk factors for arterial disease, established arterial disease, and obesity. Factors in the former category included metabolic syndrome, hypertension, and smoking status, while factors in the arterial disease included descending aortic aneurysm, mural thrombi, aortic aneurysm without a dissection, and aortic disease in general. In relation to anterior spinal artery not being detectable, significant risk factors included hypertension, smoking status, and metabolic syndrome, while those associated with arterial disease involved aortic disease and arterial thrombi. When evaluating the importance of individual clinical factors, the presence of higher body mass index was the single most important risk factor. CONCLUSION: Arterial disease, established arterial disease, and increased body mass index are risk factors in the detection of Adamkiewicz artery and anterior spinal artery. Specific diagnostic protocols should be in place for patients with these underlying conditions, thus enhancing the likelihood of detection when the Adamkiewicz artery is indeed present.

Long-Term and Sustained Therapeutic Results of a Specific Promonocyte Cell Formulation in Refractory Angina: ReACT(®) (Refractory Angina Cell Therapy) Clinical Update and Cost-Effective Analysis.

Mononuclear stem cells have been studied for their potential in myocardial ischemia. In our previous published article, ReACT(®) phase I/II clinical trial, our results suggest that a certain cell population, promonocytes, directly correlated with the perceived angiogenesis in refractory angina patients. This study is ReACT's clinical update, assessing long-term sustained efficacy. The ReACT phase IIA/B noncontrolled, open-label, clinical trial enrolled 14 patients with refractory angina and viable ischemic myocardium, without ventricular dysfunction, who were not suitable for myocardial revascularization. The procedure consisted of direct myocardial injection of a specific mononuclear cell formulation, with a certain percentage of promonocytes, in a single series of multiple injections (24-90; 0.2 ml each) into specific areas of the left ventricle. Primary endpoints were Canadian Cardiovascular Society Angina Classification (CCSAC) improvement at the 12-month follow-up and ischemic area reduction (scintigraphic analysis) at the 12-month follow-up, in correlation with ReACT's formulation. A recovery index (for patients with more than 1 year follow-up) was created to evaluate CCSAC over time, until April 2011. Almost all patients presented progressive improvement in CCSAC beginning 3 months (p=0.002) postprocedure, which was sustained at the 12-month follow-up (p=0.002), as well as objective myocardium ischemic area reduction at 6 months (decrease of 15%, p<0.024) and 12 months (decrease of 100%, p<0.004) The recovery index (n=10) showed that the patients were graded less than CCSAC 4 for 73.9 ± 24.2% over a median follow-up time of 46.8 months. After characterization, ReACT's promonocyte concentration suggested a positive correlation with CCSAC improvement (r=-0.575, p=0.082). Quality of life (SF-36 questionnaire) improved significantly in almost all domains. Cost-effectiveness analysis showed decrease in angina-related direct costs. Refractory angina patients presented a sustained long-term improvement in CCSAC and myocardium ischemic areas after the procedure. The long-term follow-up and strong improvement in quality of life reinforce effectiveness. Promonocytes may play a key role in myocardial neoangiogenesis. ReACT dramatically decreased direct costs.

Valve reconstruction in the Heart Institute of São Paulo, Brazil.

In the Heart Institute of University of São Paulo Medical School, between 1980 and 2000, were performed 712 mitral valve repair procedures, 39 aortic valve repairs and 469 tricuspid valve repairs. In our experience with mitral valve repair, the most performed techniques were quadrangular resection of the posterior leaflet, posterior annuloplasty with bovine pericardial sling and Carpentier ring annuloplasty. Quadrangular resection of the posterior leaflet is the technique of choice in mitral regurgitation due to degenerative disease, and repair is possible in 90% of the cases. Since 1994, we perform the quadrangular resection without ring annuloplasty, a modification in the technique called "Double Teflon" technique, with good results. Aortic valve repair is performed in specific situations. In congenital aortic insufficiency, we perform the suspention of the prolapsed leaflets in the comissures. In rheumatic aortic insufficiency, when we found leaflet retraction, we elongate the leaflets with bovine pericardial patchs. Our experience of aortic valve repair, between 1980 and 2000, consists of a small group of 39 patients. The results are satisfactory, but these techniques are feasible only in selected cases. Tricuspid insufficiency is generally a consequence of annular enlargement in patients with mitral valve disease and we prefer the De Vega annuloplasty in these cases. In cases with large annulus dilatation, we prefer to use the "Revuelta" or the "bicuspidization" techniques. In patients with previous tricuspid repair and annulus distortion, we prefer to use bovine pericardial sling or Carpentier ring annuloplasty.

