Musculoskeletal anatomy and nomenclature of the mammalian epipubic bones.

Despite the well-established anatomy nomenclature for the marsupial skeleton, there are no names for the epipubic bone structures. Epipubic bones are paired bones articulating with the pubis and projecting cranially in the ventral body wall, present on the pelvic girdle of cynodonts, monotremes and marsupials. These bones were commonly thought to be related to pouch support in marsupials and more recently associated with locomotion. The parts of the epipubic bones have not been named and this has impeded proper morphological analysis. We analyzed the epipubic bones of 302 skeletons comprising American and Australian marsupials, as well as 27 monotreme skeletons, and dissected 10 marsupials for myological attachments analysis. We suggest the following nomenclature for the epipubic bone structures: crest for the cranial end, shaft for the body of the bone, lateral tubercle and the medial articular process. Some markings on the epipubic bone include the oblique line, pertaining to the attachment of external abdominal oblique muscle from the opposite side. The pyramidalis line is the suggested nomenclature for the pyramidalis muscle attachment and the inguinal ligament line for the inguinal ligament attachment. Regarding myology and attachments, based on dissections and review of the literature, the muscles pyramidalis, pectineus, external and internal abdominal oblique, transversus abdominis and rectus abdominis and the structures linea alba, linea semilunaris and the inguinal ligament are connected to the epipubic bone. As has been previously noted, anatomically, epipubic bones are so named due to their position (epi-above, pubic-pubis), and the same applies to structures such as the "epipubic process" or "epipubic cartilage" in amphibians and reptiles. While testing epipubic bone homology in vertebrates is beyond the scope of this work, we believe that using "epipubic bones" or epipubic cartilage/process as standardized terms for the structures found in the most cranial part of the superior ramus of the pubis would facilitate better anatomical communication. This should be valid for other similar terms, such as "epipubes" or "prepubis", that might occur in the literature in relation to this same physiographic position, and it should also be named as epipubic. We believe that this nomenclature will help in future morphologic studies.

Human umbilical cord tissue-derived mesenchymal stromal cells as adjuvant therapy for myocardial infarction: a review of current evidence focusing on pre-clinical large animal models and early human trials.

Although biologically appealing, the concept of tissue regeneration underlying first- and second-generation cell therapies has failed to translate into consistent results in clinical trials. Several types of cells from different origins have been tested in pre-clinical models and in patients with acute myocardial infarction (AMI). Mesenchymal stromal cells (MSCs) have gained attention because of their potential for immune modulation and ability to promote endogenous tissue repair, mainly through their secretome. MSCs can be easily obtained from several human tissues, the umbilical cord being the most abundant source, and further expanded in culture, making them attractive as an allogeneic "of-the-shelf" cell product, suitable for the AMI setting. The available evidence concerning umbilical cord-derived MSCs in AMI is reviewed, focusing on large animal pre-clinical studies and early human trials. Molecular and cellular mechanisms as well as current limitations and possible translational solutions are also discussed.

Early And Midterm Outcomes Following Aortic Valve Replacement With Mechanical Versus Bioprosthetic Valves In Patients Aged 50 To 70 Years.

OBJECTIVES: To compare 7-year survival and freedom from reoperation, as well as early clinical and hemodynamic outcomes, after surgical aortic valve replacement (SAVR) with mechanical or bioprosthetic valves in patients aged 50-70 years. METHODS: single-center retrospective cohort study including adults aged 50-70 years who underwent SAVR in 2012 with a mechanical or bioprosthetic valve. Median follow-up was 7 years. Univariable analyses were performed using Kaplan-Meier curves and Log-Rank tests for survival and freedom from reoperation analyses. Multivariable time-to-event analyses were conducted using Cox Regression. RESULTS: Of a total of 193 patients, 76 (39.4%) received mechanical valves and 117 (60.6%) received bioprosthetic valves. A trend for better survival was found for mechanical prostheses when adjusting for EuroSCORE II (HR: 0.35; 95%CI: 0.12-1.02, p=0.054), but using a backward stepwise Cox regression prosthesis type was not retained by the model as an independent predictor of survival. Moreover, mechanical prostheses showed trends for higher freedom from reoperation (100% vs. 95.5%, Log-Rank, p=0.076), higher median EuroSCORE II (2.52% vs. 1.95%, p=0.06) and early mortality (7.9% vs. 2.6%, p=0.086). However, after adjusting for EuroSCORE II, there was no significant difference in early mortality (OR: 2.3, 95%CI: 0.5-10.5, p=0.272). Regarding hemodynamic performance at follow-up echocardiogram, there were no differences other than left ventricular mass regression, which was not as pronounced in the mechanical group (-12% vs. -21%, p=0.002). CONCLUSION: Mechanical and bioprosthetic aortic valves prostheses showed similar mid-term survival in the 50-70 age group. Further prospective and larger studies are needed to provide evidence-based recommendations on this topic.

[Safety and feasibility of conservative aortic valve surgery: single center experience]. / Segurança e Exequibilidade da Cirurgia Conservadora da Válvula Aórtica: Experiência de um Centro Cirúrgico Nacional.

