Additional improvement in regional myocardial ischemia after intracardiac injection of bone marrow cells during CABG surgery.

Background: Post-procedure residual ischemia is associated with worse prognosis in patients with coronary artery diasease (CAD). Objective: We evaluated whether autologous bone marrow-derived cells (BMC) contribute to additional reduction in regional stress-induced myocardial ischemia (SIMI) in patients undergoing incomplete coronary artery bypass graft surgery (CABG). Methods: In a double-blind, randomized, placebo-controlled trial, we enrolled 143 patients (82% men, 58 ± 11 years) with stable CAD and not candidates for complete CABG. They received 100 million BMC (n = 77) or placebo (n = 66) injected into ischemic non-revascularized segments during CABG. The primary outcome was improvement on SIMI quantified as the area at risk in injected segments assessed by cardiovascular magnetic resonance (CMR) 1, 6, and 12 months after CABG. Results: The reduction in global SIMI after CABG was comparable (p = 0.491) in both groups indicating sustained beneficial effects of the surgical procedure over 12 month period. In contrast, we observed additional improvement in regional SIMI in BMC treated group (p = 0.047). Baseline regional SIMI values were comparable [18.5 (16.2-21.0) vs. 18.5 (16.5-20.7)] and reached the lowest values at 1 month [9.74 (8.25; 11.49) vs. 12.69 (10.84; 14.85)] for BMC and placebo groups, respectively. The ischemia's improvement from baseline represented a 50% difference in regional SIMI in favor of the BMC transplanted group at 30 days. We found no differences in clinical and LVEF% between groups during the 12 month follow-up period. The 1 month rate of major adverse cerebral and cardiovascular events (MACCE) (p = 0.34) and all-cause mortality (p = 0.08) did not differ between groups 1 month post intervention. Conclusion: We provided evidence that BMC leads to additional reduction in regional SIMI in chronic ischemic patients when injected in segments not subjected to direct surgical revascularization. This adjuvant therapy deserves further assessment in patients with advanced CAD especially in those with microcirculation dysfunction. Clinical trial registration: https://clinicaltrials.gov/, identifier NCT01727063.

Endomyocardial fibrosis: pathological and molecular findings of surgically resected ventricular endomyocardium.

Endomyocardial fibrosis (EMF) is a restrictive cardiomyopathy of unknown etiology prevalent in tropical regions affecting the inflow tract and apex of one or both ventricles, which show fibrous thickening of the endocardium and adjacent myocardium. Surgical treatment is recommended for patients in functional classes III or IV (New York Heart Association). The gross and histological features of the heart have been comprehensively studied in autopsies, but studies in surgical samples are still lacking. Histological and immunohistochemical features of EMF in surgical samples collected from 32 patients were described and correlated with clinical data. Polymerase chain reaction (PCR) and reverse transcription-PCR, performed on formalin fixed endomyocardial samples, were used retrospectively to detect genomes of certain cardiotropic viruses and Toxoplasma gondii. Ventricular endocardium was thickened by superficial acellular hyaline collagen fibers type I and III, with predominance of the former type. Besides fibrosis, a chronic inflammatory process and an anomalous lymphatic rich vascular pattern were observed in the deep endocardium, connected to the terminal coronary circulation of the myocardium, which might be an important pathological finding concerning EMF pathogenesis. Molecular analysis of the endomyocardium revealed high incidence of cardiotropic infective agents (6/12, 50%); however, their role in the disease pathogenesis is still controversial.

Ontario score and cardiac risk during waiting for elective coronary bypass grafting.

BACKGROUND: Waiting lists for coronary bypass grafting are of major concern in several countries and prioritisation systems to the surgery have been proposed. The aim of this study was to verify the adequacy of Ontario score in predicting cardiac events during the waiting for elective coronary bypass grafting. METHODS: A composite end-point (sudden or cardiac death, myocardial infarction, unstable angina or hospital admission) and sudden, cardiac death were analysed in 460 patients referred to the surgery. The relation between Ontario score and events was verified. RESULTS: Median waiting time was 126 days. The composite end-point and sudden, cardiac death occurred in 21.7% and 2.7% of the cases, respectively. In relation to Ontario score > or = 6.00, considered the lower-risk subset, only patients in score <4.00 (7.2% of whole study population) presented a higher chance of the composite end-point during the waiting. ROC curve did not show adequate accuracy of Ontario score in predicting the composite end-point (area under the curve 0.53, p = 0.36). Ontario score could not predict the risk of death. Total complications and death occurred within acceptable waiting times by Ontario recommendation in 47.8% and 36.4% of the cases, respectively. Waiting longer than maximum wait defined by Ontario was not associated with an excess of complications. CONCLUSIONS: Ontario score showed a limited value in predicting cardiac events during the waiting for elective coronary bypass grafting. The results emphasise the need for shortening the wait in order to reduce complications in the period.

