Genetic Markers at ANRIL, FTO and 2q36.3 Locus in Czech Patients Undergoing Coronary Artery Bypass Graft Surgery.

Coronary artery bypass graft (CABG) surgery is one of the most commonly performed operations worldwide. We compared genotype frequencies of three major cardiovascular disease (CVD)-associated genetic markers (ANRIL, FTO and 2q36.3 locus) between 753 patients who underwent CABG at the Institute for Clinical and Experimental Medicine (Prague, Czech Republic) and 2,559 controls from the Czech post-MONICA study. Subjects with at least one major A allele in the rs10757274 polymorphism (ANRIL) were more prevalent in patients after CABG than in the controls (81.7 % vs 72.7 %; OR [95 % CI] 1.67 [1.35-2.05]; P < 0.0001). In contrast, variants within the FTO gene (OR 0.87; 95 % CI, 0.70-1. 09 in a TT vs. GG comparison, P = 0.24) and 2q36.3 locus (OR 1.16; 95% CI, 0.98-1.37 in a +A vs. CC comparison, P = 0.08) were not significantly associated with CVD in our study. Variants were not associated with anthropometric, biochemical, or clinical characteristics within the patient group. Our study suggests that patients with CABG are more commonly carriers of some but not all CVD-associated alleles.

Cell Differentiation and Aging Lead To Up-Regulation of FTO, While the ALKBH5 Protein Level Was Stable During Aging but Up-Regulated During in vitro-Induced Cardiomyogenesis.

FTO and ALKBH5 proteins are essential erasers of N6-adenosine methylation in RNA. We studied how levels of FTO and ALKBH5 proteins changed during mouse embryonic development, aging, cardiomyogenesis, and neuroectodermal differentiation. We observed that aging in male and female mice was associated with FTO up-regulation in mouse hearts, brains, lungs, and kidneys, while the ALKBH5 level remained stable. FTO and ALKBH5 proteins were up-regulated during experimentally induced cardiomyogenesis, but the level of ALKBH5 protein was not changed when neuroectodermal differentiation was induced. HDAC1 depletion in mouse ES cells caused FTO down-regulation. In these cells, mRNA, carrying information from genes that regulate histone signature, RNA processing, and cell differentiation, was characterized by a reduced level of N6-adenosine methylation in specific gene loci, primarily regulating cell differentiation into neuroectoderm. Together, when we compared both RNA demethylating proteins, the FTO protein level undergoes the most significant changes during cell differentiation and aging. Thus, we conclude that during aging and neuronal differentiation, m6A RNA demethylation is likely regulated by the FTO protein but not via the function of ALKBH5.

[Outcomes of combined mitral valve repair surgery and aortic valve replacement in IKEM Praha]. / Výsledky kombinované plastiky mitrální a náhrady aortální chlopne v IKEM Praha.

AIM OF THE STUDY: We retrospectively analyzed long-term outcome of concomitant mitral valve repair and aortic valve replacement. METHODS: From 1996 to 2009 we performed mitral valve plasty with aortic valve replacement in 50 patients. Clinical and echocardiographic data were obtained from computer database and hospital records. Missing data were obtained through mailed questionnaire. We evaluated hospital mortality, long-term survival, thromboembolic and hemorrhagic complications and TR of 3+ on follow up echocardiography. RESULTS: Four patients who had previously undergone aortic valve surgery were excluded from the study. Aortic valve pathology was stenosis in 21 patients, regurgitation in 20 and 4 patients presented with mixed aortic disease. The etiology of mitral regurgitation was rheumatic in 6, non-rheumatic in 31 and infective in 6 patients. Aortic valve was replaced with mechanical prosthesis in 22 (mean age 59) and tissue prosthesis in 24 (mean age 71) patients. Additional surgical procedure was performed in 26 patients. Follow-up was 94% complete, with a mean duration of 51 months. Hospital mortality was 13%. Two and five year survival was 79% and 64% respectively. We noted one case of retroperitoneal hemorrhage and one stroke. We recorded 9 (19.6%) patients with residual TR of more than 3+ grade on follow up echocardiography. Out of 9 patients with residual TR, 3 were operated for rheumatic and 6 for non-rheumatic mitral valve disease. One patients underwent successful mitral valve replacement with mechanical prosthesis, 3 died and 5 are treated expectantly. CONCLUSION: We conclude that concomitant mitral valve repair with aortic valve replacement has high hospital mortality, excellent long-term survival and low complication rate. The durability of mitral valve repair in patients with rheumatic mitral valve disease is limited and replacement, rather that repair should be considered in this patient group.