Relationship of subgingival and salivary microbiota to gingival overgrowth in heart transplant patients following cyclosporin A therapy.

BACKGROUND: Severe gingival overgrowth (GO) is induced in patients taking cyclosporin A (CsA) following organ transplantation. Determining which patient will develop GO is still not possible. The purpose of this study was to establish an association between CsA and gingival overgrowth in heart transplant patients taking into account periodontal and microbiological conditions. METHODS: Thirty patients (10 female, 20 male; range: 13 to 67 years; mean age: 44.89) undergoing CsA treatment were evaluated using the gingival index (GI), plaque index (PI), probing depth (PD), and clinical attachment level (CAL). Subgingival samples collected from the deepest site of each quadrant and saliva samples were submitted to microbial analysis. All patients had at least 12 teeth. Exclusion criteria were the use of antibiotics and/or having undergone periodontal treatment 6 months prior to the study. Patients were divided in two groups: with gingival (GO+) and without gingival overgrowth (GO-). RESULTS: There were no statistically significant differences between the GO+ and GO- groups when CsA dosage, time since transplant, GI, PI, PD, and CAL were compared. Microbiological examination of the subgingival samples detected the following microorganisms: Actinobacillus actinomycetemcomitans (23%), Porphyromonas gingivalis (36%), Prevotella intermedia (93%), Fusobacterium sp. (66%), Campylobacter rectus (30%), Micromonas micros (66%), enteric rods (0%), and yeasts (30%). A positive association between M. micros and the GO+ group was found (P < 0.001). Yeasts were detected in 30% of the subgingival and saliva samples. CONCLUSIONS: Clinical parameters were not sufficient to determine which patients would develop GO. However, colonization by M. micros might play a role in the etiology of GO.

Thyroid hormone levels in patients with aortic dissection: comparison with controls and correlation with the percentage of the aortic media composed of myxoid deposits.

OBJECTIVE: Deposits of myxoid material, similar to myxedema related to thyroid disease, are described in the medial layer of aortas with dissection. We analyzed the clinical or subclinical thyroid dysfunction of patients with this disease and analyzed whether a correlation exists between serum levels of thyroid-related hormones and the myxoid content of the aortic media. METHODS: We measured, with standard methods, serum levels of triiodothyronine (T3), thyroxine (T4), and thyroid stimulating hormone (TSH) in 28 patients who underwent aortic dissection and free T4 in 20 of them. The same hormones were quantified in 20 control patients matched by sex and age. Results were compared by using the Mann-Whitney test. We also measured the percentage of the aortic media occupied by myxoid material in the surgical specimens of 25 of the patients with aortic dissection and analyzed its correlation with hormone levels by using the Pearson test. RESULTS: In the 20 pairs in which the amount of hormones was compared, the mean values for T3, T4, free T4, and TSH were 1.22ng/mL, 9.89mcg/dL, 1.18ng/dL, and 5.45 microIU/mL in study patients and 1.15ng/mL, 8.57mcg/dL, 1.32ng/dL, and 2.15 microIU/mL in controls. Neither these differences nor the correlation between the percentage of myxoid content (mean=30%) and the values for T3, T4, free T4, and TSH (mean 1.22ng/mL, 9.44mcg/dL, 1.20ng/dL, and 5.08 microIU/mL, respectively; n= 25) were significant. CONCLUSION: Our data suggest that serum levels of thyroid hormones have no relation with the myxoid content in the aortic media in cases of aortic dissection.

[Vascular prosthesis infection in thoracic aorta surgery: review of the experience and a case report illustrating treatment with an unconventional technique]. / Infecção de prótese vascular em cirurgia da aorta torácica: revisão da experiência e relato de caso tratado por técnica não convencional.