Cell biology, MRI and geometry: insight into a microscopic/macroscopic marriage.

OBJECTIVE: The concept of cell therapy as an adjunctive therapy to myocardial surgical revascularization for patients with severe coronary artery disease is illustrated by two case reports of ischemic cardiac disease that were unsuitable for revascularization by coronary grafting. The potential interaction of cell therapy, magnetic resonance imaging (MRI) of viability, and left ventricle (LV) restoration is described. METHODS: Each patient had an ejection fraction below 30%, a relatively conical heart, and MRI gadolinium scan showing predominantly viable muscle. RESULTS: Intramyocardial injections of autologous bone marrow-derived cells (BMC) were performed along with either incomplete coronary artery bypass grafting (CABG) (to mother regions) or with transmyocardial laser revascularization (TMLR). An improvement in contractile function was seen at 6-12-month intervals after the procedure. CONCLUSIONS: The implications of possible underlying mechanisms of improvement in both myocardial perfusion and contractility suggest the striking importance of both micro- and macroenvironment for any cell-based therapeutic strategy. These observations imply that the interaction of cell biology, viability by MRI and geometry may be important in the future, as geometry can be restored surgically, and the new architectural form may develop enhanced function if it contains viable tissue and cell-based treatment can be delivered.

Ascending aortic aneurysm after pediatric heart transplantation: case report of an unusual complication.

A 28-month-old boy, weighing 11 kg, with severe dilated cardiomyopathy, was transplanted on December 1995. Hypertension and supraventricular tachycardia were detected in the immediate post-operative period, with favorable outcome. After 5 months of clinically asymptomatic follow-up, a dilation in the ascending aorta was observed on routine echocardiogram. Nuclear magnetic resonance imaging (NMRI) confirmed an ascending aortic aneurysm, with a diameter of 38 mm. An operation was performed, a bovine pericardium patch was sutured with reconstruction of the aortic wall, excluding the aneurysm. Good recovery was obtained and the child was discharged on Day 7 postoperatively. A post-operative echocardiogram showed absence of the aortic aneurysm and good surgical results. Another NMRI was done 5 months later, showing an intact ascending aorta. After 64 months, the patients clinical condition was confirmed as normal by echocardiogram. Surgical treatment was successful and the positive results have been maintained.

Coronary revascularization with the left internal thoracic artery and radial artery: comparison of short-term clinical evolution between elective and emergency surgery.

BACKGROUND: Left internal thoracic artery-to left anterior descending artery grafting has become a fundamental part of coronary artery bypass grafting. This grafting has led to increased use of other arterial conduits, of which the radial artery is most popular. Whether radial grafting can be used in the emergency patient is not known. This study compares the short-term clinical evolution between elective vs emergency coronary artery bypass grafting surgery with left internal thoracic artery and radial artery. METHODS: A retrospective study of 47 patients who underwent elective or emergency coronary artery bypass grafting from 1996 to 2003. All patients had coronary stenosis>70% in all target vessels. Only the left internal thoracic artery and radial artery were used as grafts. Patients were divided into elective group (23 patients) and emergency group (24 patients). Emergency criteria were unstable angina and/or critical coronary stenosis with high risk for acute myocardial infarction. Groups were similar for age and number of diseased vessels. RESULTS: The mean number of left internal thoracic artery grafts per patient in the elective and emergency groups were respectively 1.17 and 1.38 (P=.17). The mean number of radial artery grafts per patient in the elective and emergency groups was respectively 2.26 and 2.08 (P=.48). The 30-day mortality was 0. There was no postoperative cardiogenic shock. The elective group had 1 acute myocardial infarction (4.4%) postoperatively, and emergency group had 5 (20.8%). A nonsignificant trend towards acute myocardial infarction was noted in the emergency group (P=.18). Intensive care unit and postoperative stay were similar in both groups. CONCLUSION: Coronary artery bypass grafting using left internal thoracic artery and radial artery accomplishing complete revascularization can be performed in emergency patients with results similar to those for elective patients.

Ventricular remodeling and mitral valve modifications in dilated cardiomyopathy: new insights from anatomic study.