[Technique of implantation and experience with temporary mechanical cardiac support in right ventricular failure]. / Technika implantace a zkusenosti s docasnou mechanickou srdecní podporou pri selhání pravé komory.

AIM: Severe right heart failure remains unfrequent but fatal complication of cardiac surgical procedures. Implantation of temporary right ventricular assist device may be life-saving procedure in various situations of right heart failure as: heart transplantation, LVAD therapy and post-cardiotomy failure. The aim of the study is an introduction of the implantation technique and retrospective review of current experience with the method. MATERIAL AND METHODS: Since January 2007 isolated right ventricular assist device Levitronix CentriMag has been implanted in 16 patients. Patients were divided into 3 groups: post transplantation (post-Tx), post LVAD implantation (post-LVAD) and other cardiac procedures (OCP). Success rate of weaning from RVAD, 30-days mortality and major complications has been assessed. OUTCOMES: Distribution of implants in groups was: post-Tx 5 pts (31%), post-LVAD 6 pts (38%) and 5 in OCP group (31%). The mean support time was 12 days. Off-pump implantation was achieved in 9 pts. The device was successfully weaned in 13 (81%) patients. 30-days mortality occurred in 1 case only. CONCLUSION: Presented outcomes are encouraging for broader acceptance of the therapy. Excellent success rate has been reached in post-Tx and post-LVAD. This study emphasises decesive role of proactive approach in early indication of RVAD implantation for achieving satisfactory results.

[Cardiosurgical procedures in patients refusing blood transfusions: IKEM outcomes]. / Kardiochirurgické operace u pacientu odmítajících krevní transfuze: výsledky v IKEM.

INTRODUCTION: Jehovah's Witnesses who require cardiac operation represent a specific challenge to the physicians. Members of this faith will not accept blood or blood products under any circumstances on the basis of religious grounds. Nevertheless cardiac operations belong to surgical interventions with potential severe bleeding and necessity of blood transfusions. THE AIM OF THE STUDY: The aim of this retrospective study was to analyze clinical data, operative and postoperative courses of patients operated at IKEM who refused blood transfusions. METHODS AND RESULTS: From January 1995 to August 2010, 73 Jehovah's Witnesses ranging in age from 19 to 82 years underwent cardiac surgery at our institute. Aortocoronary bypass were performed in 34 patients, valve surgery in 25 patients, 6 patients underwent concomitant aortocoronary bypass and valve surgery, 2 patients underwent aortocoronary bypass and resection of the left ventricle aneurysm and 2 patients underwent atrial septal defect repair and tricuspid valve anuloplasty. Ventricular septal sefect repair, atrial septal defect repair, Cor Cap device implantation and left ventricular epicardial electrodes implantation were performed in the other patients. Early 30-days mortality was 2.8 % (2 patients). CONCLUSION: We can conclude that cardiac surgery in Jehovah's Witnesses can be performed safety without blood transfusion and belongs to standard operating procedures at our institution.

[Vascular complications in transcatheter aortic valve implantation in IKEM]. / Cévní komplikace pri transkatetrové implantaci aortální chlopne v IKEM.

AIM: Retrograde transfemoral arterial approach is the most common technique of transcatheter aortic valve implantation. Diameter of available catheters is the limiting factor for percutaneous usage. We currently use 18 French third generation Medtronic Core Valve system. We retrospectively analyzed procedure related complications in our patient cohort. MATERIAL AND METHODS: Transcatheter aortic vale implantation with 18 French Medtronic Core Valve was performed in 35 patients (23 females, 12 males) in between 12/2008 and 7/2010. RESULTS: Mean age was 81.4 +/- 6.1 years (range 69-92), mean logistics EuroSCORE was 19.3 +/- 8.9% (range 8-42), mean aortic valve gradient 59.8 +/- 19.8 mm Hg (range 30-86 mm Hg (mean indexed aortic valve area 0.37 +/- 0.11 cm.