BACKGROUND: In selected cases, aortic valve repair (RVAo) is an alternative to prostesic aortic valve replacement. AIM: To compare mid-term survival, need of reoperation and echocardiographic findings associated with RVAo. METHODS: Retrospective single-center cohort study including consecutive patients younger than 70 years-old, with non-stenotic aortic valve disease, who underwent RVAo between 2012 and 2017. A comparison was made with a group of patients who underwent mechanical aortic valve replacement (SVAo) in the same period. The groups were characterized and compared using Chi-Square and t-tests for independent samples and survival and reoperation were analyzed using Kaplan-Meier curves and Cox regressions. RESULTS: We included 72 patients submitted to RVAo. Mean follow-up time was 4 years, maximum 7. Although the mean age was relatively low (47±13 years), patients undergoing RVAo presented a lower prevalence of rheumatic etiology (3%). The cardiopulmonary bypass (148±74 minutes) and cross clamping aortic times (108±52 minutes) are the usual times for this type of surgery and similar to those of the comparing group (SVAo). In the echocardiographic follow-up (median of 3 months), we verified a left ventricular mass regression of 21% and a prevalence of aortic insufficiency of 4%. At 7 years, cumulative survival and freedom from reoperation of patients undergoing RVAo were 98.8% and 97.6%, respectively. CONCLUSION: RVAo can be a safe and effective alternative, with good mid-term results if patient selection is judicious.

Introdução: Em casos selecionados, a reparação da válvula aórtica (RVAo) constitui uma alternativa à substituição por prótese. Objetivo: Avaliar a sobrevida e necessidade de reoperação a médio prazo, bem como o resultado funcional após RVAo. Métodos: Estudo de coorte retrospetivo, unicêntrico incluindo consecutivamente doentes com idade ≤70 anos, submetidos a RVAo por doença da válvula aórtica não-estenótica, entre 2012-2017. Os resultados foram comparados com os obtidos após substituição valvular aórtica por prótese mecânica (SVAo) no mesmo período. Os grupos foram caracterizados e comparados utilizando testes Qui-Quadrado e t para amostras independentes e a sobrevida e reoperações foram analisadas através de curvas de Kaplan-Meier e regressões de Cox. Resultados: Foram incluídos 72 indivíduos submetidos a RVAo. O follow-up médio foi de 4 anos, máximo de 7. Apesar da idade média relativamente baixa à data da intervenção (47±13 anos), os doentes submetidos a RVAo apresentam uma baixa prevalência de etiologia reumática (3%). Os tempos de circulação extracorporal (148±74 minutos) e de clampagem aórtica (108±52 minutos) são os habituais para este tipo de cirurgias e semelhantes aos do grupo SVAo. Durante o seguimento ecocardiográfico (mediano de 3 meses) verificou-se uma regressão de massa do ventrículo esquerdo de 21% e uma prevalência de insuficiência aórtica de 4%. Aos 7 anos, a sobrevida cumulativa e a sobrevida livre de reoperação dos doentes submetidos a RVAo foram, respetivamente, 96,4% e 94,4%. Conclusões: Com uma seleção adequada dos doentes, a RVAo pode ser uma alternativa segura e efetiva, com bons resultados a médio prazo.

MicroRNA-155 Amplifies Nitric Oxide/cGMP Signaling and Impairs Vascular Angiotensin II Reactivity in Septic Shock.

OBJECTIVES: Septic shock is a life-threatening clinical situation associated with acute myocardial and vascular dysfunction, whose pathophysiology is still poorly understood. Herein, we investigated microRNA-155-dependent mechanisms of myocardial and vascular dysfunction in septic shock. DESIGN: Prospective, randomized controlled experimental murine study and clinical cohort analysis. SETTING: University research laboratory and ICU at a tertiary-care center. PATIENTS: Septic patients, ICU controls, and healthy controls. Postmortem myocardial samples from septic and nonseptic patients. Ex vivo evaluation of arterial rings from patients undergoing coronary artery bypass grafting. SUBJECTS: C57Bl/6J and genetic background-matched microRNA-155 knockout mice. INTERVENTIONS: Two mouse models of septic shock were used. Genetic deletion and pharmacologic inhibition of microRNA-155 were performed. Ex vivo myographic studies were performed using mouse and human arterial rings. MEASUREMENTS AND MAIN RESULTS: We identified microRNA-155 as a highly up-regulated multifunctional mediator of sepsis-associated cardiovascular dysfunction. In humans, plasma and myocardial microRNA-155 levels correlate with sepsis-related mortality and cardiac injury, respectively, whereas in murine models, microRNA-155 deletion and pharmacologic inhibition attenuate sepsis-associated cardiovascular dysfunction and mortality. MicroRNA-155 up-regulation in septic myocardium was found to be mostly supported by microvascular endothelial cells. This promoted myocardial microvascular permeability and edema, bioenergetic deterioration, contractile dysfunction, proinflammatory, and nitric oxide-cGMP-protein kinase G signaling overactivation. In isolate cardiac microvascular endothelial cells, microRNA-155 up-regulation significantly contributes to LPS-induced proinflammatory cytokine up-regulation, leukocyte adhesion, and nitric oxide overproduction. Furthermore, we identified direct targeting of CD47 by microRNA-155 as a novel mechanism of myocardial and vascular contractile depression in sepsis, promoting microvascular endothelial cell and vascular insensitivity to thrombospondin-1-mediated inhibition of nitric oxide production and nitric oxide-mediated vasorelaxation, respectively. Additionally, microRNA-155 directly targets angiotensin type 1 receptor, decreasing vascular angiotensin II reactivity. Deletion of microRNA-155 restored angiotensin II and thrombospondin-1 vascular reactivity in LPS-exposed arterial rings. CONCLUSIONS: Our study demonstrates multiple new microRNA-155-mediated mechanisms of sepsis-associated cardiovascular dysfunction, supporting the translational potential of microRNA-155 inhibition in human septic shock.