We report the case of a 37-year-old-female patient who had undergone a Bentall procedure at our service and returned with intense chest pain and acute aortic dissection type III, which was diagnosed and clinically treated. One year after this episode, this dissection expanded, and the patient underwent surgery with interposition of a Dacron graft in the descending aorta. In the immediate postoperative period, the patient experienced left bronchopneumonia and was discharged afebrile and in good condition. One month after discharge, she returned with fever and toxemia. Pleural empyema was diagnosed, and she underwent an exploratory thoracotomy that did not confirm this diagnosis, but revealed intense effusion thickening. Four months after the exploratory thoracotomy, Klebsiella pneumoniae and Enterobacter sp were isolated in a blood culture. Magnetic resonance imaging revealed shapes compatible with perigraft infection. With this clinical and laboratory picture, graft removal was indicated as was axillo-bifemoral grafting. Surgery was successfully performed, the patient was discharged in good condition, and remains well after a 57-month follow-up without complications. The methods used for diagnosis and treatment of prosthesis infection in thoracic aorta surgery are discussed.

Improvement in cardioplegic perfusion technique in single aortic clamping - initial results.

INTRODUCTION: The most common method used for myocardial protection is administering cardioplegic solution in the coronary circulation. Nevertheless, protection may be achieved by intermittent perfusion of the coronary system with patient's own blood. The intermittent perfusion may be performed by multiple sequences of clamping and opening of the aortic clamp or due single clamping and accessory cannulation of the aortic root as in the improved technique proposed in this study, reperfusion without the need for multiple clamping of the aorta. OBJECTIVE: To evaluate the clinical outcome and the occurrence of neurological events in in-hospital patients submitted to myocardial revascularization surgery with the "improved technique" of intermittent perfusion of the aortic root with single clamping. METHODS: This is a prospective, cross-sectional, observational study that describes a myocardial management technique that consists of intermittent perfusion of the aortic root with single clamping in which 50 patients (mean age 58.5 ± 7.19 years old) have been submitted to the myocardial revasculrization surgery under the proposed technique. Clinical and laboratory variables, pre- and post-surgery, have been assessed. RESULTS: The mean peak level of post-surgery CKMB was 51.64 ± 27.10 U/L in the second post-surgery and of troponin I was 3.35 ± 4.39 ng/ml in the fourth post-surgery, within normal limits. No deaths have occurred and one patient presented mild neurological disorder. Hemodynamic monitoring has not indicated any changes. CONCLUSION: The myocardial revascularization surgery by perfusion with the improved technique with intermittent aortic root with single clamping proved to be safe, enabling satisfactory clinical results.

Desenvolvimento de modelo clínico para predição da possibilidade de identificação da artéria de Adamkiewicz por angiotomografia / Development of a clinical model to predict the likelihood of identification of the Adamkiewicz artery by angiotomography

Contexto: Diferenças morfológicas da artéria de Adamkiewicz (AKA) entre a população portadora e não portadora de doença aórtica têm importância clínica, influenciando as complicações neuroisquêmicas da medula espinhal em procedimentos operatórios. Ainda não é conhecida a correlação entre parâmetros clínicos e a previsibilidade da identificação dessa artéria pela angiotomografia. Objetivo: Desenvolver um modelo matemático que, através de parâmetros clínicos correlacionados com aterosclerose, possa prever a probabilidade de identificação da AKA em pacientes submetidos a angiotomografias. Método: Estudo observacional transversal utilizando banco de imagens e dados de pacientes. Foi feita análise estatística multivariada e criado modelo matemático logit de predição para identificação da AKA. Variáveis significativas foram utilizadas na montagem da fórmula para cálculo da probabilidade de identificação. O modelo foi calibrado, e a discriminação foi avaliada pela curva receiver operating characteristic (ROC). A seleção das variáveis explanatórias foi guiada pela maior área na curva ROC (p = 0,041) e pela significância combinada das variáveis. Resultados: Foram avaliados 110 casos (54,5% do sexo masculino, com idade média de 60,97 anos e etnia com coeficiente B -2,471, M -1,297, N -0,971), com AKA identificada em 60,9%. Índice de massa corporal: 27,06 ± 0,98 (coef. -0,101); fumantes: 55,5% (coef. -1,614/-1,439); diabéticos: 13,6%; hipertensos: 65,5% (coef. -1,469); dislipidêmicos: 58,2%; aneurisma aórtico: 38,2%; dissecção aórtica: 12,7%; e trombo mural: 24,5%. Constante de 6,262. Fórmula para cálculo da probabilidade de detecção: ( ) ( ) . . . . . tan 1 ( 1) Coef Etnia Coef IMC IMC Coef fumante Coef HAS Coe f dislip Cons te e − + ×+ + + + − + . O modelo de predição foi criado e disponibilizado no link https://vascular.pro/aka-model. Conclusão: Com as covariáveis etnia, índice de massa corporal, tabagismo, hipertensão arterial e dislipidemia, foi possível criar um modelo matemático de predição de identificação da AKA com significância combinada de nove coeficientes (p = 0,042)