[Right ventricular dysfunction after left ventricular assist device implantation]. / Dysfunkce pravé komory po implantaci levostranné mechanické srdecní podpory.

OBJECTIVE: The frequency of long-term left ventricular assist device (LVAD) implantation is increasing. Acute right ventricular dysfunction or right ventricular failure after LVAD implantation has important influence on morbidity and mortality. The aim of our study was to assess the management of right ventricular dysfunction after LVAD implantation. METHODS: The study group comprised 21 patients with implanted HeartMate II LVAD since December, 2006 to April, 2009. We evaluated in retrospective fashion baseline parameters of cardiovascular and other organ systems before LVAD implantation, applied pharmacological and mechanical support for the right ventricle, and important clinical outcomes to the end ofJune, 2009. RESULTS: LVAD was implanted in 18 men and 3 women with mean age of 48.7 +/- 11.2 years. The most frequent diagnosis was dilatational cardiomyopathy (9 patients; 42.9%), and the most frequent indication for implantation was bridge-to-transplantation (19 patients; 90.4%). Pharmacological support of the right ventricle after LVAD implantation comprised dobutamine (21 patients; 100%), milrinone (21 patients; 100%), isoproterenol (1 patient; 4.8%), and levosimendan (5 patients; 23.8%). In 2 (9.5%) cases there was a need for repeated application of levosimendan during postoperative course. Inhalational nitric oxide was used in 14 (66.7%) patients. Despite extensive pharmacological support, 3 (14.3%) patients needed right ventricular assist device (RVAD) implantation. Most patients (9; 42.8%) survived to heart transplantation; in one (4.8%) case LVAD was successfuly explanted; 6 (28.6%) patients is living with LVAD; 5 (23.8%) patients died during LVAD support. CONCLUSION: After LVAD implantation there is a need for aggressive pharmacological, and in some cases mechanical, support of the right ventricular function to provide adequate blood flow to LVAD in order to minimize morbidity and mortality.

Modification of human pericardium by chemical crosslinking.

Autologous and allogenic human pericardia used as biomaterials for cardiovascular surgery are traditionally crosslinked with glutaraldehyde. In this work, we have evaluated the resistivity to collagenase digestion and the cytotoxicity of human pericardium crosslinked with various concentrations of glutaraldehyde in comparison with pericardium crosslinked by genipin, nordihydroguaiaretic acid, tannic acid, and in comparison with unmodified pericardium. Crosslinking retained the wavy-like morphology of native pericardium visualized by second harmonic generation microscopy. The collagenase digestion products were analyzed using SDS-PAGE, capillary electrophoresis, and a hydroxyproline assay. Glutaraldehyde and genipin crosslinking protected the native pericardium efficiently against digestion with collagenase III. Only low protection was provided by the other crosslinking agents. The cytotoxicity of crosslinked pericardium was evaluated using xCELLigence by monitoring the viability of porcine valve interstitial cells cultured in eluates from crosslinked pericardium. The highest cell index, reflecting both the number and the shape of the monitored cells was observed in eluates from genipin. Crosslinking pericardium grafts with genipin therefore seems to be a promising alternative procedure to the traditional crosslinking with glutaraldehyde, because it provides similarly high protection against degradation with collagenase, without cytotoxic effects.

The role of cardiac surgery in treatment of chronic heart failure.

Chronic heart failure has become a significant health problem. Cardiac surgery has an important role in the treatment of patients with heart failure. There are traditional surgical techniques in cardiac surgery - coronary revascularization, valve surgery, ventricular reconstructive surgery as well as new surgical techniques - cardiac support device (CorCap), mechanical circulatory support and resynchronization therapy. Cardiac surgery has a definitive role in the treatment algorithm for chronic heart failure.

[Transmyocardial laser revascularization]. / Transmyokardiální laserová revaskularizace.