Mini-sternotomy versus full sternotomy aortic valve replacement: a single-centre experience.

BACKGROUND: full sternotomy (FS) is the gold standard approach to perform surgical aortic valve replacement (AVR). However, potential advantages of a less traumatic approach fomented the development of so-called minimally invasive procedures, which include upper mini-sternotomy (MS). OBJECTIVE: to compare immediate postoperative clinical results and mid-term mortality after AVR through MS and FS. METHODS: single-centre retrospective study including all patients who underwent isolated AVR through MS between January 1, 2011 and July 31, 2017. These were then matched with patients who underwent the same procedure through FS and by the same surgeons who performed MS, using coarsened exact matching for the variables age, gender, body mass index and diabetes mellitus. Groups were later characterized and compared regarding postoperative results using Qui- -squared and Mann-Whitney tests and regarding mid-term mortality through Kaplan-Meier curves. RESULTS: we included 82 patients (n=41 in each group). Aortic cross clamp [78 vs. 63 minutes, p=0.001] and cardiopulmonary bypass times [107 vs. 90 minutes, p=0.002] were significantly longer in the MS group vs. FS group, respectively. Although without reaching statistical significant difference, a smaller percentage of patients from the MS group required red blood cells transfusions during surgery (39.0% vs. 53.7%, p=0.184). Similar results were found regarding mechanical ventilation, inotropic support, morphine infusion, intensive care unit length of stay and incidence of de novo atrial fibrillation. Cumulative survival at 6 years was 86.7% after MS and 88.5% after FS (p=0.650). CONCLUSIONS: Aortic valve replacement through MS seems to be a safe alternative to the gold standard FS.

Introdução: a esternotomia completa (EC) é a abordagem gold standard da cirurgia de substituição valvular aórtica (SVA). Contudo, as potenciais vantagens de uma abordagem menos traumática promoveram o desenvolvimento de procedimentos minimamente invasivos, incluindo a mini-esternotomia (ME). Objetivo: comparar resultados clínicos no pós-operatório imediato e mortalidade, após SVA por ME e EC. Métodos: estudo retrospetivo unicêntrico incluindo todos os doentes submetidos a SVA isolada por ME, de 1 de janeiro de 2011 a 31 de julho de 2017, emparelhados com doentes submetidos ao mesmo procedimento, pelos mesmos cirurgiões por EC. Utilizou-se o método de emparelhamento coarsened exact matching para as variáveis idade, género, índice massa-corporal e diabetes mellitus. Os grupos foram caracterizados e comparados quanto aos resultados no pós-operatório imediato através de testes Qui-quadrado e Mann-Whitney e quanto à sobrevida através de curvas de Kaplan-Meier. Resultados: foram incluídos 82 doentes (n=41 em cada grupo). Os tempos de clampagem aórtica [78 vs. 63 minutos, p=0,001] e de circulação extracorporal [107 vs. 90 minutos, p=0.002] foram significativamente superiores no grupo ME vs. EC, respetivamente. Embora a frequência de transfusões sanguíneas durante a cirurgia fosse menor no grupo ME, essa diferença não foi estatisticamente significativa (39,0% vs. 53,7%, p=0,184). Os resultados foram semelhantes relativamente ao tempo de ventilação mecânica, suporte inotrópico, infusão de morfina, tempo de permanência em unidade de cuidados intensivos e incidência de fibrilação auricular de novo. A sobrevida cumulativa aos 6 anos foi de 86,7% após ME e 88,5% após EC (p=0,650). Conclusões: a SVA por ME parece ser uma alternativa segura comparativamente ao gold standard EC.

Abundance of small mammals in the Atlantic Forest (ASMAF): a data set for analyzing tropical community patterns.

Local abundance results from the interaction between populational and environmental processes. The abundance of the species in a community is also one of the most basic descriptors of its structure. Despite its importance, information about species abundances is fragmentary, creating a knowledge gap about species abundances known as the Prestonian Shortfall. Here we present a comprehensive data set of small mammal abundance in the Atlantic Forest. Data were extracted from 114 published sources and from unpublished data collected by our research groups spanning from 1943 to 2017. The data set includes 1,902 records of at least 111 species in 155 localities, totaling 42,617 individuals represented. We selected studies that (1) were conducted in forested habitats of the Atlantic Forest, (2) had a minimum sampling effort of at least 500 trap-nights, and (3) contained species abundance data in detail. For each study, we recorded (1) latitude and longitude, (2) name of the locality, (3) employed sampling effort, (4) type of traps used, (5) study year, (6) country, and (7) species name with (8) its respective abundances. For every locality, we also obtained information regarding its (9) ecoregion, (10) predominant vegetation type, and (11) biogeographic subdivision. Whenever necessary, we also (12) updated the species names as new species were described and some genera suffered taxonomic revision since the publication. The localities are spread across the Atlantic Forest and most of the small mammal species known to occur in Atlantic Forest are present in the data set, making it representative of communities of the entire biome. This data set can be used to address various patterns in community ecology and geographical ecology, as the relation between local abundance and environmental suitability, hypothesis regarding local and regional factors on community structuring, species abundance distributions (SAD), functional and phylogenetic mechanisms on community assembling.