OBJECTIVE: The purpose of this study was to analyze the behavior of the mitral valve ring and the left ventricle in dilated cardiomyopathy. METHODS: We analyzed 68 fixed adult human hearts, divided into 48 hearts with dilated cardiomyopathy of ischemic or idiopathic origin and 20 hearts free of pathologic heart conditions. Digital images of the mitral ring perimeter, attachment of the anterior and posterior leaflets, and fibrous and muscular portions were collected. We also measured the internal perimeter of the left ventricle, the distance from the septum to the anterior and posterior papillary muscles, the distance between the papillary muscles, and the extension of interventricular septum. RESULTS: The analysis of the results showed proportional distribution of the ring's fibrous portion (r2 = 0.98) and muscular portion (r2 = 0.99) according to the degree of mitral valve dilation. Linear regression revealed that the perimeters of anterior and posterior leaflet attachments (r2 = 0.96 and r2 = 0.98, respectively) also had a proportional relation. We did not observe proportionality between the degree of dilation of the mitral ring and the left ventricle. It was observed that dilation of the left ventricle takes place globally in its segments. CONCLUSION: Differently from what was thought, in ischemic or idiopathic dilated cardiomyopathy, dilation of mitral ring is proportional and does not exclusively affect the posterior portion. The degree of left ventricular dilation does not determine the degree of dilation of the mitral ring because they are independent processes. These observations shed new light on the techniques used to correct mitral valve insufficiency in dilated cardiomyopathy.

Thymectomy by partial sternotomy for the treatment of myasthenia gravis.

BACKGROUND: Myasthenia gravis is an autoimmune disease characterized by weakness and fatigue of voluntary muscles. Surgical treatment of choice for myasthenia gravis has been thymectomy. However, thymectomy indications and surgical approach are still controversial. The purpose of this study is to evaluate the efficacy of partial median sternotomy approach to the thymus. METHODS: From 1973 to 1999, 478 patients with myasthenia gravis underwent thymectomy through a partial median sternotomy. RESULTS: Sixty-one patients (12.7%) had complete remission of symptoms, 299 (62.5%) had a significant improvement, and 83 (17.4%), a mild improvement; whereas 35 patients (7.4%) had no improvement of clinical symptoms. CONCLUSIONS: Partial median sternotomy has shown to be a useful surgical approach to the thymus, as demonstrated by the good functional and aesthetic results, associated with low morbidity and no mortality.

Harvesting the inferior epigastric artery through a transverse suprapubic incision.

The inferior epigastric artery has been used as an alternative arterial conduit in coronary artery bypass graft surgery. Its harvesting requires a single or double, long abdominal paramedian incision that is technically difficult and does not yield a good cosmetic result. We describe an alternative new approach to one or both inferior epigastric arteries through a transverse suprapubic cosmetic incision.

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.

Cardiac complications during waiting for elective coronary artery bypass graft surgery: incidence, temporal distribution and predictive factors.

OBJECTIVES: Since waiting lists for coronary artery bypass graft surgery are common and carry a risk of severe events, the purposes of this study were: (1) to analyse the incidence and temporal distribution of cardiac complications during waiting for elective coronary artery bypass grafting; (2) to identify predictive factors of such complications. METHODS: Data were collected from 574 patients referred to surgery from 1 January 1998 to 12 July 2001. Two types of complications were defined: (1) a composite end-point, which included cardiac death, myocardial infarction, unstable angina or hospital admission due to cardiac cause; (2) sudden or any cardiac death. Previous cardiac events, risk factors, clinical features, laboratory exams, non-invasive tests for myocardial ischemia, left ventricular function and coronary anatomy were analysed. Kaplan-Meier method, multivariate Cox regression and Student's t-test were used for statistical analyses. RESULTS: Median time to surgery was 126 days (5-1022). Among 516 patients consecutively referred to the surgery from 1 January 1998 to 31 December 2000, sudden or cardiac death occurred in 2.5% and the composite end-point in 22.9%. Most complications (72.1%) were observed within 120 days. The main factors predictive of sudden or cardiac death were severe left ventricular dysfunction and heart failure (univariate analysis). Independent predictive factors of the composite end-point were angina, heart failure functional classes and high triglyceride levels. CONCLUSIONS: During long delay for coronary artery bypass surgery, cardiac events are frequent and tend to occur early. Severe left ventricular dysfunction, advanced angina, heart failure functional classes and high triglyceride level must be considered when selection is necessary, in order to diminish morbidity and mortality during the waiting period.

Late evolution of mitral commissurotomy in patients with low echocardiographic score.