AIM OF THE STUDY: The study looked at our results with transmyocardial laser revascularization. We also tried to ascertain the role of TMLR in current cardiothoracic surgical practice. METHODS: Twenty patients underwent TMLR at IKEM Praha in a period from 1999 to 2007. Patients were categorized into two separate groups. The first included patients who had TMLR as a single procedure. Second group comprised patients who underwent combined TMLR and direct bypass revascularization. Outcome measures were reduction of angina, improvements in exercise tolerance and left ventricular systolic function. RESULTS: Improvement in CCS classification of two and more classes has been achieved in almost half the patients who underwent TMLR combined with CABG, but only in 20% of patients after isolated TMLR. There was no change in left ventricular systolic function either in group of patients after TMLR or in group with hybrid procedure. There was also no change detected in myocardial perfusion in thallium scintigraphy studies. CONCLUSION: The study confirmed that TMLR has minimal perioperative complication rate and is safe. On the other hand our results failed to demonstrate any significant improvement in quality of life following TMLR. In our opinion TMLR should be reserved for symptomatic patients in CCS IV class when all other conventional treatment options have been exhausted.

[Management of deep device related infection in patient implanted with mechanical cardiac support device using V.A.C. system]. / Terapie závazných raných infekcí u pacientu se zavedenou mechanickou srdecní podporou pomocí V.A.C systému.

Infection remains the most significant cause of morbidity and mortality in pacients implanted with mechanical circulatory support devices (MCSD), reaching prevalence of 40-60% according various authors. Successful treatment of the whole spectrum of infectious complications is the basic determinant in archieving good results in MCSD patients. The treatment involves standard surgical procedures, as well as the use of vacuum assisted closure (V.A.C.) therapy in the last few years. We demonstrate successful management of deep device related infection using V.A.C therapy in a patient with MCSD, giving him the opportunity to heart transplantation, and thereafter successful treatment of poststernotomy mediastinitis in this imunosupressed pacient after heart transplantation.

Intraventricular placement of a spring expander does not attenuate cardiac atrophy of the healthy heart induced by unloading via heterotopic heart transplantation.

An important complication of the prolonged left ventricle assist device support in patients with heart failure is unloading-induced cardiac atrophy which proved resistant to various treatments. Heterotopic heart transplantation (HTx) is the usual experimental model to study this process. We showed previously that implantation of the newly designed intraventricular spring expander can attenuate the atrophy when examined after HTx in the failing heart (derived from animals with established heart failure). The present study aimed to examine if enhanced isovolumic loading achieved by implantation of the expander would attenuate cardiac post-HTx atrophy also in the healthy heart. Cardiac atrophy was assessed as the ratio of the transplanted-to-native heart weight (HW) and its degree was determined on days 7, 14, 21 and 28 after HTx. The transplantation resulted in 32±3, 46±2, 48±3 and 46±3 % HW loss when measured at the four time points; implantation of the expander had no significant effect on these decreases. We conclude that enhanced isovolumic loading achieved by intraventricular implantation of the expander does not attenuate the development of cardiac atrophy after HTx in the healthy heart. This indicates that such an approach does not represent a useful therapeutic measure to attenuate the development of unloading-induced cardiac atrophy.

Effects of increased myocardial tissue concentration of myristic, palmitic and palmitoleic acids on the course of cardiac atrophy of the failing heart unloaded by heterotopic transplantation.

The present experiments were performed to evaluate if increased heart tissue concentration of fatty acids, specifically myristic, palmitic and palmitoleic acids that are believed to promote physiological heart growth, can attenuate the progression of unloading-induced cardiac atrophy in rats with healthy and failing hearts. Heterotopic abdominal heart transplantation (HT(x)) was used as a model for heart unloading. Cardiac atrophy was assessed from the ratio of the native- to-transplanted heart weight (HW). The degree of cardiac atrophy after HT(x) was determined on days 7, 14, 21 and 28 after HT(x) in recipients of either healthy or failing hearts. HT(x) of healthy hearts resulted in 23+/-3, 46+/-3, 48+/-4 and 46+/-4 % HW loss at the four time-points. HT(x) of the failing heart resulted in even greater HW losses, of 46+/-4, 58+/-3, 66+/-2 and 68+/-4 %, respectively (P<0.05). Activation of "fetal gene cardiac program" (e.g. beta myosin heavy chain gene expression) and "genes reflecting cardiac remodeling" (e.g. atrial natriuretic peptide gene expression) after HT(x) was greater in failing than in healthy hearts (P<0.05 each time). Exposure to isocaloric high sugar diet caused significant increases in fatty acid concentrations in healthy and in failing hearts. However, these increases were not associated with any change in the course of cardiac atrophy, similarly in healthy and post-HT(x) failing hearts. We conclude that increasing heart tissue concentrations of the fatty acids allegedly involved in heart growth does not attenuate the unloading-induced cardiac atrophy.