Survival After Bilateral Internal Mammary Artery In Coronary Artery Bypass Grafting: Are Women at Risk?

INTRODUCTION: To compare survival and safety of BIMA versus SIMA CABG between males and females at our tertiary care center. METHODS: Single-center retrospective cohort including consecutive patients with at least 2 left coronary system (LCS) vessel disease who underwent isolated CABG with at least 1 IMA conduit and a minimum of 2 conduits targeting the LCS between 2004 and 2013. All-cause mortality was the primary outcome, secondary outcomes were in-hospital mortality and reoperation due to sternal wound complications (SWC). Kaplan-Meier analysis after inverse probability weighting using propensity score (IPW) was used to compare BIMA and SIMA CABG amongst genders. Results were confirmed by subgroup analysis. RESULTS: BIMA CABG was performed in 39% out of 2424 eligible procedures and in 27% of 460 females. No differences were found in survival after BIMA and SIMA CABG (median and maximum follow-up of 5.5 and 12 years, respectively) but a statistical interaction was observed with gender (P<0.001). Females who underwent BIMA CABG showed higher mortality (weighted HR in females subset: 3.16; 95%CI: 1.56-6.29, P=0.001). BIMA CABG showed a higher incidence of reoperations due to SWC (IPW adjusted model OR: 1.74; 95% CI: 1.16-2.60) that were mostly ascribable to males (weighted OR in males: 3.10; 95%CI: 1.74-5.51, P<0.001). CONCLUSION: Females may experience higher mortality after BIMA CABG which should be further explored.

Freedom Solo Versus Trifecta Bioprotheses: Clinical and Hemodynamic Evaluation after Propensity Score Matching.

INTRODUCTION: To compare stentless Freedom Solo and stented Trifecta aortic bioprostheses regarding hemodynamic profile, left ventricular mass regression, early and late postoperative outcomes and survival. METHODS: Longitudinal cohort study of consecutive patients undergoing aortic valve replacement (from 2009 to 2016) with either Freedom Solo or Trifecta at one centre. Local databases and national records were queried. Postoperative echocardiography (3-6 months) was obtained for hemodynamic profile (mean transprosthetic gradient and effective orifice area) and left ventricle mass determination. After propensity score matching (21 covariates), Kaplan-Meier analysis and cumulative incidence analysis were performed for survival and combined outcome of structural valve deterioration and endocarditis, respectively. Hemodynamics and left ventricle mass regression were assessed by a mixed- -effects model including propensity score as a covariate. RESULTS: From a total sample of 397 Freedom Solo and 525 Trifecta patients with a median follow-up time of 4.0 (2.2- 6.0) and 2.4 (1.4-3.7) years, respectively, a matched sample of 329 pairs was obtained. Well-balanced matched groups showed no difference in survival (hazard ratio=1.04, 95% confidence interval=0.69-1.56) or cumulative hazards of combined outcome (subhazard ratio=0.54, 95% confidence interval=0.21-1.39). Although Trifecta showed improved hemodynamic profile compared to Freedom Solo, no differences were found in left ventricle mass regression. CONCLUSION: Trifecta has a slightly improved hemodynamic profile compared to Freedom Solo but this does not translate into differences in the extent of mass regression, postoperative outcomes or survival, which were good and comparable for both bioprostheses. Long-term follow-up is needed for comparisons with older models of bioprostheses.

Cardiac Catheterization After CABG With BIMA Grafting: Independent Predictors and Mid-term Bypass Viability.

INTRODUCTION: Coronary artery bypass graft (CABG) patency is an important variable, but rarely studied as the main outcome. The best use of bilateral internal mammary artery (BIMA) grafting regarding configuration type or combination with saphenous vein graft (SVG) is still debated. PURPOSE: To find independent predictors for need of cardiac catheterization and for significant lesions in CABG follow-up. METHODS: Retrospective cohort including all patients who underwent isolated CABG with BIMA grafts between 2004 and 2013 in a tertiary center. Preoperative, surgical and postoperative data were collected through clinical files and informatics databases. Kaplan-Meier curves, Cox regression and logistic regression were used to find predictors for the need of catheterization and for significant angiographic lesions after CABG. Secondary end-points studied were mid- term survival and need of re-revascularization either surgically or percutaneously. RESULTS: We included 1030 patients in this analysis. Median follow-up time was 5.5 years and 150 (15%) patients were re-catheterized in that period. Most of these procedures was due to ischemia suspicion (74%) and 61 (41%) were positive for significant angiographic lesions of conduits (IMA: 3.2% and SVG: 3.8%, p=0.488). In multivariate analysis, SVG use was found as an independent predictor of cardiac catheterization on follow-up (HR: 1.610, CI 95%: 1.038-2.499, p=0.034). On the other side, independent predictors of graft lesions were younger age (OR: 0.951, CI 95%: 0.921-0.982, p=0.002), female gender (OR: 2.231, CI 95%: 1.038-4.794, p=0.040), arterial hypertension (OR: 1.968, CI 95%: 1.022-3.791, p=0.043) and 3-vessel disease (OR: 2.820, CI 95%: 1.155-6.885, p=0.023). Among the patients with significant angiographic lesions, 48 underwent repeat revascularization (44 PCI e 4 CABG). Arterial hypertension and younger age were independent predictors of re-revascularization. CONCLUSION: In BIMA patients the addition of SVG predicts the need of catheterization; however prevalence of significant angiographic lesions was similar in IMA and SVG. Our results suggest that arterial hypertension is an independent predictor of graft patency and re-revascularization rate.