Background: There are clinically important morphological differences in the Adamkiewicz artery (AKA) between populations that do and do not have aortic disease and they have an influence on the neuroischemic complications involving the spinal cord during surgical operations. It is not yet known whether clinical parameters correlate with the predictability of identification of the artery using angiotomography. Objective: To develop a mathematical model that by correlating clinical parameters with atherosclerosis enables prediction of the probability of identification of the AKA in patients examined with angiotomography. Method: This is a cross-sectional, observational study using a patient database and image bank. A multivariate statistical analysis was conducted and a logit mathematical model was constructed to predict AKA identification. Significant variables were used to build a formula for calculation of the probability of identification. This model was calibrated and its power of discrimination was assessed using receiver operating characteristic (ROC) curves. Selection of explanatory variables was based on largest area under the ROC curve (p = 0.041) and combined significance of variables. Results: A total of 110 cases were analyzed (54.5% were male, mean age was 60.97 years, and ethnicity coefficients were white -2.471, brown -1.297, and black -0.971) and the AKA was identified in 60.9%. Body mass index: 27.06 ± 0.98 (coef. -0.101); smokers: 55.5% (coef. -1.614/-1.439); diabetes: 13.6%; hypertension: 65.5% (coef. -1.469); dyslipidemia: 58.2%; aortic aneurysm: 38.2%; aortic dissection: 12.7%; and mural thrombus: 24.5%. The constant was 6.262. The formula for calculating the probability of detection is as follows: ( ) ( ) . . . ker . . tan 1 ( 1) Coef Etnicity Coef BMI BMI Coef smo Coef SAH Coef dyslip Cons t e − + ×+ + + + − + . The prediction model was constructed and made available at: https://vascular.pro/aka-model. Conclusions: Using the covariates ethnicity, body mass index, smoking, arterial hypertension, and dyslipidemia, it proved possible to create a mathematical model for predicting identification of the AKA with a combined significance of nine coefficients (p = 0.042)

Mortality impact of thoracic aortic disease in São Paulo state from 1998 to 2007.

BACKGROUND: The epidemiological characteristics of thoracic aortic diseases (TAD) in the State of São Paulo and in Brazil, as well as their impact on the survival of these patients have yet to be analyzed. OBJECTIVES: To evaluate the mortality impact of TAD and characterize it epidemiologically. METHODS: Retrospective analysis of data from the public health system for the TAD registry codes of hospitalizations, procedures and deaths, from the International Code of Diseases (ICD-10), registered at the Ministry of Health of São Paulo State from January 1998 to December 2007. RESULTS: They were 9.465 TAD deaths, 5.500 men (58.1%) and 3.965 women (41.9%); 6.721 dissections (71%) and 2.744. aneurysms. In 86.3% of cases the diagnosis was attained during autopsy. There were 6.109 hospitalizations, of which 67.9% were males; 21.2% of them died (69% men), with similar proportions of dissection and aneurysm between sexes, respectively 54% and 46%, but with different mortality. Men with TAD die more often than women (OR = 1.5). The age distribution for deaths and hospitalizations was similar with predominance in the 6th decade. They were 3.572 surgeries (58% of hospitalizations) with 20.3% mortality (patients kept in clinical treatment showed 22.6% mortality; p = 0.047). The number of hospitalizations, surgeries, deaths of in-patients and general deaths by TAD were progressively greater than the increase in population over time. CONCLUSIONS: Specific actions for the early identification of these patients, as well as the viability of their care should be implemented to reduce the apparent progressive mortality from TAD seen among our population.