OBJECTIVE: The purpose of this study was to analyze the late results with open mitral commissurotomy in patients with low echocardiographic scores and to identify variables influencing these late results. METHODS: We studied 50 patients who underwent open mitral commissurotomy due to rheumatic mitral stenosis at the Heart Institute University of São Paulo Medical School. Enrolled patients had a Wilkins echocardiographic score

Limited Left Thoracotomy for Reoperative Coronary Artery Bypass Grafting without Cardiopulmonary Bypass for Circumflex Grafting in Patients with Patent Internal Thoracic Artery Graft.

Abstract Background: We describe our experience with the limited left thoracotomy strategy for reoperative coronary artery bypass graft (CABG)to the circumflex coronary artery system, emphasizing the indications, our particular operative technique, and early clinical follow-up. Methods: From January 2001 to January 2002, 8 consecutive patients underwent redo revascularization via limited left thoracotomy and without cardiopulmonary bypass. This operation was indicated for patients with recurrent myocardial ischemia confined to the lateral wall of the left ventricle, especially if a patent left internal thoracic artery (LITA)-to-left anterior descending coronary artery (LAD)graft was present. Results: All 8 patients underwent successful redo revascularization via limited left thoracotomy. Eight patients received 14 saphenous vein grafts (mean 1.7 grafts/patient). No instances of postoperative myocardial infarction or death occurred. During a follow-up period ranging from 1 to 12 months (mean, 5. 2 months), all patients were asymptomatic and without evidence of ischemia or infarction. Conclusions: For select patients who have patent LITA grafted into the LAD and who need redo CABG to the coronary artery circumflex system, the limited left thoracotomy approach without cardiopulmonary bypass is a safe operation and a less invasive alternative to repeat sternotomy and conventional CABG.

Ligation of the thoracic duct for the treatment of chylothorax in heart diseases.

In children, chylothorax occurs mainly after cardiac and thoracic surgeries. One of the recommended postsurgery treatments is ligation of the thoracic tract, when all other conservative treatments have failed. We report 4 cases of chylothorax in patients who were successfully treated with this approach, which resulted in a decrease in pleural drainage without recurrent chylothorax.

Endomyocardial fibrosis in infancy.

The patient was a 4-month-old infant, who underwent persistent ductus arteriosus interruption with titanium clips at the age of 13 days and, since the age of 2 months, had crises of hypoxia and hypertonicity. After clinical investigation, the presence of pulmonary hypertension was confirmed and left ventricular inflow tract obstruction was suspected. The patient underwent surgical treatment at the age of 4 months, during which right and left ventricular endocardial fibrosis was identified. The fibrosis was resected, but the infant had an unfavorable clinical evolution with significant diastolic restriction and died on the sixth postoperative day. Anatomicopathological and surgical findings suggested endomyocardial fibrosis, although that pathology is very rare at the patient's age.

Early increase in myocardial perfusion after stem cell therapy in patients undergoing incomplete coronary artery bypass surgery.

Incomplete revascularization is associated with worse long-term outcomes. Autologous bone marrow cells (BMC) have recently been tested in patients with severe coronary artery disease. We tested the hypothesis that intramyocardial injection of autologous BMC increases myocardial perfusion in patients undergoing incomplete coronary artery bypass grafting (CABG). Twenty-one patients (19 men), 59 ± 7 years old, with limiting angina and multivessel coronary artery disease (CAD), not amenable to complete CABG were enrolled. BMC were obtained prior to surgery, and the lymphomonocytic fraction separated by density gradient centrifugation. During surgery, 5 mL containing 2.1 ± 1.3 × 108 BMC (CD34+ = 0.8 ± 0.3%) were injected in the ischemic non-revascularized myocardium. Myocardial perfusion was assessed by magnetic resonance imaging (MRI) at baseline and 1 month after surgery. The increase in myocardial perfusion was compared between patients with <50% (group A, n = 11) with that of patients with >50% (group B, n = 10) of target vessels (stenosis ≥ 70%) successfully bypassed. Injected myocardial segments included the inferior (n = 12), anterior (n = 7), and lateral (n = 2) walls. The number of treated vessels (2.3 ± 0.8) was significantly smaller than the number of target vessels (4.2 ± 1.0; P < 0.0001). One month after surgery, cardiac MRI showed a similar reduction (%) in the ischemic score of patients in group A (72.5 ± 3.2), compared to patients in group B (78.1 ± 3.2; P = .80). Intramyocardial injection of autologous BMC may help increase myocardial perfusion in patients undergoing incomplete CABG, even in those with fewer target vessels successfully treated. This strategy may be an adjunctive therapy for patients suffering from a more advanced (diffuse) CAD not amenable for complete direct revascularization.