Postoperative Atrial Fibrillation After Coronary Artery Bypass Grafting Surgery.

INTRODUCTION: Postoperative atrial fibrillation (PoAF) is the most common arrhythmia following cardiac surgery, which increase the patient's morbidity and mortality. PURPOSE: The aim of this study was to evaluate new onset of atrial fibrillation (AF) after isolated coronary artery bypass grafting (CABG) surgery, its clinical and surgical predictors, and its impact in immediate and long-term outcomes. METHODS: Retrospective study including all CABG surgeries performed in a tertiary centre, between 2004 and 2011. Patients with documented episodes of AF or pacing rhythm before cardiac surgery were excluded. Preoperative, surgical and postoperative data were collected through clinical files and informatics databases. Qui-square tests and independent t-tests were used to compare categorical and continuous data, respectively, between patients with and without PoAF. A multivariate logistic regression model was used to identify independent risk factors of PoAF. To determine the effect of PoAF in long-term survival, we used Kaplan-Meier curves, Log Rank test and multivariate Cox regression (maximum follow-up time: 13 years). RESULTS: We included 2511 patients, mean age of 63±10 years, 78.7% being male. PoAF occurred in 450 patients (18.0%), 3±3 days after surgery, the majority pharmacologically cardioverted with amiodarone (96.2%). These patients were older (67±9 vs. 62±10 years, p<0.001), more frequently obese (27.8% vs. 22.9%, p=0.026), hypertensive (76.7% vs. 69.7%, p=0.003) and had lower preoperative creatinine clearance (CC) values (73.2±27.4 vs. 81.4±28.3 ml/min, p<0.001), longer cardiopulmonary bypass time (60.0% vs. 54.8%, p=0.043) compared with patients without PoAF. In multivariate analysis, older age (OR: 1.035, 95% CI: 1.015-1.056, p=0.001), lower preoperative CC values (OR: 0.992, 95% CI: 0.985-0.999, p=0.032) and larger left atrial diameter (OR: 1.058, 95% CI: 1.024-1.093, p=0.001) were determined as independent predictors of PoAF. These patients also revealed longer hospitalization time (8 [4 to 193] vs. 6 [4 to 114] days, p<0.001) and higher hospital mortality (2.9% vs. 0.8%, p<0.001). Regarding long-term survival, patients with PoAF showed lower cumulative survival than patients without AF events (52% vs. 66%, p<0.001). PoAF was also found as an independent predictor of mortality in multivariate Cox regression (HR: 1.394, 95% CI: 1.147- 1.695, p=0.001). CONCLUSION: PoAF incidence after CABG surgery was 18%. Older age, lower CC values and larger left atrial diameter were settled as PoAF independent predictors. Additionally, the occurrence of this arrhythmia was independently associated with lower long-term survival, after CABG surgery.

Endothelial Function and Vascular Properties in Severe Aortic Stenosis Before and After Aortic Valve Replacement Surgery.

INTRODUCTION: The degenerative process that results in aortic valve stenosis (AS) has pathophysiological features similar to the atherosclerotic process. We therefore hypothesized that, as in atherosclerosis, endothelial and vascular dysfunction could be a pathophysiologic feature of AS. AIM: To evaluate endothelial function before and after aortic valve replacement (AVR) surgery in patients with severe AS. To correlate endothelial function with severity of AS and clinical profile. METHODS: Two noninvasive methods were used to evaluate endothelial function (Reactive Hyperemia Index (RHI) measure with EndoPATTM2000 system) and vascular properties (carotid-femoral Pulse Wave Velocity (PWV) measured by Complior® Analyse) in 13 patients with severe AS undergoing AVR. Sample was collected by convenience in a single-center between February and July of 2017. Pre- -operative, surgical and post-operative data were collected through clinical files and informatics databases. PWV, RHI, Augmentation Index (AI) were assessed at the day of surgery and 2.4±1.2 months post-operatively. Mean transvalvular gradients (MTG), aortic valve area (AVA) and left ventricular function were evaluated by transthoracic echocardiography at 3.4±1.6 months of follow-up. Wilcoxon or paired t-tests were used to compare pre- and post-operative values of continuous variables. Spearman correlations (rho) were done to find associations between endothelial/ vascular function parameters and clinical data. RESULTS: In our sample, mean age was 70±8 years and 69% were females. Arterial hypertension was present in 11 (85%) patients, diabetes in 3 (23%) and pre-operative NYHA functional class ≥III in 4 (31%). No patient was currently smoker and only 2 had previous history of smoking. No significant changes were observed between pre- and post-operative endothelial/vascular function values. PWV (m/s), AI (%) and RHI before and after AVR surgery were: 10.5 (6.1 to 16) vs. 9.4 (4.7 to 21.6), p=0.701; 33% [-24 to 54] vs. 23% [0 to 47], p=0.116 and 1.83 (1.08 to 3.13) vs. 1.71 (1.06 to 3.12), p=0.638, respectively. We found a significant inverse correlation between pre- operative AVA and AI (rho= -0.652, p=0.016) and a positive correlation between age and post-operative PWV (rho= 0.639, p=0.019). Pre- and post-operative MTG and AVA were 54±5 mmHg and 0.7± 0.1 cm2 vs.12±4 mmHg and 2.0±0.5 cm2, respectively (p<0.001). CONCLUSION: Considering small sample size, no differences were found in indices of endothelial/vascular function before and after AVR surgery due to AS. However, it seems that endothelial dysfunction is associated with severity of AS assessed by AVA.