Tolerance to acute ischemia in adult male and female spontaneously hypertensive rats.

Clinical and experimental studies have repeatedly indicated that overloaded hearts have a higher vulnerability to ischemia/reperfusion injury. The aim of the present study was to answer the question whether the degree of tolerance to oxygen deprivation in hearts of spontaneously hypertensive rats (SHR) may be sex-dependent. For this purpose, adult SHR and their normotensive control Wistar Kyoto (WKY) rats were used. The isolated hearts were perfused according to Langendorff at constant pressure (proportionally adjusted to the blood pressure in vivo). Recovery of contractile parameters (left ventricular systolic, diastolic and developed pressure as well as the peak rate of developed pressure) was measured during reperfusion after 20 min of global no-flow ischemia in 5 min intervals. Mean arterial blood pressure was measured by direct puncture of carotid artery under light ether anesthesia in a separate group of animals. The degree of hypertension was comparable in both sexes of SHR. The recovery of contractile functions in SHR males and females was significantly lower than in WKY rats during the whole investigated period. There was no sex difference in the recovery of WKY animals; on the other hand, the recovery was significantly better in SHR females than in SHR males. It may be concluded that the hearts of female SHR are more resistant to ischemia/reperfusion injury as compared with male SHR. This fact could have important clinical implications for the treatment of cardiovascular disease in women.

[Surgical treatment of gastrointestinal complications after the heart transplantation]. / Chirurgické výkony na gastrointestinálním traktu po transplantaci srdce.

BACKGROUND: Orthotopic heart transplantation (OHT) is standard treatment of patients with end-stage heart failure. Long-term immunosuppressive therapy leads to the increased risk of the infection and cancer. METHODS AND RESULTS: Our retrospective study was aimed to evaluate gastrointestinal surgery procedures after OHT. The retrospective study was carried out at the Institute of clinical and experimental medicine (IKEM), between January 1, 1996 and December 31, 2006. Our group of patients includes 587 transplant recipients and 22 gastrointestinal surgery procedures. CONCLUSIONS: Results from our department did not show statistical differences in the length of hospital stay, morbidity and mortality in comparison with patients after OHT and control group.

Sensitivity to perioperative ischemia/reperfusion injury in male and female donor myocardium.

Many functions of the cardiovascular apparatus are affected by gender. The aim of our study was find out whether markers of cell death present in the donor myocardium differ in male and female hearts. The study involved 81 patients undergoing heart transplantation from September 2010 to January 2013. Patients were divided into two groups: male allograft (n=49), and female allograft (n=32). Two types of myocardial cell death were analyzed. High-sensitive cardiac troponin T as a necrosis marker and protein bcl-2, caspase 3 and TUNEL as apoptosis markers were measured. We observed a significantly higher level of high-sensitive cardiac troponin T after correcting for predicted ventricular mass in female donors before transplantation as well as in the female allograft group after transplantation throughout the monitored period (P=0.011). There were no differences in apoptosis markers (bcl-2, caspase 3, TUNEL) between male and female hearts before transplantation. Both genders showed a significant increase of TUNEL-positive myocytes one week after transplantation without differences between the groups. Moreover, there were no differences in caspase 3 and bcl-2 expression between the two groups. Our results demonstrated the presence of necrotic and apoptotic cell death in human heart allografts. High-sensitive cardiac troponin T adjusted for predicted ventricular mass as a marker of myocardial necrosis was higher in female donors, and this gender difference was even more pronounced after transplantation.

[Methylene blue in the therapy of vasoplegic syndrome after cardiac surgery procedure]. / Metylenová modr v lécbe vazoplegického syndromu po kardiochirurgické operaci.

Vasoplegic syndrome after cardiac surgery with cardiopulmonary bypass is severe complication with high morbidity and mortality. Without appropriate therapy the syndrome advances to the shock state with subsequent multiorgan failure. Basic haemodynamic parameters of vasoplegic syndrome include low systemic vascular resistance with severe hypotension, tachycardia, and normal or increased cardiac output and low filling pressures. In therapy norepinephrine and vasopressin or its analogues are used. Methylene blue is other therapeutic option. The case of successful application of methylene blue for the treatment of vasoplegic syndrome is presented.