Seasonal dynamics with compensatory effects regulate populations of tropical forest marsupials: a 16-year study.

The conditions that a population experiences during one season can affect the strength of density dependence in the following season. In the tropics, many populations face their biggest challenges in the dry season due to limited food and cold-dry conditions. Seasonal environmental changes can be especially problematic for small, short-lived, seasonally breeding endotherms. To investigate the effects of seasonality on population dynamics, we studied five marsupial species in the Brazilian Atlantic Forest, using a 16-year dataset. We tested if (1) compensatory density feedback is stronger in the dry season, due to the high population sizes and limited food; (2) lower temperatures and the overall abundance of small mammals negatively affect dry season population growth rates; and (3) rainfall, a proxy for food availability, is positively related to wet season population growth rates. Population growth rates were regressed against seasonal population sizes and exogenous variables, and analyzed with linear autoregressive models. Seasonal compensatory density feedback occurred in both seasons, with compensation processes in just one season being sufficient to allow population persistence. Rainfall and the overall abundance of small mammals had little influence on populations, while colder temperatures decreased population growth rate of smaller species in both seasons. Although the study marsupials share similar life histories and phylogeny, they varied with respect to the season when compensatory density feedback was strongest. Our results demonstrate that seasonality plays a key role in driving marsupial population dynamics, and highlight the need to account for seasonality in demographic studies even in tropical environments.

[Surgical treatment of type A acute aortic syndrome: a single-center 10-year experience]. / Tratamento cirúrgico do síndrome aórtico agudo do tipo A: experiência de um centro hospitalar em 10 anos.

INTRODUCTION: Acute Aortic Syndrome (AAS) affecting the ascending aorta still represents a challenge to cardiologists and cardiothoracic surgeons, being associated with high mortality even with early surgery. AIMS: To describe the immediate post-operative results and long-term survival after the surgical treatment of type A AAS. Secondary outcomes include hospital mortality, length of hospital stay and long-term mortality. METHODS: Retrospective longitudinal study, including all patients who underwent ascending aorta replacement for surgical treatment of type A AAS, in a tertiary center, between January 2005 and December 2015. Preoperative, surgical and postoperative characteristics were evaluated. In addition to the descriptive analysis, the impact of some variables on long-term mortality, hospital mortality and length of hospital stay was evaluated. RESULTS: We included 78 patients, the most common type of AAS was aortic dissection (92,3%). 6 patients died at operation room and 12 in the immediate post-operative period, completing 23,1% of in-hospital mortality. Considering 60 survivors who were followed by a mean time of 5 years, maximum of 12, we registered a cumulative survival at 1, 3, 5, 10-years of 93,5%, 84,3%, 77% and 69,5%, respectively. Marfan Syndrome was found to be a risk factor of higher long term mortality (HR: 3,85, p=0,045). CONCLUSION: Our study confirms previous observations associating AAS type A with high rates of morbidity and mortality, despite significant advances in diagnostic and therapeutic techniques.

Introdução: O Síndrome Aórtico Agudo (SAA) é frequentemente um desafio para cardiologistas e cirurgiões cardioto- rácicos já que mesmo com cirurgia atempada confere uma mortalidade elevada. Objetivos: Descrever os resultados clínicos no pós-operatório imediato e mortalidade a longo-prazo após abordagem cirúrgica do SAA tipo A. O objetivo secundário é identificar que fatores estão associados com a mortalidade hospitalar, internamento prolongado e mortalidade a longo prazo. Métodos: Estudo retrospetivo longitudinal incluindo todos os doentes submetidos a substituição da aorta ascendente para tratamento cirúrgico de SAA tipo A, num centro terciário, entre janeiro de 2005 e dezembro de 2015. Foram excluídos SAA de causa traumática. Avaliaram-se retrospetivamente as características pré-operatórias, cirúrgicas e pós-operatórias. Para além da análise descritiva, foi estimado o impacto de determinadas variáveis na mortalidade a longo prazo através da regres- são de Cox e relativamente aos resultados secundários através de regressão logística. Resultados: Foram incluídos 78 indivíduos cujo principal tipo de SAA foi a disseção da aorta (92,3%). Registaram-se 6 mortes intraoperatórias e 12 no pós-operatório imediato, sendo a mortalidade hospitalar de 23,1%. Dos 60 indivíduos sobreviventes, o tempo médio de seguimento foi de 5 anos, máximo de 12 anos, com sobrevida cumulativa aos 1, 3, 5 e 10 anos de 93,5%, 84,3%, 77% e 69,5%, respetivamente. O Síndrome de Marfan foi preditor de maior risco de mortalidade a longo prazo (HR: 3,85, p=0,045). Conclusões: O nosso estudo confirma observações prévias associando o SAA tipo A a altas taxas de morbi-mortalidade, apesar dos avanços significativos em termos diagnósticos e terapêuticos.

[Do diabetic patients benefit from bilateral internal mammary artery?] / O Benefício na Sobrevida da Dupla Artéria Torácica Interna Prevalece nos Pacientes com Diabetes?

INTRODUCTION: Bilateral internal mammary artery (BIMA) grafting has been associated with increased long term survival when compared to single IMA, but its benefit on diabetic patients remains controversial. AIMS: To compare long-term survival following BIMA versus single internal mammary artery (SIMA) grafting between diabetic and non-diabetic patients. METHODS: We retrospectively reviewed all the patients who underwent isolated CABG and received two or more grafts with at least one IMA graft between 2004 and 2013. Mean follow-up was 4 years and maximum 10. Kaplan-Meier analysis was used to compare long-term survival between BIMA and SIMA in both groups (diabetic vs. non-diabetic). Propensity score matching was used to adjust for treatment selection bias. RESULTS: 1259 out of 3045 eligible patients were diabetic. BIMA was associated with better long-term survival than SIMA on unadjusted analysis in both groups (cumulative survival of 87% vs. 70% in diabetic patients and 89% vs. 79% in non-diabetic patients, respectively). After propensity score matching, BIMA was associated with increased long-term survival in the non-diabetic cohort (n=1042, HR: 0.570 CI95%: 0.342-0.950), but there was no statistically significant difference in the diabetic cohort (n=850, HR: 0.774 CI95% 0.447-1.339). In-hospital mortality and sternal wound infection were low in matching cohorts irrespectively of the number of IMA grafts or diabetes status. CONCLUSIONS: BIMA grafting appears to be safe for diabetic patients, despite the apparent lack of significant survival advantage.

[Bilateral Internal Mammary Artery Versus Single Internal Mammary Artery in Myocardial Revascularization Surgery. Propensity Score - Adjusted Survival Analysis]. / Dupla Artéria Torácica Interna Versus Artéria Torácica Interna Única na Cirurgia de Revascularização do Miocárdio : Análise Ajustada de Sobrevida com Emparelhamento por Propensy Score.

BACKGROUND: Although arterial grafts are superior to venous grafts in terms of long-term patency, single internal mammary artery (SIMA) is still the preferred strategy in most cardiac surgical centres. Our main aim was to compare long- -term survival between BIMA and SIMA at our own tertiary care centre. METHODS: Retrospective cohort including patients referred to Centro Hospitalar São João (CHSJ), from 2004 to 2011, who underwent isolated CABG and received two or more bypass with at least 1 IMA graft. Kaplan-Meier, Cox regression and propensity score matching 2:1 were used to compare long-term survival between BIMA and SIMA. RESULTS: BIMA was performed in 696 (29.3%) out of 2329 eligible procedures. Mean follow-up time was 5.1 years (2-9.9 years). All-cause mortality was superior in patients with only one internal mammary artery - cumulative survival of 75% for SIMA vs 88% for BIMA. Because of discrepancy between groups regarding preoperative and surgical characteristics, we ran a propensity score matching which revealed BIMA as an independent predictor of survival (n=1510, 40.3% BIMA, HR: 0.648, 95% CI: 0.452-0.927). CONCLUSION: BIMA is associated with significantly better long-term survival than SIMA in CABG. A higher sample size might clarify BIMA advantages, discriminating specific groups that might profit the most with this approach.

Angiotensin-(1-7) modulates angiotensin II-induced vasoconstriction in human mammary artery.

PURPOSE: The renin-angiotensin system plays a key role in cardiovascular pathophysiology and one of its members, angiotensin-(1-7) (ANG-(1-7)), is now recognized as a peptide with the ability to counter-regulate angiotensin II (ANGII) effects. We sought to investigate ANG-(1-7) actions in human vessels, particularly its effect on ANGII-induced vasoconstriction in human mammary arteries (HMA). METHODS: Samples of HMA from patients submitted to coronary revascularization (22 patients, mean age 67 years) were cut into small rings, mounted in a myograph bath system, normalized and allowed to contract and dilate isometrically. In baseline experiments, the rings were incubated with ANG-(1-7) or vehicle, followed by increasing concentrations of ANGII. This protocol was repeated in the presence of A-779, PD123177, losartan and after mechanical endothelium removal. Western blot analysis and immunofluorescence were also performed in order to verify the presence of Mas receptor in HMA. RESULTS: ANG-(1-7) significantly attenuated ANGII-induced contraction, producing a maximal inhibition of approximately 65.2%. This effect was not abolished by A-779, PD123177 or endothelium removal. In the presence of losartan, ANGII response was attenuated and no differences were observed between ANG-(1-7) and vehicle treated rings. Finally, we observed, for the first time, that the Mas receptor is expressed in HMA endothelium. CONCLUSIONS: ANG-(1-7) significantly attenuates ANGII-induced vasoconstriction and, although the Mas receptor is expressed in HMA, this effect seems to be independent of its activation. Additionally, AT2 receptor and endothelium are not involved in this mechanism, which suggests a direct effect on smooth muscle cells.