Safety and Efficacy of Immunoadsorption in Heart Transplantation Program.

BACKGROUND: Antibody-mediated rejection (AMR) is a serious complication of organ transplantation, and its treatment is complex. The aim of this study was to assess immunoadsorption (IA) for treatment-immunized patients before heart transplantation (HTX) and as the first step of AMR treatment after HTX. METHODS: The cohort consisted of 10 patients (8 men, 2 women; age range, 20-57 years). For 3 of these patients, IA was included in the desensitization protocol before HTX; for 7 patients, IA was the first step of the treatment protocol. One patient underwent IA before and after HTX. RESULTS: A comparison of values before IA and after the last procedure showed a decrease in immunoglobulin subgroups (G, M, and A). In patients before HTX, a decline was noted in panel reactive antibodies. After HTX, IA procedures led to a significant decrease in donor-specific antibody (DSA) class I; DSA class II fell in 6 of 7 patients, with 51% falling below the detection limit. CONCLUSIONS: IA in patients during HTX is safe procedure for reducing DSA. The removal of antibodies is the first step in comprehensive treatment and must be followed by a procedure that prevents their further development.

Biomarkers of cellular apoptosis and necrosis in donor myocardium are not predictive of primary graft dysfunction.

Primary graft dysfunction (PGD) is a life-threatening complication among heart transplant recipients and a major cause of early mortality. Although the pathogenesis of PGD is still unclear, ischemia/reperfusion injury has been identified as a predominant factor. Both necrosis and apoptosis contribute to the loss of cardiomyocytes during ischemia/reperfusion injury, and this loss of cells can ultimately lead to PGD. The aim of our prospective study was to find out whether cell death, necrosis and apoptosis markers present in the donor myocardium can predict PGD. The prospective study involved 64 consecutive patients who underwent orthotopic heart transplantation at our institute between September 2010 and January 2013. High-sensitive cardiac troponin T (hs-cTnT) as a marker of minor myocardial necrosis was detected from arterial blood samples before the donor's pericardium was opened. Apoptosis (caspase-3, active + pro-caspase-3, bcl-2, TUNEL) was assessed from bioptic samples taken from the right ventricle prior graft harvesting. In our study, 14 % of transplant recipients developed PGD classified according to the standardized definition proposed by the ISHLT Working Group. We did not find differences between the groups in regard to hs-cTnT serum levels. The mean hs-cTnT value for the PGD group was 57.4+/-22.9 ng/l, compared to 68.4+/-10.8 ng/l in the group without PGD. The presence and severity of apoptosis in grafted hearts did not differ between grafts without PGD and hearts that subsequently developed PGD. In conclusion, our findings did not demonstrate any association between measured myocardial cell death, necrosis or apoptosis markers in donor myocardium and PGD in allograft recipients. More detailed investigations of cell death signaling pathways in transplanted hearts are required.

[34,450 days of cardiac surgery in the Czech Republic]. / 34 450 dnu kardiochirurgie v ceských zemích.

Professor Karel Maydl was born in Rokytnice nad Jizerou, where his father was employed at the local court. Czech cardio-surgery was born with the first successful treatment of the stab in the heart, which was done by professor Rychlík in 1910. The next few years the cardio-surgery was represented only by occasional treatment of heart injury. Only in 1934 Jirí Divis excided ganglion stelatum to cure angina pectoris and in 1936 he performed surgical treatment of constrictive pericarditis. Article reviews all Essentials moments in the development of cardio-surgery in Bohemia and Moravia. The second part of the paper gives at present the most frequently performed surgeries. It is concluded that the Czech cardio-surgery has according to the numbers and duality of the treatment the west-European level. At the end Professor Maydl, who died for heart failure, is quoted, why he himself had to be stroked by the disease, which is not possible to treat with the knife. In the 100 years since that it is possible to evaluate that in ICEM 283 medical doctors have been treated for the heart disease and results of their operations were Berger than in standard population. It reproves the bad record of doctors to be bad patients.