A Minimally Invasive Model of Aortic Stenosis in Swine.

Large animal models of heart failure play an essential role in the development of new therapeutic interventions due to their size and physiological similarities to humans. Efforts have been dedicated to creating a model of pressure-overload induced heart failure, and ascending aortic banding while still supra-coronary and not a perfect mimic of aortic stenosis in humans, closely resembling the human condition. The purpose of this study is to demonstrate a minimally invasive approach to induce left ventricular pressure overload by placing an aortic band, precisely calibrated with percutaneously introduced high-fidelity pressure sensors. This method represents a refinement of the surgical procedure (3Rs), resulting in homogenous trans-stenotic gradients and reduced intragroup variability. Additionally, it enables swift and uneventful animal recovery, leading to minimal mortality rates. Throughout the study, animals were followed for up to 2 months after surgery, employing transthoracic echocardiography and pressure-volume loop analysis. However, longer follow-up periods can be achieved if desired. This large animal model proves valuable for testing new drugs, particularly those targeting hypertrophy and the structural and functional alterations associated with left ventricular pressure overload.

Human-umbilical cord matrix mesenchymal cells improved left ventricular contractility independently of infarct size in swine myocardial infarction with reperfusion.

Background: Human umbilical cord matrix-mesenchymal stromal cells (hUCM-MSC) have demonstrated beneficial effects in experimental acute myocardial infarction (AMI). Reperfusion injury hampers myocardial recovery in a clinical setting and its management is an unmet need. We investigated the efficacy of intracoronary (IC) delivery of xenogeneic hUCM-MSC as reperfusion-adjuvant therapy in a translational model of AMI in swine. Methods: In a placebo-controlled trial, pot-belied pigs were randomly assigned to a sham-control group (vehicle-injection; n = 8), AMI + vehicle (n = 12) or AMI + IC-injection (n = 11) of 5 × 105 hUCM-MSC/Kg, within 30 min of reperfusion. AMI was created percutaneously by balloon occlusion of the mid-LAD. Left-ventricular function was blindly evaluated at 8-weeks by invasive pressure-volume loop analysis (primary endpoint). Mechanistic readouts included histology, strength-length relationship in skinned cardiomyocytes and gene expression analysis by RNA-sequencing. Results: As compared to vehicle, hUCM-MSC enhanced systolic function as shown by higher ejection fraction (65 ± 6% vs. 43 ± 4%; p = 0.0048), cardiac index (4.1 ± 0.4 vs. 3.1 ± 0.2 L/min/m2; p = 0.0378), preload recruitable stroke work (75 ± 13 vs. 36 ± 4 mmHg; p = 0.0256) and end-systolic elastance (2.8 ± 0.7 vs. 2.1 ± 0.4 mmHg*m2/ml; p = 0.0663). Infarct size was non-significantly lower in cell-treated animals (13.7 ± 2.2% vs. 15.9 ± 2.7%; Δ = -2.2%; p = 0.23), as was interstitial fibrosis and cardiomyocyte hypertrophy in the remote myocardium. Sarcomere active tension improved, and genes related to extracellular matrix remodelling (including MMP9, TIMP1 and PAI1), collagen fibril organization and glycosaminoglycan biosynthesis were downregulated in animals treated with hUCM-MSC. Conclusion: Intracoronary transfer of xenogeneic hUCM-MSC shortly after reperfusion improved left-ventricular systolic function, which could not be explained by the observed extent of infarct size reduction alone. Combined contributions of favourable modification of myocardial interstitial fibrosis, matrix remodelling and enhanced cardiomyocyte contractility in the remote myocardium may provide mechanistic insight for the biological effect.

Aortic Valve Surgery in Patients with Infective Endocarditis: Mid-Term Follow-up of Patients Treated With the ST. Jude Medical Trifecta Valve.

BACKGROUND: It is particularly difficult to choose the appropriate prosthesis to treat infective endocarditis. OBJECTIVES: To investigate the outcomes after aortic valve replacement with a stented bioprosthesis (Trifecta) in patients with active or previous infective endocarditis. METHODS: We performed a single-centre, retrospective study including consecutive patients with infective endocarditis who underwent aortic valve replacement between July 2011 and June 2019. Survival and reintervention were assessed as of December 2021. Hospital mortality was defined as death in-hospital or within 30-days of surgery. Kaplan-Meier method was used for time-to-event outcome assessment (all-cause mortality and reoperation). Data are median (minimum and maximum) or absolute (relative) frequencies. RESULTS: We included 51 patients, median age of 69 (40 to 87) years, 78% male. The median follow-up time was 5.4 years and the maximum was 10 years. Most patients (71%) had native valve infective endocarditis and 16% had previous endocarditis. Surgery was urgent in 82%. Hospital mortality occurred in 10 patients (20%). After excluding these patients, 1-, 3-, 6-, and 9-years cumulative survival rates were 93%, 78%, 72%, and 72%, respectively. There were five bioprosthesis-related reoperations: 4 due to endocarditis at 1-year, 3-years, and 5-years on follow-up (n=1, 1 and 2, respectively) and 1 due to non-structural deterioration, 6-years after surgery. CONCLUSIONS: Despite the small sample size, this report supports a satisfactory performance profile of the Trifecta bioprosthesis in the treatment of infective endocarditis.